Comparison of periprocedure complications resulting from direct stent placement compared with those due to conventional and staged stent placement in the basilar artery.
OBJECTIVE
Medically refractory, symptomatic atherosclerotic disease of the basilar artery (BA) portends a poor prognosis. Studies have shown morbidity rates following placement of stents in these lesions to be quite variable, ranging from 0 to 30%. The authors review their experience with BA stent placement for severe atherosclerotic disease to determine whether an increase in neurological morbidity is associated with direct stent placement (that performed without predilation angioplasty) compared with conventional stent placement (that performed immediately after predilation angioplasty) or staged stent placement (angioplasty followed > or = 1 month later by stent placement with or without repeated angioplasty).


METHODS
The authors retrospectively reviewed the medical records from a consecutive series of 10 patients who underwent stent placement for medically refractory, symptomatic atherosclerotic disease of the BA between February 1999 and November 2002. Patient records were analyzed for symptoms at presentation, percentage of angiographically visible stenosis, devices used, procedure-related morbidity, and clinical and radiographic outcomes. Patients with symptomatic intracranial vertebral artery stenosis but without concomitant severe (> 50%) BA stenosis were excluded from the study. Four patients were treated with direct stent placement, three with a staged procedure (these were included in a previous publication), and three with conventional stent placement. In the group treated with direct stent placement, a dense quadriparesis developed in two patients after the procedure. Computerized tomography or magnetic resonance imaging revealed infarction of the ventral pons in these patients. In the staged stent placement group, no permanent neurological complications occurred after the procedure and, in the conventional stent placement group, one of three patients experienced a neurological complication involving homonymous hemianopsia.


CONCLUSIONS
Direct stent placement in the BA is associated with a relatively high complication rate, compared with a staged procedure. Complications may result from an embolic shower following disruption of atheromatous plaque debris attained using high-profile devices such as stents, as demonstrated by the postoperative imaging appearance of acute pontine infarctions. Additionally, displacement of debris by the stent into the ostia (snowplowing) of small brainstem perforating vessels may be responsible for the complications noted. Although direct stent placement in peripheral and coronary vessels has been shown to be safe, the authors suggest that direct stent placement in the BA should be avoided to minimize the risk of periprocedure morbidity.
Levy
Elad I
EI
Department of Neurosurgery and Toshiba Stroke Research Center, School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, New York 14209, USA.
Hanel
Ricardó A
RA
Boulos
Alan S
AS
Bendok
Bernard R
BR
Kim
Stanley H
SH
Gibbons
Kevin J
KJ
Qureshi
Adnan I
AI
Guterman
Lee R
LR
Hopkins
L Nelson
LN
D000368:Aged; D000369:Aged, 80 and over; D001921:Brain / Q000473:pathology; D002533:Cerebral Angiography; D005260:Female; D006801:Humans; D002537:Intracranial Arteriosclerosis / Q000150:complications; D007431:Intraoperative Complications; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000379:methods*; D011183:Postoperative Complications; D012189:Retrospective Studies; D015607:Stents; D014715:Vertebrobasilar Insufficiency / Q000175:diagnosis / Q000209:etiology / Q000601:surgery*