Intracranial Dotter angioplasty using Tenzing (Tenzingplasty) for acute ischemic stroke with underlying intracranial atherosclerotic disease

INTRODUCTION: Catheter-mediated (Dotter) angioplasty has been previously described for extracranial/peripheral arteries. Tenzing (Route 92 Medical, San Mateo, California, USA), a shelf-reducing delivery catheter, has an atraumatic tapered distal tip that progressively enlarges to maximal outer diameter of 1.2 mm (Tenzing 5), 1.6 mm (Tenzing 7), and 2.1 mm (Tenzing 8). OBJECTIVE: To report our initial experience treating acutely symptomatic intracranial atherosclerotic disease (ICAD) using Dotter angioplasty with Tenzing (Tenzingplasty). METHODS: After institutional review board approvals, we retrospectively reviewed clinical and procedural data of patients with underlying ICAD treated with off-label Tenzingplasty between 2022 and 2025, either as part of endovascular treatment for large vessel occlusion, or after medical therapy failure <96 hours from presentation. RESULTS: We identified 53 consecutive patients with symptomatic ICAD who underwent Tenzingplasty, median (IQR) age 63 (57-70) years, 29 (55%) male. ICAD locations were: M1 (24), M2 (9), internal carotid artery (3), vertebral V4 segment (7), basilar (8), vertebrobasilar junction (1), and A2 anterior cerebral artery (1). First pass aspiration thrombectomy for patients with an initial modified Thrombolysis in Cerebral Infarction score 0 (without crossing the ICAD lesion) was performed in 34/53 (64%). After median 1 (IQR 1-2) Tenzingplasty pass, median (IQR) stenosis improved from 100% (95-100) to 60% (42-76) post-Tenzingplasty (P<0.0001). Subsequent balloon angioplasty or stenting was performed in 4% and 21%, respectively. Successful final reperfusion (expanded Thrombolysis in Cerebral Infarction 2b-3) was achieved in 81%, with one Tenzingplasty-related complication (a non-flow limiting dissection), and no perforations. In follow up, 25/44 (57%) had a 90-day modified Rankin Scale score of 0-2. CONCLUSION: Tenzingplasty may be a feasible and safe rescue therapy for improving luminal caliber, flow restoration, and/or lesion preparation for stenting in acutely symptomatic ICAD.