In-stent Stenosis after p64 Flow Diverter Treatment

There is limited information available on the incidence of in-stent stenosis (ISS) secondary to the use of flow-diverting stents in the intracranial vasculature. We sought to determine the incidence, severity, and clinical course of ISS on angiographic follow-up after treatment of saccular aneurysms with p64.

We retrospectively reviewed all patients who underwent treatment of a saccular (ruptured and unruptured) intracranial aneurysm with ≥1 p64 between 2011 and 2015. Fusiform aneurysms and dissections were excluded. Aneurysms with prior or concomitant saccular treatment (e. g., coiling, clipping) were included. Extradural targets and aneurysms with parent vessel implants other than p64 were excluded. ISS was assessed on follow-up angiography and defined as <50% (mild), 50–75% (moderate), or >75% (severe).

In total, 205 patients (147 female, 71.7%; median age 57 years), with 223 saccular aneurysms were treated with p64 and had at least 9 months of digital subtraction angiography (DSA) follow-up completed. There was no DSA follow-up available in 8 patients. ISS of any degree at any time was recognized in 65/223 (29.1%) of all target aneurysms. The maximal degree of lumen loss was <50% in 40 lesions (17.9%), 50–75% in 19 lesions (8.5%), and >75% in 6 lesions (2.7%). ISS did not cause a focal neurological deficit in any patient. No progression from stenosis to occlusion was observed. Balloon angioplasty was performed in 1 lesion and was well tolerated. In 56 lesions (84.8%), a significant reduction of ISS occurred spontaneously, 2 mild stenoses remained stable, and for 6 lesions the long-term follow-up is pending.

Treatment with p64 is associated with an overall rate of 8.5% moderate ISS (50–75%) and 2.7% severe ISS (>75%), which is comparable with the rate of ISS reported in the literature for other flow diverting stents. There is a tendency for ISS to spontaneously improve over time.