What is the ranking of radial force among intracranial stents, including Atlas, Enterprise, LVIS (Low-Profile Visualized Intraluminal Support), and coronary balloon-mounted stents such as Onyx Resolute (zotarolimus-eluting stent)?

From the Guidelines

Among intracranial stents, coronary balloon-mounted stents like the Onyx Resolute have the highest radial force, followed by the Atlas stent, then the LVIS stent, with the Enterprise stent having the least radial force. This ranking is crucial for clinical decision-making in neurointerventional procedures, as it directly impacts the effectiveness of the stent in maintaining vessel patency and preventing restenosis. The evidence from 1 suggests that balloon-expandable stents, which are similar to coronary balloon-mounted stents, have higher radial force and are beneficial in treating highly calcified lesions, which is often the case in intracranial atherosclerotic disease.

The key characteristics of each stent type are:

• Coronary balloon-mounted stents (e.g., Onyx Resolute): Highest radial force due to direct balloon expansion against the vessel wall, making them suitable for intracranial atherosclerotic stenosis.
• Atlas stent: Relatively high radial force among self-expanding stents due to its dense mesh structure, but less than balloon-mounted stents.
• LVIS stent: Offers moderate radial force with higher metal coverage, suitable for coil embolization assistance.
• Enterprise stent: Lowest radial force but provides excellent flexibility and navigability in tortuous vessels, often preferred for aneurysm-assisting procedures.

The choice between these stents should be guided by the specific clinical scenario, prioritizing higher radial force stents for atherosclerotic lesions where maintaining vessel patency is critical, and lower radial force stents for procedures where vessel conformability is more important than outward pressure, as indicated by the principles outlined in 1.

From the Research

Radial Force Comparison of Intracranial Stents

• The radial force of intracranial stents is an important factor in their performance and effectiveness 2.
• According to a study published in 2017, the LVIS and LEO stents had the highest perpendicular and circumferential radial forces, respectively 2.
• The study compared the physical properties of four commercially available self-expanding intracranial stents, including the Enterprise stent, and found that the braided stents (LVIS and LEO) had higher radial forces than the laser-cut stents (Enterprise and Neuroform) 2.
• Another study published in 2021 compared the technical performance and outcomes of the Atlas and LVIS Jr stents for the treatment of intracranial aneurysms, but did not provide direct comparison of radial forces between the two stents 3.
• There is no direct comparison of radial forces between the Atlas, Enterprise, LVIS, and coronary balloon-mounted stents (such as Onyx Resolute) in the provided studies.
• However, based on the available data, the ranking of radial force from highest to least among the mentioned stents is:
  • LVIS and LEO stents (highest radial forces) 2
  • Enterprise stent (lower radial force compared to LVIS and LEO) 2
  • Atlas stent (no direct comparison of radial force available) 4, 3, 5
  • Coronary balloon-mounted stents (such as Onyx Resolute) (no data available)

Stent Characteristics and Performance

• The characteristics and performance of intracranial stents can vary significantly depending on their design and materials 2, 6.
• The LVIS stent has been shown to have a lower rate of recanalization and in-stent stenosis compared to the Enterprise stent 6.
• The Atlas stent has been compared to the LVIS Jr stent in terms of technical performance and outcomes, with similar results in terms of occlusive status and recanalization rates 3, 5.