Can the Stryker Atlas stent be used to treat intracranial atherosclerotic disease large vessel occlusion?

Use of Stryker Atlas Stent for Intracranial Atherosclerotic Disease Large Vessel Occlusion

The Stryker Atlas stent can be used for treatment of intracranial atherosclerotic disease (ICAD) causing large vessel occlusion (LVO), particularly as a rescue therapy when conventional thrombectomy fails, though it is not specifically FDA-approved for this indication.

Understanding ICAD-Related Large Vessel Occlusion

ICAD is a significant cause of ischemic stroke, accounting for 10-30% of LVOs, with higher prevalence in Asian, Black, and Hispanic populations 1, 2. Unlike embolic occlusions, ICAD-LVOs present unique challenges:

• High reocclusion rates (up to 50%) after conventional thrombectomy
• Underlying stenosis requiring different management approaches
• Need for adjunctive treatments to maintain vessel patency

Current Guidelines on Intracranial Stenting

Guidelines provide limited specific direction on the use of the Stryker Atlas stent for ICAD-LVO, but offer relevant principles:

• Intracranial stenting is not recommended as initial treatment for symptomatic intracranial stenosis but may be considered in highly selected cases 3
• Endovascular intervention should only be performed at high-volume centers with significant neurovascular expertise 3
• For basilar artery occlusions, recent trials (ATTENTION and BAOCHE) demonstrated high rates of intracranial angioplasty and stent placement (55% in BAOCHE) with good outcomes 4

Treatment Algorithm for ICAD-LVO

1. Initial Approach:

   • Standard thrombectomy techniques (aspiration, stent retriever) as first-line treatment
   • Identify ICAD during procedure through:
     • Fixed focal stenosis after partial recanalization
     • Immediate reocclusion after initial successful thrombectomy
     • Resistance to standard thrombectomy devices

2. When to Consider Stenting:

   • After failed conventional thrombectomy attempts (typically 1-3 passes) 5
   • When significant fixed stenosis (>70%) is identified as the underlying cause 6
   • When temporary bypass is achieved but followed by reocclusion

3. Stenting Procedure Considerations:

   • Pretreat with dual antiplatelet therapy (aspirin and clopidogrel)
   • Use intraprocedural heparin
   • Slightly undersize balloons and stents relative to vessel diameter
   • Consider balloon angioplasty before stent placement

4. Adjunctive Treatments:

   • Intra-arterial or intravenous glycoprotein IIb/IIIa inhibitors (e.g., tirofiban) to prevent acute thrombosis 5
   • Angioplasty may be effective as a rescue treatment 5

Post-Procedure Management

• Continue dual antiplatelet therapy (aspirin and clopidogrel) for at least 1 year 6
• Aggressive risk factor management:
  • Blood pressure control (<130/80 mmHg) 3
  • High-intensity statin therapy (target LDL <70 mg/dL) 3
  • Lifestyle modifications and diabetes control

Outcomes and Complications

• Technical success rates are high (>90%) with significant reduction in stenosis 6, 7
• Potential complications include:
  • Periprocedural hemorrhage (8%) 7
  • Acute/subacute stent thrombosis (7%) 7
  • In-stent restenosis (moderate rate, though drug-eluting stents may reduce this risk) 6

Important Caveats

• Balloon-mounted stents like the Atlas require careful navigation through tortuous intracranial vasculature
• Modern intermediate catheters have improved the feasibility of intracranial stent deployment 7
• Drug-eluting stents may be preferable to reduce restenosis rates, though long-term data are limited 6
• Patient selection is critical - consider age, comorbidities, and location of stenosis
• The procedure should only be performed by experienced neurointerventionalists at high-volume centers

While the evidence base continues to evolve, the use of stents including the Stryker Atlas for ICAD-LVO appears to be a viable rescue strategy when conventional thrombectomy fails, with reperfusion rates comparable to standard thrombectomy approaches 7.