Background: The optimal treatment approach for patients with severe atherosclerotic vertebral artery ostial stenosis (VAOS) is not yet supported by evidence from large-scale studies. Even with optimal medical treatment and effective risk factor management, substantial numbers of patients experience symptoms or recurrent strokes. Endovascular treatment is a potential solution, particularly when medicinal therapy alone is insufficient for symptom and stroke risk reduction. This study was aimed at assessing the safety and effectiveness of stent angioplasty in patients with VAOS. Methods: This single-centre retrospective analysis included 564 procedures in 525 patients (symptomatic n=265, without recent symptoms n=260; 72.2% male; median age: 70 years; stenosis >75% n=371) who underwent stenting for atherosclerotic VAOS between 2008 and 2022. Vertebrobasilar tandem lesions and dissections were excluded. Digital subtraction angiography was performed in all patients during the follow-up. Patients’ characteristics, periprocedural and postprocedural neurological events, and follow-up data were evaluated. Results: Stenting was successfully performed in all cases. The in-hospital stroke rate was 0.6% (disabling n=2; non-disabling n=1). No ipsilateral stroke or treatment-associated deaths occurred during a mean follow-up period of 56 months (min.–max., 9–183 months). In-stent restenosis >50% was found in 89 (15.8%) implanted stents, with the majority (70 out of 89) diagnosed within the first year, at a median time of 7 months. Conclusions: Stent angioplasty was demonstrated to be a safe and feasible option for patients with VAOS, with a low risk of periprocedural stroke and symptom recurrence, and favourable stent patency rates at mid-term and long-term follow-up.

Introduction: In-stent restenosis (ISRS) is a major concern following vertebral artery (VA) ostial stenting, potentially leading to recurrent symptoms or ischemic strokes. Despite the growing use of endovascular treatment for VA ostial stenosis (VAOS), data on efficacy and safety of the endovascular re-treatment for ISRS is sparse. Aim of study: To evaluate the incidence of ISRS after VA ostial stenting and assess the safety and effectiveness of endovascular re-interventions. Methods: This single-center retrospective analysis included patients who underwent re-treatment for ISRS >50% using either balloon angioplasty with a drug-coated balloon (DCB), or re-stenting with drug-eluting balloon-mounted stents (DES). The angiographic follow-up was performed in all cases following re-treatment. Periprocedural neurological events, need for re-treatment, and follow-up outcomes were systematically evaluated. Results: Over a mean follow-up period of 56 months (range: 9–183 months) after 564 stenting procedures for VAOS in 525 patients, ISRS >50% was found in 89 stents (15.8%), with the majority (70 out of 89) diagnosed within the first year, at a median time of 7 months (range: 1–147 months). Re-treatment was performed in 88 cases, with DES used in 43.2% and DCB in 56.8%. No periprocedural strokes were observed. Recurrent ISRS was detected in 19 stents (21.6%) at a mean of 23.2 months (range: 4–117 months) following re-treatment. Tobacco use and dyslipidemia were significantly associated with the development of ISRS and its recurrence. Conclusion: The observed ISRS rate underscores the importance of rigorous follow-up after VA ostial stenting. Endovascular re-treatment of high-grade ISRS with DES or DCB appears to be safe and effective, while risk factor management, including smoking cessation, may further reduce recurrence rates.

Purpose Although flow diverters (FDs) revolutionized the treatment of unruptured intracranial aneurysms (UIAs), clinically silent microinfarcts (SMs) are consistently detected in postprocedural diffusion-weighted imaging (DWI), and their clinical consequences remain unknown. This study examined the incidence of, and factors associated with, SM development after the use of two surface-modified FDs: the p48MW-HPC and p64MW-HPC. Methods A non-concurrent cohort study was conducted in 404 consecutive patients with UIAs treated with these two FDs between January 2020 and July 2023. The primary endpoint was the number of asymptomatic DWI lesions within 72 h after the procedure. Results SMs were detected in 58.2% of the cases, and ≥ 20 lesions were identified in 7.2% of cases. Multivariate analysis revealed that the use of two specific types of microcatheters—Prowler Select Plus (P < 0.001; IRR, 3.2) and RapidTransit (P = 0.001; IRR, 2.2)—and difficulty in microcatheter navigation to the target vessel (P = 0.039; IRR, 1.8) were significantly associated with greater numbers of lesions. After exclusion of outlier cases, these devices remained associated with a significant 2‑ to 3‑fold increase in SMs. Diabetes was associated with fewer SMs (P = 0.024; IRR, 0.5), although this association disappeared after exclusion of outlier cases. Conclusion The postprocedural incidence of SMs associated with hydrophilic polymer-coated FDs was similar to that previously reported. Interestingly, the main factor contributing to this phenomenon was the use of certain microcatheters. Careful device selection is crucial, and further research is needed to improve the safety of neurovascular interventions.

Purpose: Endovascular and surgical treatments of stenosis of the extracranial internal carotid artery (ICA) are common procedures, yet both introduce a risk of restenosis due to endothelial hyperplasia. Drug-coated balloons (DCBs) are designed to decrease neointimal hyperplasia, however rarely used in the neurovascular setting. This study retrospectively analyzes mid-term results of DCB-treated in-stent restenosis (ISR) of the ICA. Materials and Methods: The medical history, comorbidities, and periprocedural data of patients receiving DCB treatment for > 50% ISR of the ICA after carotid artery stenting were analyzed. Follow-up after DCB treatment was performed with Doppler ultrasound. Suspicious cases were checked with CT- or MR-angiography and—if there was agreement between the modalities—validated with digital subtraction angiography. Potential risk factors for restenosis and differences in outcomes after PTA with three types of DCB balloons were evaluated. Results: DCB treatment was performed in 109 cases, 0.9% of which involved in-hospital major stroke; no minor strokes occurred. A total of 17 patients (15.6%) had recurrent ISR after DCB treatment, after a mean time of 30.2 months (7–85 months). Tobacco use was significantly associated with a higher incidence of recurrent ISR. Conclusion: DCB angioplasty for ISR is an effective treatment that may delay and decrease restenosis. Treating comorbidities and adopting lifestyle changes may additionally help prevent ISR. Graphical

Background: Carotid artery stenting (CAS) is a minimally invasive and proven percutaneous procedure that is widely used to treat patients with symptomatic and asymptomatic carotid artery stenosis. The purpose of this study was to characterize the in-hospital outcomes of symptomatic and asymptomatic patients undergoing CAS at a single neurovascular center. Methods: The study was conducted as a retrospective analysis of 1158 patients (asymptomatic, n = 636; symptomatic, n = 522; male, n = 816; median age, 71 years; NASCET method, 70–99% stenosis, n = 830) who underwent CAS between May 2009 and December 2020. In-hospital neurological outcomes, adverse reactions to iodinated contrast media, acute myocardial infarction, intraprocedural complications, and access-site issues were evaluated. The primary endpoints were disabling stroke (including disabling cerebral hyperperfusion syndrome [CHS]) and all in-hospital deaths. Results: A carotid stent could not be deployed in one patient due to calcified plaques (technical failure rate of 0.09%). Four patients (0.3%) experienced in-hospital, stroke-associated death, while five patients (0.4%) died from non-stroke-related causes. All stroke-associated deaths occurred in the symptomatic group and were due to CHS. The disabling stroke rate was 0.9% overall (n = 10; 0.5% versus 1.3% in asymptomatic versus symptomatic patients, respectively). Nineteen patients (1.6%) reached the in-hospital primary endpoint. More patients in the symptomatic group achieved this endpoint than in the asymptomatic group (2.5% versus 0.9%, respectively; p = 0.060). Conclusions: An evaluation was conducted on the in-hospital outcomes of 1158 patients at a single center who underwent CAS and was performed by trained physicians who were supervised by a senior neurovascular interventionist with over 20 years of experience, confirming the excellent safety profile of this procedure with a low rate of complications.

Purpose To evaluate the safety, efficacy, and clinical outcomes of stent-assisted coiling (SAC) and flow diversion (FD) with hydrophilic polymer-coated (HPC) devices under prasugrel single antiplatelet therapy (SAPT) in the treatment of acutely ruptured wide-neck intracranial aneurysms. Methods This multicenter retrospective case series included patients with ruptured saccular intracranial aneurysms treated through SAC or FD with HPC-coated devices under SAPT at four specialized neurovascular centers. Baseline demographics, aneurysm characteristics, procedural details, and clinical outcomes were analyzed. The primary outcomes included technical success, periprocedural complications, aneurysm occlusion rates at follow-up (FU), and functional outcomes assessed with the modified Rankin Scale (mRS). Results A total of 46 patients were included (mean age 57.4 years). SAC and FD were performed in equal proportions. Technical success was achieved in 100% of cases. The immediate complete occlusion rate was significantly higher for SAC (95.7%) than FD (21.7%, p < 0.001). However, the occlusion rates at 12-month FU were comparable (SAC 100% vs. FD 95%, p = 0.364). The overall periprocedural complication rate was low (4.3%), and mortality before discharge was 10.9%. Favorable functional outcomes (mRS ≤ 2) at the last FU were achieved in 84% of patients, and no significant differences were observed between the SAC and FD groups. Conclusion SAC and FD with HPC-coated devices under prasugrel SAPT appeared to be safe and effective in treating ruptured wide-neck aneurysms. Whereas SAC achieved higher immediate occlusion rates, the long-term outcomes were comparable between groups. These findings support the feasibility of SAPT in this high-risk population and warrant further prospective validation.