Exchange-free single-pass gateway balloon-assisted neuroform atlas stenting for symptomatic high-grade intracranial atherosclerotic stenosis: clinical and angiographic outcomes.

BACKGROUND

Symptomatic high-grade intracranial atherosclerotic stenosis (sICAS) is associated with a high risk of early recurrent ischemic events despite optimized medical therapy. Conventional angioplasty-to-stent workflows typically require intracranial exchange maneuvers, which may increase procedural complexity and vessel manipulation in perforator-rich territories of the brain. We evaluated the safety and early angiographic outcomes of a standardized, exchange-free, single-pass Gateway balloon-assisted Neuroform Atlas stenting strategy.

METHODS

We retrospectively analyzed consecutive adults with 70-99% sICAS treated at a single center (between January 2018 and January 2025). Following controlled submaximal angioplasty using a Gateway PTA balloon, a Neuroform Atlas stent was deployed directly through the balloon catheter lumen (without microcatheter exchange). Lesion morphology was retrospectively classified according to the Mori system. The primary endpoint was technical success rate. The secondary endpoints were 30-day stroke/intracranial hemorrhage/death and in-stent restenosis (ISR) > 50% on 3-month digital subtraction angiography (DSA).

RESULTS

Fifty-seven patients (median age, 70 years; 68.4% men) were treated after neurological stabilization (median event-to-stent interval, 9 days; range, 7-15 days); 63.2% had posterior circulation targets. By Mori classification, 2 lesions (3.5%) were Type A, 18 (31.6%) Type B, and 37 (64.9%) Type C. The technical success rate was 100%. No flow-limiting dissections, perforations, distal embolizations, acute in-stent thromboses, symptomatic vasospasms, 30-day strokes, or intracranial hemorrhages occurred. The 30-day mortality rate was 1.8% (due to sepsis). Median stenosis improved from 87% pre-procedure to 21.5% post-procedure and was 30% at 3-month DSA (p < 0.001). ISR > 50% at 3 months occurred in 7.1% (4/56); cumulative ISR/occlusion during imaging follow-up was 10.5% (6/57), with reintervention in 1.8% of the patients. All early ISR events occurred in the basilar artery lesions. ISR/occlusion rates showed a gradient by Mori type (Type A 0%, Type B 5.6%, Type C 13.5%).

CONCLUSION

Exchange-free Gateway-Atlas stenting appears technically feasible and was associated with a low observed 30-day neurological complication rate and meaningful luminal gain in a selected cohort of patients with medically refractory sICAS, including a large proportion of morphologically complex (Mori Type C) lesions. The observed basilar artery-predominant restenosis pattern is exploratory and hypothesis-generating, and may justify closer posterior circulation surveillance in future prospective studies.