Distal protection of endovascular recanalization for symptomatic non-acute occlusion of vertebrobasilar artery

Distal protection of endovascular recanalization for symptomatic non-acute occlusion of vertebrobasilar artery | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Distal protection of endovascular recanalization for symptomatic non-acute occlusion of vertebrobasilar artery Qiuli Li, Xiaoxi Yao, Yuanbiao Lei, Haipeng Li, Liu Tu, Yi Zhang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5716220/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 15 Apr, 2025 Read the published version in Acta Neurochirurgica → Version 1 posted 9 You are reading this latest preprint version Abstract Purpose The research aimed to investigate the safety and efficacy of distal protection of endovascular recanalization for symptomatic non-acute occlusion of the intracranial vertebrobasilar artery. Methods 8 consecutive patients with symptomatic non-acute VBA from January April 2023 to April 2024 who underwent endovascular recanalization were retrospectively analyzed. Results 8 patients (median age 56 years; mean pretreatment National Institutes of Health Stroke Scale (NIHSS) score 6; 87.5% male) presenting with recurrent transient ischemic attacks(TIAs) (n = 1) or strokes (n = 23) were treated from January April 2023 to April 2024. Median time from symptoms onet to treatment was 21 days(range: 10–43). Median time from occlusion confirmed to treatment was 13 days(range:8–26). Among the 8 patients, 8 (100%) achieved successful recanalization. The rate of periprocedural complications was 25%(2/8). Periprocedural complications included one asymptomatic intracranial hemorrhage(asICH) and thrombus translocation. The median follow-up time was 9 months (range: 6–12), with no stroke or TIA. At 90 days, there were one death (unrelated to the procedure) and 75% patients with an available modified Rankin Scale (mRS) score achieved a good outcome (mRS score of 0–2). Conclusion The distal protection of stent retriever for endovascular recanalization for symptomatic non-acute occlusion of VBA is technically safe and may decrease procedure-related complications. distal protection endovascular recanalization safety and efficacy vertebrobasilar artery Figures Figure 1 Introduction The intracranial vertebral artery (VA) and the basilar arter (BA) are the common sites of atherosclerotic occlusion[3, 4, 8, 13], and a subset of patients may still suffer from repeated TIAs and strokes in the non-acute or chronic stage even under aggressive medication[7, 15]. One fifth of strokes occur in the territory of the posterior circulation but neurointervention procedures for secondary prevention, have received much less attention than similar interventions for the anterior circulation[11]. With the improvement of the concept of ischemic prevention and treatment and the progress of endovascular instruments, endovascular recanalization and stenting of non-acute occlusion of intracranial arteries has been increasingly performed. The possible periprocedural complications of endovascular recanalization for non-acute occlusion of the intracranial VBA mainly include ischemic complications such as perforator stroke, vascular dissection, acute thrombosis, distal embolism, and hemorrhagic complications[16, 18–20]. Therefore, endovascular recanalization for patients with non-acute intracranial VBA occlusion remains clinically challenging[5, 14]. There some advantages of The Balloon Angioplasty with the distal protection of Stent Retriever technique, referred to as the distal protection of stent retriever technique was described in acute intracranial artery atherosclerosis-related occlusion, which may be associated with decreasing procedure-related complications and time savings[17]. We aimed to assess the safety and efficacy of the distal protection of endovascular recanalization for symptomatic non-acute occlusion of the intracranial VBA. Methods Study design and ethics This retrospective study was approved by the Ethics Committee of Chenzhou No 1 People's Hospital(2024017) and performed in accordance with the Decla ration of Helsinki. Study population “Non-acute occlusion” was defined as symptomatic (TIA or stroke) complete occlusion of intracranial VBA of presumed atherosclerotic etiology in which endovascular therapy was performed more than 48h from the time the patients was last seen well[1]. Data from 8 consecutive patients who presented with aggressive ischemic events in the non-acute stage of VBA occlusion and treated with the distal protection of endovascular recanalization at our institution from April 2023 to April 2024 were retrospectively reviewed. The study was approved by the Institutional Review Board of the hospital’s ethics committee and received informed consent from all patients. 87.5% of the subjects were male, with a mean age of 56 years (range 47–67 years). The inclusion criteria were as follows: (1) intracranial atherosclerosis was the primary etiology; (2) experienced recurrent TIAs or stroke related to occluded VBA despite aggressive medical treatment, which was defined as the treatment including antiplatelet therapy, statin, blood pressure and glucose control, smoking cessation; (3) patients were normally recanalized with dominant VA occlusion together with contralateral occlusion, hypoplasia, or severe stenosis (> 70%) or BA occlusion; and (4) hemodynamic failure were confirmed based on the clinical and imaging evidence. The exclusion criteria were as follows: (1) non-atherosclerotic occlusion, such as vasculitis, arterial dissection, or embolic disease; (2) clinical symptoms were stable with aggressive medical treatment; (3) contraindications to operation, such as known allergy or contraindication to aspirin, clopidogrel, or anesthesia; (4) the distal protection of stent retriever technique was adopted. (5) life expectancy < 1 year because of other medical conditions. Endovascular procedures Combination therapy with oral aspirin (100 mg) and clopidogrel (75 mg) was initiated at least 3 days before endovascular procedures. The procedures were performed under general anesthesia. The right femoral artery was inserted by an 8F sheath, using a Seldinger technique. Unfractionated heparin at 50IU/kg was injected intravenously for systemic heparinization. With coaxial technology, thrombectomy catheter was placed in the area of total occlusion, a 0.014 inch microguide wire was carefully passed through the occlusion under the guidance of a micro-guide wire. Angiography was used to confirm that the distal vessel was occluded (Fig. 1 A). A Syphonet (Achieva, China) stent was selected as the distal protection device, and the proximal 1/3 of the stent was located at the lesion. After the distal end of the thrombectomy stent was anchored, the microcatheter could be removed directly (Fig. 1 B). During the operation, angiography was performed under sufficient pressure to accurately identify the internal components of the occluded segment. If the occluded segment could not be accurately assessed after the microcatheter was withdrawn, a suitble-diameter balloon would be used to dilate the suspected primary lesion and subsequent thrombosis from the distal to proximal under the guidance of the Syphonet stent with guide wire. Then again angiography was performed through the aspiration catheter to further identify the internal components of the occluded segment. When a thrombus escapes during the procedure, the aspiration catheter would be advanced and aspirated under continuous negative pressure to remove the thrombus across the proximal occlusion. The distal protection device of the stent retriever will be withdrawn to remove the thrombus in the stent capture basket. The stent was then repositioned at the lesion site, a suitable balloon was dilated from the distal to the proximal site (Fig. 1 C). Finally, the stent was withdrawn after angiography confirmed the absence of thrombus and stable antegrade blood flow (Fig. 1 D). After recanalization, antegrade blood flow was assessed according to the modified thrombolysis in cerebral infarction (mTICI) grading, and mTICI ≥ 2b indicated successful recanalization (Fig. 1 E). Digital subtraction angiography was performed 6months after recanalization (Fig. 1 F), and restenosis was described as ≥ 50% stenosis after stent implantation and ≥ 20% absolute luminal loss at follow-up[10]. Low molecular weight tirofiban 6-8mL/h (based on the patient’s body weight) was given 12 or 24 hours only if intracranial hemorrhage was excluded after operation. Postoperative systolic/diastolic pressures were controlled less than 110/70mmHg. All patients were advised to take aspirin (100 mg/day) and clopidogrel (75 mg/day) for 6 months with or without subsequent cessation of clopidogrel. Data collection The data of patient included demographics and cardiovascular risk factors, including age, sex, hypertension, diabetes mellitus, hyperlipidemia, previous history of stroke, coronary artery disease and smoking. The median time between symptom onset and occlusion comfirmed were recorded. The mRS scores and NIHSS scores were assessed. Technical procedure complications, clinical follow-up and follow-up angiography were evaluated. Favorable functional outcome was defined as an mRS score 0–2. Statistical analysis The statistical methods used were descriptive. Quantitative data were expressed as means ± standard deviation or as medians with interquartile range, whereas categorical data were presented as numbers and percentages. Results 8 patients (56years; range, 47–67years) with male predominance who were treated with the distal protection of endovascular recanalization were enrolled. The baseline demographic and clinical characteristics are listed in Table 1 . 8 patients had acute stroke. Occlusion was in the intracranial VA in 7(87.5%) patients and BA in one patients (12.5%). All patients had evidence of previous infarction in the VBA distribution on MR imaging. Hypertension was present in 7 patients, 6 patients had diabetes mellitus, one patient had cardiovascular disease, and 3 patients had smoking history and hyperlipidemia. The duration from symptom onset to treatment was 10–43 days (median 21) and 8–26 days (median 13) from occlusion confirmed to treatment. The overall technical success rate was 100%. Postoperative complications took place in 2(25%) patients. 2 patients experienced thrombus translocation, which were removed successfully after thrombectomy. One patient recovered well without neurologic impairment and one experienced asymptomatic ICH. Although the patient didn’t suffer a asymptomatic deterioration after asymptomatic ICH, he died of pneumonia and respiratory failure 2 months after discharge. The patients were followed up for a mean of 9 months (range: 6–12). Excluding the patient who died (case 6), the rate of mRS (range: 0–2) scores were 75% at the 90-day follow-up, which was 62.5% higher than before endovascular treatment. Angiographic follow-up was available for 7 patients, in-stent stenosis was 25.7% (10–60%). Discussion Previous studies showed the recanalization of non-acute occlusion of the VBA was a high-risk procedure[6]. The recanalization and stenting for non-acute occlusion of the VBA has generally been used in clinical practice but the rates of perioperative complications were also high[9], such as cerebral hemorrhage, dissection, acute reocclusion and thrombus disruption and translocation. During the recanalization, the major technical challenge is traversing the occlusion site with a guidewire. Since there were fewer side and perforating branches in the intracranial VA, it was easier to result in blood flow retardation proximal to the occlusion and subsequent thrombus formation, leading to longer segments of occlusion in the VA[21], which make it more difficult to cross. It was reported that the application of the distal protection in treating acute intracranial artery atherosclerosis-related occlusion may increase the rates of successful reperfusion and decrease procedure-related complications[17]. In this study, all patients were treated with the distal protection of endovascular recanalization. It is more likely to go through the occlusion site after balloon angioplasty at the stenotic site, which may explain high technique success in our case series. Meanwhile, a thrombus may be dislodged distally when crossing the occluded segment during recanalization. Embolization is a well-known and serious complication of endovascular therapies, and distal protection devices have been developed and are currently being used widely in carotid artery stenting (CAS) procedures to limit cerebral embolism[2]. Moreover, the management of high-burden thrombus in intracranial VA is more tricky. Once the clot migration in VA occlusion occured during the procedures, the consequence was lethal. Compared with in the internal carotid artery, there was no report of the distal protection for endovascular recanalization of symptomatic non-acute occlusion of VBA. As the application of distal protection, the rates of perioperative complications decreased. Though two patients experienced thrombus translocation and the thrombus were removed Successfully. This is the first case series to evaluate the significance of the distal protection for endovascular recanalization involving VBA occlusion. Because of reducing the frequency of instrument exchanges, thereby it can minimize the risk of complications caused by instrument exchanges. By using the retrieval basket of the Syphonet thrombectomy stent as protection, the distal protection of stent retriever technique can reduce the risk of thrombus disruption and translocation caused by balloon dilatation. Limitations Except sample size is too small, there was other limit in our findings. Considering that the occlusion time of VBA in these patients was relatively short and the thrombus had not yet fully organized, it was hypothesized that the microguidewire might pass through more easily[12]. Therefore, we did not perform high-resolution MRI for this group of patients. Conclusion Our case series suggests that the distal protection of stent retriever for endovascular recanalization for symptomatic non-acute occlusion of VBA is technically safe and may decrease procedure-related complications. Declarations Author contributions Study concept and design: Yi Zhang, Qiuli Li. Data collection and analysis: Qiu Li, Xiaoxi yao, Yuanbiao Lei, Haipeng Li, Liu Tu. Data interpretation:Yi Zhang, Qiuli Li, Xiaoxi yao, Yuanbiao Lei, Haipeng Li, Liu Tu. Reviewing and editing: Qiu Li, Xiaoxi yao, Yuanbiao Lei, Haipeng Li, Liu Tu. Supervision: Yi Zhang. All authors approved the final version of the submitted manuscript Funding This study was supported by the Department of science and Technology of Hunan Province (Grant No. 2023JJ50372). Data availability The authors declare all original data is available for review representing partial patient files as the case may apply. Declarations Ethics approval This retrospective study was approved by the Ethics Committee of Chenzhou No 1 People's Hospital (approval ethics number: 2024017) and performed in accordance with the Decla ration of Helsinki. Consent to participate For this retrospective study, Written informed consent for participation was not required. Consent for publication Not applicable because all personal information was anonymized and no images were presented that could identify the patient. Conflicts of interest The authors declare no competing interests. References Aghaebrahim A, Jovin T, Jadhav AP, Noorian A, Gupta R, Nogueira RG (2014) Endovascular recanalization of complete subacute to chronic atherosclerotic occlusions of intracranial arteries. J Neurointerv Surg 6: 645–648 Doi 10.1136/neurintsurg-2013-010842 Baik SK, Jeon U, Choo KS, Kim YW, Pil-Park K (2011) What is the real risk of dislodging thrombi during endovascular revascularization of a proximal internal carotid artery occlusion? Neurosurgery 68: 1084–1090; discussion 1091 Doi 10.1227/NEU.0b013e31820a19fc Caplan LR (2012) The intracranial vertebral artery: a neglected species. The Johann Jacob Wepfer Award 2012. Cerebrovascular diseases (Basel, Switzerland) 34: 20–30 Doi 10.1159/000339629 Duan H, Chen L, Shen S, Zhang Y, Li C, Yi Z, Wang Y, Zhang J, Li L (2021) Staged Endovascular Treatment for Symptomatic Occlusion Originating From the Intracranial Vertebral Arteries in the Early Non-acute Stage. Front Neurol 12: 673367 Doi 10.3389/fneur.2021.673367 Gao F, Sun X, Zhang H, Ma N, Mo D, Miao Z (2020) Endovascular Recanalization for Nonacute Intracranial Vertebral Artery Occlusion According to a New Classification. Stroke 51: 3340–3343 Doi 10.1161/strokeaha.120.030440 Gao P, Wang Y, Ma Y, Yang Q, Song H, Chen Y, Jiao L, Qureshi AI (2018) Endovascular recanalization for chronic symptomatic intracranial vertebral artery total occlusion: Experience of a single center and review of literature. J Neuroradiol 45: 295–304 Doi 10.1016/j.neurad.2017.12.023 Gorelick PB, Wong KS, Bae HJ, Pandey DK (2008) Large artery intracranial occlusive disease: a large worldwide burden but a relatively neglected frontier. Stroke 39: 2396–2399 Doi 10.1161/strokeaha.107.505776 He X, Zhang L, Yang J, Zheng H, Li K, Liu Y (2017) Multimodal Therapy for Non-Superacute Vertebral Basilar Artery Occlusion. Interv Neurol 6: 254–262 Doi 10.1159/000477626 He Y, Bai W, Li T, Xue J, Wang Z, Zhu L, Hui F (2014) Perioperative complications of recanalization and stenting for symptomatic nonacute vertebrobasilar artery occlusion. Ann Vasc Surg 28: 386–393 Doi 10.1016/j.avsg.2013.03.014 Levy EI, Turk AS, Albuquerque FC, Niemann DB, Aagaard-Kienitz B, Pride L, Purdy P, Welch B, Woo H, Rasmussen PAet al (2007) Wingspan in-stent restenosis and thrombosis: incidence, clinical presentation, and management. Neurosurgery 61: 644–650; discussion 650 − 641 Doi 10.1227/01.NEU.0000290914.24976.83 Markus HS, Michel P (2022) Treatment of posterior circulation stroke: Acute management and secondary prevention. Int J Stroke 17: 723–732 Doi 10.1177/17474930221107500 Quan T, Hou H, Xue W, Yu G, Ma H, Sun J, Guan S, Xu Y, Xu H (2019) Endovascular treatment of acute intracranial vertebrobasilar artery occlusion: a multicenter retrospective observational study. Neuroradiology 61: 1477–1484 Doi 10.1007/s00234-019-02282-1 Tao C, Li R, Zhu Y, Qun S, Xu P, Wang L, Zhang C, Liu T, Song J, Sun Wet al (2022) Endovascular treatment for acute basilar artery occlusion: A multicenter randomized controlled trial (ATTENTION). Int J Stroke 17: 815–819 Doi 10.1177/17474930221077164 Wang H, Liu C, Xu H, Zhang Y, Gao P, Geng S, Kong W, Zhi Y, Yuan K, Tian L (2022) The Association between Serum Anion Gap and All-Cause Mortality in Cerebral Infarction Patients after Treatment with rtPA: A Retrospective Analysis. Dis Markers 2022: 1931818 Doi 10.1155/2022/1931818 Wang Y, Zhao X, Liu L, Soo YO, Pu Y, Pan Y, Wang Y, Zou X, Leung TW, Cai Yet al (2014) Prevalence and outcomes of symptomatic intracranial large artery stenoses and occlusions in China: the Chinese Intracranial Atherosclerosis (CICAS) Study. Stroke 45: 663–669 Doi 10.1161/strokeaha.113.003508 Yao YD, Liu AF, Qiu HC, Zhou J, Li C, Wang Q, Lv J, Jiang WJ (2019) Outcomes of late endovascular recanalization for symptomatic non-acute atherosclerotic intracranial large artery occlusion. Clin Neurol Neurosurg 187: 105567 Doi 10.1016/j.clineuro.2019.105567 Yi T-y, Wu Y-m, Lin D-l, Pan Z-n, Zheng X-f, Gan J, Wu M-h, Lin X-h, Chen R-c, Zeng L-set al (2022) Application of Balloon AngioplaSty with the dIstal protection of Stent Retriever (BASIS) technique for acute intracranial artery atherosclerosis-related occlusion. Frontiers in Neurology 13: Doi 10.3389/fneur.2022.1049543 Zhang X, Xie Y, Wang H, Yang D, Jiang T, Yuan K, Gong P, Xu P, Li Y, Chen Jet al (2020) Symptomatic Intracranial Hemorrhage After Mechanical Thrombectomy in Chinese Ischemic Stroke Patients: The ASIAN Score. Stroke 51: 2690–2696 Doi 10.1161/STROKEAHA.120.030173 Zhao W, Zhang J, Meng Y, Zhang Y, Zhang J, Song Y, Sun L, Zheng M, Wang W, Yin Het al (2020) Symptomatic Atherosclerotic Non-acute Intracranial Vertebral Artery Total Occlusion: Clinical Features, Imaging Characteristics, Endovascular Recanalization, and Follow-up Outcomes. Frontiers in Neurology 11: Doi 10.3389/fneur.2020.598795 Zhao W, Zhang J, Song Y, Sun L, Zheng M, Yin H, Zhang J, Wang W, Han J (2019) Endovascular Recanalization for Symptomatic Subacute to Chronic Atherosclerotic Basilar Artery Occlusion. Front Neurol 10: 1290 Doi 10.3389/fneur.2019.01290 Zhou Z, Li T, Zhu L, Wu L, Guan M, Ma Z, Liu Y, Qin J, Gao B (2023) Endovascular recanalization of symptomatic non-acute occlusion of the vertebrobasilar artery. Front Neurol 14: 1125244 Doi 10.3389/fneur.2023.1125244 Tables TABLE 1 Patients' baseline demographic and clinical characteristics. Sex,male Age,years,median Medical History,n(%) Hypertension Diabetes mellitus Cardiovascular disease Smoking Hyperlipidemia mRS score on admission, n(%) 0-2 3-5 NIHSS,on admission, median(range)) Symptom onset to treatment,days,median(range) Occlusion confirmed to treatment,days,median(range) recanalization artery,n(%) VA intracranial BA technical success,n(%) RSR,median(range) Complication rate, n (%) Dissection Perforation asICH Hyperperfusion syndrome Thrombus translocation Follow-up time,months,median(range) 30-DAY stroke or death, n (%) 90-day mRS score,median(range) 0-2 3-5 ISR on follow-up image,median(range) 7(87.5%) 56(47-67) 7(87.5%) 6(75%) 1(12.5%) 3(37.5%) 3(37.5%) 5(62.5%) 3(37.5%) 6(2-12) 21(10-43) 13(8-26) 7(87.5%) 1(12.5%) 8(100%) 21%(10-40%) 2（25%） 0（0%） 0（0%） 1（12.5%） 0（0%） 2（25%） 9(6-12) 1（12.5%） 6(75%) 1(12.5%) 25.7%(10-60%) NIHSS, National Institutes of Health Stroke Scale; mRS, modified Rankin Scale; asICH, asymptomatic intracranial hemorrhage; BA, basilar artery; VA, vertebral artery; ISR, in-stent restenosis rate. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 15 Apr, 2025 Read the published version in Acta Neurochirurgica → Version 1 posted Editorial decision: Revision requested 06 Feb, 2025 Reviews received at journal 06 Feb, 2025 Reviews received at journal 04 Feb, 2025 Reviewers agreed at journal 24 Jan, 2025 Reviewers agreed at journal 24 Jan, 2025 Reviewers invited by journal 14 Jan, 2025 Editor assigned by journal 13 Jan, 2025 Submission checks completed at journal 13 Jan, 2025 First submitted to journal 26 Dec, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5716220","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":401984118,"identity":"ea39344a-7db8-44a2-a43d-2c09f2f53f46","order_by":0,"name":"Qiuli Li","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Qiuli","middleName":"","lastName":"Li","suffix":""},{"id":401984119,"identity":"6b2e18de-617f-452f-87b0-17e47621a7ca","order_by":1,"name":"Xiaoxi Yao","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Xiaoxi","middleName":"","lastName":"Yao","suffix":""},{"id":401984120,"identity":"4bce311b-6ba4-4f2d-bf6e-4e6870073a5e","order_by":2,"name":"Yuanbiao Lei","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Yuanbiao","middleName":"","lastName":"Lei","suffix":""},{"id":401984121,"identity":"90b8600f-332c-4bcf-8ce1-d33519eb6edc","order_by":3,"name":"Haipeng Li","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Haipeng","middleName":"","lastName":"Li","suffix":""},{"id":401984122,"identity":"f26c72e3-0988-4a40-acb2-b75c5e136aa6","order_by":4,"name":"Liu Tu","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Liu","middleName":"","lastName":"Tu","suffix":""},{"id":401984123,"identity":"63ca5c3a-3c1c-4fc2-9c48-ce5d94c05a0b","order_by":5,"name":"Yi Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7UlEQVRIiWNgGAWjYDACCSjJxt588MEHAxs54rXw8xxLNpxRkGZMrBYGBskZPmbSPB8OJxLUIT+7+dnDr20WDAY3GIyNbQyYExjYDx/dgE8L45xj5saybRIMBrcbEh/nGLDlMfCkpd3Ap4VZIsFMWhKk5c6Bw8Y5BjzFDBI8Zni1sEmkf4NouZHYJm1hIJHYQEgLj0SOmeRHoBbJGcls0gwGBoS1SEjklEkznAMHMrNhj0GCMRshv8jPSN8m+aOsDhiV/R8f/PjzX46f/fAxvFpAgJmXjaG+Ae47QspBgPHHH2KUjYJRMApGwYgFAAtWRI9uXMcoAAAAAElFTkSuQmCC","orcid":"","institution":"","correspondingAuthor":true,"prefix":"","firstName":"Yi","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2024-12-26 12:53:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5716220/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5716220/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00701-025-06525-4","type":"published","date":"2025-04-15T15:57:42+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":73868312,"identity":"75f71a4e-e41f-46e8-94a7-dd06f1411fe9","added_by":"auto","created_at":"2025-01-15 12:07:20","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":3770811,"visible":true,"origin":"","legend":"\u003cp\u003eIllustrative case of a patient. Male patient, 56 years old; prestented with dizziness and slurred speech with VA occlusion treated with distal protection for endovascular recanalization.; The admission NIHSS score was 4, and the mRS score was 2. \u003cstrong\u003eA\u003c/strong\u003e. Digital subtraction angiography shows that distal segments vertebral artery is occluded. \u003cstrong\u003eB\u003c/strong\u003e. Digital subtraction angiography displayed Syphonet stent and the occluded segment of vertebral artery. \u003cstrong\u003eC\u003c/strong\u003e. a suitble-diameter balloon was performed to dilate the suspected primary lesion and subsequent thrombosis from the distal to proximal with the distal protection of stent retriever. \u003cstrong\u003eD\u003c/strong\u003e. After intermediate catheter passed through lesion site, The stent retriever was withdrawn under continuous negative pressure. \u003cstrong\u003eE\u003c/strong\u003e. Postprocedure Angiography reveald that the residual stenosis rate was 20%. \u003cstrong\u003eF\u003c/strong\u003e. At 9 months the in-stent restenosis was 50%.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5716220/v1/c57b07adf09572f908bb42d7.png"},{"id":81050870,"identity":"70ec2eb4-4fca-4888-bfef-fc34544b5c02","added_by":"auto","created_at":"2025-04-21 16:06:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4771921,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5716220/v1/26fe1f16-9654-4572-b0a2-3a2da6448638.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Distal protection of endovascular recanalization for symptomatic non-acute occlusion of vertebrobasilar artery","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe intracranial vertebral artery (VA) and the basilar arter (BA) are the common sites of atherosclerotic occlusion[3, 4, 8, 13], and a subset of patients may still suffer from repeated TIAs and strokes in the non-acute or chronic stage even under aggressive medication[7, 15]. One fifth of strokes occur in the territory of the posterior circulation but neurointervention procedures for secondary prevention, have received much less attention than similar interventions for the anterior circulation[11]. With the improvement of the concept of ischemic prevention and treatment and the progress of endovascular instruments, endovascular recanalization and stenting of non-acute occlusion of intracranial arteries has been increasingly performed. The possible periprocedural complications of endovascular recanalization for non-acute occlusion of the intracranial VBA mainly include ischemic complications such as perforator stroke, vascular dissection, acute thrombosis, distal embolism, and hemorrhagic complications[16, 18\u0026ndash;20]. Therefore, endovascular recanalization for patients with non-acute intracranial VBA occlusion remains clinically challenging[5, 14]. There some advantages of The Balloon Angioplasty with the distal protection of Stent Retriever technique, referred to as the distal protection of stent retriever technique was described in acute intracranial artery atherosclerosis-related occlusion, which may be associated with decreasing procedure-related complications and time savings[17]. We aimed to assess the safety and efficacy of the distal protection of endovascular recanalization for symptomatic non-acute occlusion of the intracranial VBA.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and ethics\u003c/h2\u003e \u003cp\u003e This retrospective study was approved by the Ethics Committee of Chenzhou No 1 People's Hospital(2024017) and performed in accordance with the Decla ration of Helsinki.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy population\u003c/h3\u003e\n\u003cp\u003e\u0026ldquo;Non-acute occlusion\u0026rdquo; was defined as symptomatic (TIA or stroke) complete occlusion of intracranial VBA of presumed atherosclerotic etiology in which endovascular therapy was performed more than 48h from the time the patients was last seen well[1]. Data from 8 consecutive patients who presented with aggressive ischemic events in the non-acute stage of VBA occlusion and treated with the distal protection of endovascular recanalization at our institution from April 2023 to April 2024 were retrospectively reviewed. The study was approved by the Institutional Review Board of the hospital\u0026rsquo;s ethics committee and received informed consent from all patients. 87.5% of the subjects were male, with a mean age of 56 years (range 47\u0026ndash;67 years). The inclusion criteria were as follows: (1) intracranial atherosclerosis was the primary etiology; (2) experienced recurrent TIAs or stroke related to occluded VBA despite aggressive medical treatment, which was defined as the treatment including antiplatelet therapy, statin, blood pressure and glucose control, smoking cessation; (3) patients were normally recanalized with dominant VA occlusion together with contralateral occlusion, hypoplasia, or severe stenosis (\u0026gt;\u0026thinsp;70%) or BA occlusion; and (4) hemodynamic failure were confirmed based on the clinical and imaging evidence. The exclusion criteria were as follows: (1) non-atherosclerotic occlusion, such as vasculitis, arterial dissection, or embolic disease; (2) clinical symptoms were stable with aggressive medical treatment; (3) contraindications to operation, such as known allergy or contraindication to aspirin, clopidogrel, or anesthesia; (4) the distal protection of stent retriever technique was adopted. (5) life expectancy\u0026thinsp;\u0026lt;\u0026thinsp;1 year because of other medical conditions.\u003c/p\u003e\n\u003ch3\u003eEndovascular procedures\u003c/h3\u003e\n\u003cp\u003eCombination therapy with oral aspirin (100 mg) and clopidogrel (75 mg) was initiated at least 3 days before endovascular procedures. The procedures were performed under general anesthesia. The right femoral artery was inserted by an 8F sheath, using a Seldinger technique. Unfractionated heparin at 50IU/kg was injected intravenously for systemic heparinization. With coaxial technology, thrombectomy catheter was placed in the area of total occlusion, a 0.014 inch microguide wire was carefully passed through the occlusion under the guidance of a micro-guide wire. Angiography was used to confirm that the distal vessel was occluded (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA). A Syphonet (Achieva, China) stent was selected as the distal protection device, and the proximal 1/3 of the stent was located at the lesion. After the distal end of the thrombectomy stent was anchored, the microcatheter could be removed directly (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). During the operation, angiography was performed under sufficient pressure to accurately identify the internal components of the occluded segment. If the occluded segment could not be accurately assessed after the microcatheter was withdrawn, a suitble-diameter balloon would be used to dilate the suspected primary lesion and subsequent thrombosis from the distal to proximal under the guidance of the Syphonet stent with guide wire. Then again angiography was performed through the aspiration catheter to further identify the internal components of the occluded segment. When a thrombus escapes during the procedure, the aspiration catheter would be advanced and aspirated under continuous negative pressure to remove the thrombus across the proximal occlusion. The distal protection device of the stent retriever will be withdrawn to remove the thrombus in the stent capture basket. The stent was then repositioned at the lesion site, a suitable balloon was dilated from the distal to the proximal site (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC). Finally, the stent was withdrawn after angiography confirmed the absence of thrombus and stable antegrade blood flow (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eD). After recanalization, antegrade blood flow was assessed according to the modified thrombolysis in cerebral infarction (mTICI) grading, and mTICI\u0026thinsp;\u0026ge;\u0026thinsp;2b indicated successful recanalization (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eE). Digital subtraction angiography was performed 6months after recanalization (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eF), and restenosis was described as \u0026ge;\u0026thinsp;50% stenosis after stent implantation and \u0026ge;\u0026thinsp;20% absolute luminal loss at follow-up[10].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eLow molecular weight tirofiban 6-8mL/h (based on the patient\u0026rsquo;s body weight) was given 12 or 24 hours only if intracranial hemorrhage was excluded after operation. Postoperative systolic/diastolic pressures were controlled less than 110/70mmHg. All patients were advised to take aspirin (100 mg/day) and clopidogrel (75 mg/day) for 6 months with or without subsequent cessation of clopidogrel.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eThe data of patient included demographics and cardiovascular risk factors, including age, sex, hypertension, diabetes mellitus, hyperlipidemia, previous history of stroke, coronary artery disease and smoking. The median time between symptom onset and occlusion comfirmed were recorded. The mRS scores and NIHSS scores were assessed. Technical procedure complications, clinical follow-up and follow-up angiography were evaluated. Favorable functional outcome was defined as an mRS score 0\u0026ndash;2.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe statistical methods used were descriptive. Quantitative data were expressed as means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or as medians with interquartile range, whereas categorical data were presented as numbers and percentages.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e8 patients (56years; range, 47\u0026ndash;67years) with male predominance who were treated with the distal protection of endovascular recanalization were enrolled. The baseline demographic and clinical characteristics are listed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. 8 patients had acute stroke. Occlusion was in the intracranial VA in 7(87.5%) patients and BA in one patients (12.5%). All patients had evidence of previous infarction in the VBA distribution on MR imaging. Hypertension was present in 7 patients, 6 patients had diabetes mellitus, one patient had cardiovascular disease, and 3 patients had smoking history and hyperlipidemia. The duration from symptom onset to treatment was 10\u0026ndash;43 days (median 21) and 8\u0026ndash;26 days (median 13) from occlusion confirmed to treatment. The overall technical success rate was 100%. Postoperative complications took place in 2(25%) patients. 2 patients experienced thrombus translocation, which were removed successfully after thrombectomy. One patient recovered well without neurologic impairment and one experienced asymptomatic ICH. Although the patient didn\u0026rsquo;t suffer a asymptomatic deterioration after asymptomatic ICH, he died of pneumonia and respiratory failure 2 months after discharge. The patients were followed up for a mean of 9 months (range: 6\u0026ndash;12). Excluding the patient who died (case 6), the rate of mRS (range: 0\u0026ndash;2) scores were 75% at the 90-day follow-up, which was 62.5% higher than before endovascular treatment. Angiographic follow-up was available for 7 patients, in-stent stenosis was 25.7% (10\u0026ndash;60%).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePrevious studies showed the recanalization of non-acute occlusion of the VBA was a high-risk procedure[6]. The recanalization and stenting for non-acute occlusion of the VBA has generally been used in clinical practice but the rates of perioperative complications were also high[9], such as cerebral hemorrhage, dissection, acute reocclusion and thrombus disruption and translocation. During the recanalization, the major technical challenge is traversing the occlusion site with a guidewire. Since there were fewer side and perforating branches in the intracranial VA, it was easier to result in blood flow retardation proximal to the occlusion and subsequent thrombus formation, leading to longer segments of occlusion in the VA[21], which make it more difficult to cross. It was reported that the application of the distal protection in treating acute intracranial artery atherosclerosis-related occlusion may increase the rates of successful reperfusion and decrease procedure-related complications[17]. In this study, all patients were treated with the distal protection of endovascular recanalization. It is more likely to go through the occlusion site after balloon angioplasty at the stenotic site, which may explain high technique success in our case series. Meanwhile, a thrombus may be dislodged distally when crossing the occluded segment during recanalization. Embolization is a well-known and serious complication of endovascular therapies, and distal protection devices have been developed and are currently being used widely in carotid artery stenting (CAS) procedures to limit cerebral embolism[2]. Moreover, the management of high-burden thrombus in intracranial VA is more tricky. Once the clot migration in VA occlusion occured during the procedures, the consequence was lethal. Compared with in the internal carotid artery, there was no report of the distal protection for endovascular recanalization of symptomatic non-acute occlusion of VBA. As the application of distal protection, the rates of perioperative complications decreased. Though two patients experienced thrombus translocation and the thrombus were removed Successfully. This is the first case series to evaluate the significance of the distal protection for endovascular recanalization involving VBA occlusion. Because of reducing the frequency of instrument exchanges, thereby it can minimize the risk of complications caused by instrument exchanges. By using the retrieval basket of the Syphonet thrombectomy stent as protection, the distal protection of stent retriever technique can reduce the risk of thrombus disruption and translocation caused by balloon dilatation.\u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eExcept sample size is too small, there was other limit in our findings. Considering that the occlusion time of VBA in these patients was relatively short and the thrombus had not yet fully organized, it was hypothesized that the microguidewire might pass through more easily[12]. Therefore, we did not perform high-resolution MRI for this group of patients.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur case series suggests that the distal protection of stent retriever for endovascular recanalization for symptomatic non-acute occlusion of VBA is technically safe and may decrease procedure-related complications.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e Study concept and design: Yi Zhang, Qiuli Li. Data collection and analysis: Qiu Li, Xiaoxi yao, Yuanbiao Lei, Haipeng Li, Liu Tu. Data interpretation:Yi Zhang, Qiuli Li, Xiaoxi yao, Yuanbiao Lei, Haipeng Li, Liu Tu. Reviewing and editing: Qiu Li, Xiaoxi yao, Yuanbiao Lei, Haipeng Li, Liu Tu. Supervision: Yi Zhang. All authors approved the final version of the submitted manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the Department of science and Technology of Hunan Province (Grant No. 2023JJ50372).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare all original data is available for review representing partial patient files as the case may apply.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclarations\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective study was approved by the Ethics Committee of Chenzhou No 1 People\u0026apos;s Hospital (approval ethics number: 2024017) and performed in accordance with the Decla ration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor this retrospective study, Written informed consent for participation was not required.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable because all personal information was anonymized and no images were presented that could identify the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAghaebrahim A, Jovin T, Jadhav AP, Noorian A, Gupta R, Nogueira RG (2014) Endovascular recanalization of complete subacute to chronic atherosclerotic occlusions of intracranial arteries. J Neurointerv Surg 6: 645\u0026ndash;648 Doi 10.1136/neurintsurg-2013-010842\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaik SK, Jeon U, Choo KS, Kim YW, Pil-Park K (2011) What is the real risk of dislodging thrombi during endovascular revascularization of a proximal internal carotid artery occlusion? Neurosurgery 68: 1084\u0026ndash;1090; discussion 1091 Doi 10.1227/NEU.0b013e31820a19fc\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCaplan LR (2012) The intracranial vertebral artery: a neglected species. The Johann Jacob Wepfer Award 2012. Cerebrovascular diseases (Basel, Switzerland) 34: 20\u0026ndash;30 Doi 10.1159/000339629\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDuan H, Chen L, Shen S, Zhang Y, Li C, Yi Z, Wang Y, Zhang J, Li L (2021) Staged Endovascular Treatment for Symptomatic Occlusion Originating From the Intracranial Vertebral Arteries in the Early Non-acute Stage. Front Neurol 12: 673367 Doi 10.3389/fneur.2021.673367\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGao F, Sun X, Zhang H, Ma N, Mo D, Miao Z (2020) Endovascular Recanalization for Nonacute Intracranial Vertebral Artery Occlusion According to a New Classification. Stroke 51: 3340\u0026ndash;3343 Doi 10.1161/strokeaha.120.030440\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGao P, Wang Y, Ma Y, Yang Q, Song H, Chen Y, Jiao L, Qureshi AI (2018) Endovascular recanalization for chronic symptomatic intracranial vertebral artery total occlusion: Experience of a single center and review of literature. J Neuroradiol 45: 295\u0026ndash;304 Doi 10.1016/j.neurad.2017.12.023\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGorelick PB, Wong KS, Bae HJ, Pandey DK (2008) Large artery intracranial occlusive disease: a large worldwide burden but a relatively neglected frontier. Stroke 39: 2396\u0026ndash;2399 Doi 10.1161/strokeaha.107.505776\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHe X, Zhang L, Yang J, Zheng H, Li K, Liu Y (2017) Multimodal Therapy for Non-Superacute Vertebral Basilar Artery Occlusion. Interv Neurol 6: 254\u0026ndash;262 Doi 10.1159/000477626\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHe Y, Bai W, Li T, Xue J, Wang Z, Zhu L, Hui F (2014) Perioperative complications of recanalization and stenting for symptomatic nonacute vertebrobasilar artery occlusion. Ann Vasc Surg 28: 386\u0026ndash;393 Doi 10.1016/j.avsg.2013.03.014\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevy EI, Turk AS, Albuquerque FC, Niemann DB, Aagaard-Kienitz B, Pride L, Purdy P, Welch B, Woo H, Rasmussen PAet al (2007) Wingspan in-stent restenosis and thrombosis: incidence, clinical presentation, and management. Neurosurgery 61: 644\u0026ndash;650; discussion 650\u0026thinsp;\u0026minus;\u0026thinsp;641 Doi 10.1227/01.NEU.0000290914.24976.83\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarkus HS, Michel P (2022) Treatment of posterior circulation stroke: Acute management and secondary prevention. Int J Stroke 17: 723\u0026ndash;732 Doi 10.1177/17474930221107500\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQuan T, Hou H, Xue W, Yu G, Ma H, Sun J, Guan S, Xu Y, Xu H (2019) Endovascular treatment of acute intracranial vertebrobasilar artery occlusion: a multicenter retrospective observational study. Neuroradiology 61: 1477\u0026ndash;1484 Doi 10.1007/s00234-019-02282-1\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTao C, Li R, Zhu Y, Qun S, Xu P, Wang L, Zhang C, Liu T, Song J, Sun Wet al (2022) Endovascular treatment for acute basilar artery occlusion: A multicenter randomized controlled trial (ATTENTION). Int J Stroke 17: 815\u0026ndash;819 Doi 10.1177/17474930221077164\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang H, Liu C, Xu H, Zhang Y, Gao P, Geng S, Kong W, Zhi Y, Yuan K, Tian L (2022) The Association between Serum Anion Gap and All-Cause Mortality in Cerebral Infarction Patients after Treatment with rtPA: A Retrospective Analysis. Dis Markers 2022: 1931818 Doi 10.1155/2022/1931818\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang Y, Zhao X, Liu L, Soo YO, Pu Y, Pan Y, Wang Y, Zou X, Leung TW, Cai Yet al (2014) Prevalence and outcomes of symptomatic intracranial large artery stenoses and occlusions in China: the Chinese Intracranial Atherosclerosis (CICAS) Study. Stroke 45: 663\u0026ndash;669 Doi 10.1161/strokeaha.113.003508\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYao YD, Liu AF, Qiu HC, Zhou J, Li C, Wang Q, Lv J, Jiang WJ (2019) Outcomes of late endovascular recanalization for symptomatic non-acute atherosclerotic intracranial large artery occlusion. Clin Neurol Neurosurg 187: 105567 Doi 10.1016/j.clineuro.2019.105567\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYi T-y, Wu Y-m, Lin D-l, Pan Z-n, Zheng X-f, Gan J, Wu M-h, Lin X-h, Chen R-c, Zeng L-set al (2022) Application of Balloon AngioplaSty with the dIstal protection of Stent Retriever (BASIS) technique for acute intracranial artery atherosclerosis-related occlusion. Frontiers in Neurology 13: Doi 10.3389/fneur.2022.1049543\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang X, Xie Y, Wang H, Yang D, Jiang T, Yuan K, Gong P, Xu P, Li Y, Chen Jet al (2020) Symptomatic Intracranial Hemorrhage After Mechanical Thrombectomy in Chinese Ischemic Stroke Patients: The ASIAN Score. Stroke 51: 2690\u0026ndash;2696 Doi 10.1161/STROKEAHA.120.030173\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhao W, Zhang J, Meng Y, Zhang Y, Zhang J, Song Y, Sun L, Zheng M, Wang W, Yin Het al (2020) Symptomatic Atherosclerotic Non-acute Intracranial Vertebral Artery Total Occlusion: Clinical Features, Imaging Characteristics, Endovascular Recanalization, and Follow-up Outcomes. Frontiers in Neurology 11: Doi 10.3389/fneur.2020.598795\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhao W, Zhang J, Song Y, Sun L, Zheng M, Yin H, Zhang J, Wang W, Han J (2019) Endovascular Recanalization for Symptomatic Subacute to Chronic Atherosclerotic Basilar Artery Occlusion. Front Neurol 10: 1290 Doi 10.3389/fneur.2019.01290\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhou Z, Li T, Zhu L, Wu L, Guan M, Ma Z, Liu Y, Qin J, Gao B (2023) Endovascular recanalization of symptomatic non-acute occlusion of the vertebrobasilar artery. Front Neurol 14: 1125244 Doi 10.3389/fneur.2023.1125244\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"639\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTABLE 1 Patients\u0026apos; baseline demographic and clinical characteristics.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 75.5869%;\"\u003e\n \u003cp\u003eSex,male\u003c/p\u003e\n \u003cp\u003eAge,years,median\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMedical History,n(%)\u003c/p\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003cp\u003eDiabetes mellitus\u003c/p\u003e\n \u003cp\u003eCardiovascular disease\u003c/p\u003e\n \u003cp\u003eSmoking\u003c/p\u003e\n \u003cp\u003eHyperlipidemia\u003c/p\u003e\n \u003cp\u003emRS score on admission, n(%)\u003c/p\u003e\n \u003cp\u003e0-2\u003c/p\u003e\n \u003cp\u003e3-5\u003c/p\u003e\n \u003cp\u003eNIHSS,on admission, median(range))\u003c/p\u003e\n \u003cp\u003eSymptom onset to treatment,days,median(range)\u003c/p\u003e\n \u003cp\u003eOcclusion confirmed to treatment,days,median(range)\u003c/p\u003e\n \u003cp\u003erecanalization artery,n(%)\u003c/p\u003e\n \u003cp\u003eVA intracranial\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBA\u003c/p\u003e\n \u003cp\u003etechnical success,n(%)\u003c/p\u003e\n \u003cp\u003eRSR,median(range)\u003c/p\u003e\n \u003cp\u003eComplication rate, n (%)\u003c/p\u003e\n \u003cp\u003eDissection\u003c/p\u003e\n \u003cp\u003ePerforation\u003c/p\u003e\n \u003cp\u003easICH\u003c/p\u003e\n \u003cp\u003eHyperperfusion syndrome\u003c/p\u003e\n \u003cp\u003eThrombus translocation\u003c/p\u003e\n \u003cp\u003eFollow-up time,months,median(range)\u003c/p\u003e\n \u003cp\u003e30-DAY stroke or death, n (%)\u003c/p\u003e\n \u003cp\u003e90-day mRS score,median(range)\u003c/p\u003e\n \u003cp\u003e0-2\u003c/p\u003e\n \u003cp\u003e3-5\u003c/p\u003e\n \u003cp\u003eISR on follow-up image,median(range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.4131%;\"\u003e\n \u003cp\u003e7(87.5%)\u003c/p\u003e\n \u003cp\u003e56(47-67)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7(87.5%)\u003c/p\u003e\n \u003cp\u003e6(75%)\u003c/p\u003e\n \u003cp\u003e1(12.5%)\u003c/p\u003e\n \u003cp\u003e3(37.5%)\u003c/p\u003e\n \u003cp\u003e3(37.5%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5(62.5%)\u003c/p\u003e\n \u003cp\u003e3(37.5%)\u003c/p\u003e\n \u003cp\u003e6(2-12)\u003c/p\u003e\n \u003cp\u003e21(10-43)\u003c/p\u003e\n \u003cp\u003e13(8-26)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7(87.5%)\u003c/p\u003e\n \u003cp\u003e1(12.5%)\u003c/p\u003e\n \u003cp\u003e8(100%)\u003c/p\u003e\n \u003cp\u003e21%(10-40%)\u003c/p\u003e\n \u003cp\u003e2（25%）\u003c/p\u003e\n \u003cp\u003e0（0%）\u003c/p\u003e\n \u003cp\u003e0（0%）\u003c/p\u003e\n \u003cp\u003e1（12.5%）\u003c/p\u003e\n \u003cp\u003e0（0%）\u003c/p\u003e\n \u003cp\u003e2（25%）\u003c/p\u003e\n \u003cp\u003e9(6-12)\u003c/p\u003e\n \u003cp\u003e1（12.5%）\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6(75%)\u003c/p\u003e\n \u003cp\u003e1(12.5%)\u003c/p\u003e\n \u003cp\u003e25.7%(10-60%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNIHSS, National Institutes of Health Stroke Scale; mRS, modified Rankin Scale; asICH, asymptomatic intracranial hemorrhage; BA, basilar artery; VA, vertebral artery; ISR, in-stent restenosis rate.\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"acta-neurochirurgica","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"anch","sideBox":"Learn more about [Acta Neurochirurgica](http://link.springer.com/journal/701)","snPcode":"701","submissionUrl":"https://submission.springernature.com/new-submission/701/3","title":"Acta Neurochirurgica","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"distal protection, endovascular recanalization, safety and efficacy, vertebrobasilar artery","lastPublishedDoi":"10.21203/rs.3.rs-5716220/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5716220/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eThe research aimed to investigate the safety and efficacy of distal protection of endovascular recanalization for symptomatic non-acute occlusion of the intracranial vertebrobasilar artery.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e8 consecutive patients with symptomatic non-acute VBA from January April 2023 to April 2024 who underwent endovascular recanalization were retrospectively analyzed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e8 patients (median age 56 years; mean pretreatment National Institutes of Health Stroke Scale (NIHSS) score 6; 87.5% male) presenting with recurrent transient ischemic attacks(TIAs) (n\u0026thinsp;=\u0026thinsp;1) or strokes (n\u0026thinsp;=\u0026thinsp;23) were treated from January April 2023 to April 2024. Median time from symptoms onet to treatment was 21 days(range: 10\u0026ndash;43). Median time from occlusion confirmed to treatment was 13 days(range:8\u0026ndash;26). Among the 8 patients, 8 (100%) achieved successful recanalization. The rate of periprocedural complications was 25%(2/8). Periprocedural complications included one asymptomatic intracranial hemorrhage(asICH) and thrombus translocation. The median follow-up time was 9 months (range: 6\u0026ndash;12), with no stroke or TIA. At 90 days, there were one death (unrelated to the procedure) and 75% patients with an available modified Rankin Scale (mRS) score achieved a good outcome (mRS score of 0\u0026ndash;2).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe distal protection of stent retriever for endovascular recanalization for symptomatic non-acute occlusion of VBA is technically safe and may decrease procedure-related complications.\u003c/p\u003e","manuscriptTitle":"Distal protection of endovascular recanalization for symptomatic non-acute occlusion of vertebrobasilar artery","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-15 12:07:15","doi":"10.21203/rs.3.rs-5716220/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-02-06T08:50:08+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-06T08:26:48+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-04T05:35:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"214354720031104851333142881577602515411","date":"2025-01-25T02:55:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"154095640087203340110963545045588580816","date":"2025-01-24T14:03:00+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-01-14T11:25:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-01-13T12:34:29+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-01-13T12:32:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"Acta Neurochirurgica","date":"2024-12-26T12:38:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"acta-neurochirurgica","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"anch","sideBox":"Learn more about [Acta Neurochirurgica](http://link.springer.com/journal/701)","snPcode":"701","submissionUrl":"https://submission.springernature.com/new-submission/701/3","title":"Acta Neurochirurgica","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"fa655214-cc70-4f5d-bc51-b321e534c43c","owner":[],"postedDate":"January 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-04-21T16:01:20+00:00","versionOfRecord":{"articleIdentity":"rs-5716220","link":"https://doi.org/10.1007/s00701-025-06525-4","journal":{"identity":"acta-neurochirurgica","isVorOnly":false,"title":"Acta Neurochirurgica"},"publishedOn":"2025-04-15 15:57:42","publishedOnDateReadable":"April 15th, 2025"},"versionCreatedAt":"2025-01-15 12:07:15","video":"","vorDoi":"10.1007/s00701-025-06525-4","vorDoiUrl":"https://doi.org/10.1007/s00701-025-06525-4","workflowStages":[]},"version":"v1","identity":"rs-5716220","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5716220","identity":"rs-5716220","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}