Influence of patient age and stenosis location on wingspan in-stent restenosis

Abstract

Background and purpose: Wingspan is a self-expanding, microcatheter-delivered microstent specifically designed for the treatment of symptomatic intracranial atherosclerotic disease. Our aim was to discuss the effect of patient age and lesion location on in-stent restenosis (ISR) rates after percutaneous transluminal angioplasty and stenting (PTAS) with the Wingspan system.

Materials and methods: Clinical and angiographic follow-up results were recorded for all patients from 5 participating institutions. ISR was defined as >50% stenosis within or immediately adjacent (within 5 mm) to the implanted stent and >20% absolute luminal loss. For the present analysis, patients were stratified into younger (</=55 years) and older (>55 years) age groups.

Results: ISR occurred at a rate of 45.2% (14/31) in the younger group and 24.2% (15/62) in the older group (odds ratio, 2.6; 95% confidence interval, 1.03-6.5). In the younger group, ISR occurred after treatment of 13/26 (50%) anterior circulation lesions versus only 1/5 (20%) posterior circulation lesions. In the older group, ISR occurred in 9/29 (31.0%) anterior circulation lesions and 6/33 (18.2%) posterior circulation lesions. In young patients, internal carotid artery lesions (10/17 treated, 58.8%), especially those involving the supraclinoid segment (8/9, 88.9%), were very prone to ISR. When patients of all ages were considered, supraclinoid segment lesions had much higher rates of both ISR (66.6% versus 24.4%) and symptomatic ISR (40% versus 3.9%) in comparison with all other locations.

Conclusion: Post-Wingspan ISR is more common in younger patients. This increased risk can be accounted for by a high prevalence of anterior circulation lesions in this population, specifically those affecting the supraclinoid segment, which are much more prone to ISR and symptomatic ISR than all other lesions.

Fig 1.

A 51-year-old woman initially presented with a right middle cerebral artery distribution stroke. A, Pretreatment angiography demonstrated an irregular stenosis of the supraclinoid segment of the ICA. B, The patient underwent successful PTAS with Wingspan. C, Routine follow-up angiography at 3 months demonstrated long-segment ISR, which was successfully treated with angioplasty.

Fig 2.

A 55-year-old woman, who initially presented with right-hemisphere watershed infarcts while taking aspirin, had additional transient ischemic attacks while taking aspirin, clopidogrel, and heparin during hospitalization. A, Initial imaging evaluation demonstrated a high-grade right supraclinoid ICA stenosis that was successfully treated with Wingspan PTAS (arrows depict the stent end markers). B, The patient returned with a history of falls and episodic left-handed and arm numbness and weakness 3.5 months after treatment. MR with diffusion imaging demonstrated several small right-hemisphere infarctions. C, Angiography demonstrated long-segment high-grade in-stent restenosis (right anterior oblique [left] and lateral [right] subtracted images). D, Corresponding right anterior oblique (left) and lateral (right) native images. This lesion was successfully retreated with angioplasty.