Navigability trumps all: Stenting of acute middle cerebral artery occlusions with a new self-expandable stent.
SUMMARY: Acute stroke intervention is rapidly evolving. New technologies are improving device deliverability and rates of recanalization. We describe 2 cases of acute middle cerebral artery occlusions wherein Wingspan stents could not be delivered to the occlusive site because of excessive vascular tortuosity. Merci thrombectomy was also unsuccessful. Revascularization was only achieved with deployment of the highly navigable Enterprise stent, resulting in thrombolysis in myocardial infarction 2/3 flow. Thus, all devices should be considered in the armamentarium of stroke therapy.
Intra-arterial therapies for acute stroke have evolved rapidly in recent years.1,2 Although the newer-generation Merci mechanical clot retriever (Concentric Medical, Mountain View, Calif) achieved successful recanalization in 70% of patients,2this was only marginally superior to the 66% recanalization rate in the Prolyse in Acute Cerebral Thromboembolism II trial.1Although encouraging, substantial room for improvement exists.
Coronary (balloon-expandable) stents have been used successfully in acute stroke intervention with published recanalization rates of 79%.3 Use of a balloon- or self-expandable stent has been found to be an independent predictor of successful recanalization (OR, 4.8).4 Modern balloon-expandable stents have become increasingly trackable and flexible; however, compared with self-expandable stents specifically designed for the intracranial circulation, balloon-expandable stents are larger and stiffer.5
On the basis of early, encouraging results of acute intracranial revascularization with stents and knowledge that self-expandable stents are more trackable and have lower profiles, a 2-center registry, Stent Assisted Recanalization in Ischemic Stroke Phase I Study to Evaluate the Safety of Wingspan Stenting (SARIS), is currently enrolling patients by using the Wingspan stent (Boston Scientific, Natick, Mass) for acute stroke intervention. We report 2 cases wherein the highly navigable Wingspan could not be delivered to occlusive sites because of excessive vascular tortuosity, and, after unsuccessful Merci thrombectomy, Enterprise self-expandable stents (Cordis, Miami Lakes, Fla) were delivered successfully to acutely occluded cerebral vessels with immediate restoration of flow.