Long-Term Risk Factors for Intracranial In-Stent Restenosis From a Multicenter Trial of Stenting for Symptomatic Intracranial Artery Stenosis Registry in China

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Long-Term Risk Factors for Intracranial In-Stent Restenosis From a Multicenter Trial of Stenting for Symptomatic Intracranial Artery Stenosis Registry in China

Xu Guo^†, Ning Ma, Feng Gao, Da-Peng Mo, Gang Luo and Zhong-Rong Miao^*

• Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China

Background: For patients with symptomatic intracranial artery stenosis (sICAS), endovascular treatment has been shown to be feasible and safe in recent studies. However, in-stent restenosis (ISR) risks the recurrence of ischemic stroke. We attempt to elucidate the risk factors for ISR.

Methods: We retrospectively analyzed 97 patients with sICAS from a prospective registry trial that included 20 centers from September 2013 to January 2015. Cases were classified into the ISR≥ 50% group or the ISR < 50% group. The baseline characteristics and long-term follow-up were compared between the two groups. Binary logistic regression analyses were identified as an association between ISR and endovascular technique factors.

Results: According to whether ISR was detected by CT angiography, 97 patients were divided into the ISR group (n = 24) and the non-ISR group (n = 73). The admission baseline features and lesion angiography characteristics were similar, while plasma hs-CRP (mg/L) was higher in the ISR≥ 50% group at admission (8.2 ± 11.4 vs. 2.8 ± 4.1, p = 0.032). Binary logistic regression analysis identified the longer stents (adjusted OR 0.816, 95% CI 0.699–0.953; p = 0.010), balloon-mounted stents (adjusted OR 5.748, 95% CI 1.533–21.546; p = 0.009), and local anesthesia (adjusted OR 6.000, 95% CI 1.693–21.262; p = 0.006) as predictors of ISR at the 1-year follow-up.

Conclusions: The longer stents, balloon-mounted stents implanted in the intracranial vertebral or basilar artery, and local anesthesia were significantly associated with in-stent restenosis. Further studies are required to identify accurate biomarkers or image markers associated with ISR in ICAS patients.

Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT01968122.

Introduction

The prevalence of intracranial atherosclerotic stenosis (ICAS) in Chinese patients was up to 46.6% in symptomatic ischemic stroke patients (1). Symptomatic ICAS (sICAS) is associated with recurrent ischemic stroke (2). SAMMPRIS and VISSIT trials have shown that aggressive medical management has been more effective and safer than endovascular therapy in the past decade (3, 4). However, a recent Wingspan Stent System Post Market Surveillance Study (WEAVE) indicated that the perioperative complication rate is quite low for on-label patients (2.6%). Patients enrolled in this study, including patients with symptomatic and severe ICAS lesions, had suffered at least two ischemic strokes (5). It is obvious that patients with sICAS who failed the best medical treatment would benefit from endovascular therapy.

As we reported, the 30-days rate of primary endpoints, including stroke, transient ischemic attack, and death, was 4.3% in a multicenter prospective registry study of stenting for sICAS in China (6). The incidence of the composite endpoint in this study at 1 year was 8.1%, and restenosis ≥50% was found in 27.6% of patients at the 12-months follow-up. Although the majority of patients (78.9%) were asymptomatic (7), restenosis would be a risk factor for ischemic stroke, causing acute large vessel occlusion or transient ischemic attack (TIA) (2). Therefore, in the present study, according to the inflammatory index (hs-CRP), features of the lesion in angiography, and characteristics of the stent in the operation procedure, we aimed to identify risk factors for in-stent restenosis of endovascular treatment in intracranial atherosclerotic stenosis in a 12-months follow-up.

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