Primary versus elective percutaneous transluminal angioplasty with stenting for symptomatic intracranial atherosclerotic stenosis: a 18-centre retrospective cohort study using the pEGASUS-HPC stent
Ali Khanafer, Ahmed Ayad, Mohammad Almohammad, Pablo Albiña-Palmarola, Ivan Lylyk, Florian Eff, Islambek Mussabekov, Alexander Sirakov, Marie-Sophie Schüngel, Tolga Tonguc, Donald Lobsien, Johannes Rückel, Aikaterini Anastasiou, Muhammad AlMatter, Zakarya Ali, Mete Dadak, Kamran Hajiyev, Mehdi Allouche, Philipp von Gottberg, Sebastian Johannes Müller, Jonas Schüssler, Shinya Hagiwara, Abdallah Aburub, Marat Sarshayev, Hansjörg Bäzner, Marios Psychogios, Thomas Liebig, José E Cohen, Stephan Felber, Joachim Klisch, Franziska Dorn, Stanimir Sirakov, Markus Holtmannspötter, Stefan Schob, Mynzhylky Berdikhojayev, André Kemmling, Michael Forsting, Pedro Lylyk, Rene Chapot, Hans HenkesAbstract
Introduction
To describe the safety and effectiveness of percutaneous transluminal angioplasty with pEGASUS-HPC stenting (PTAS) for symptomatic intracranial atherosclerotic stenosis (sICAS) and compare primary versus elective use.
Patients and methods
We retrospectively included consecutive adults with sICAS ≥50% treated with pEGASUS-HPC PTAS at 18 neurovascular centres (May 2021–February 2025). Primary PTAS was defined as treatment during non-large-vessel-occlusion acute ischaemic stroke (AIS); Elective PTAS was performed at least 7 days after the qualifying ischaemic presentation for recurrent symptoms or haemodynamic compromise despite intensive medical therapy. Outcomes included technical success (post-treatment stenosis ≤50% without intraprocedural complications), in-hospital major complications (intracerebral haemorrhage, AIS or death), restenosis and functional status, measured by the modified Rankin Scale (mRS) at last follow-up.
Results
Among 141 patients (Primary 71; Elective 70), median post-treatment stenosis was 23.0%; technical success was 94.3% (90.1% vs 98.6%; P = .063). In-hospital major complications occurred in 7.1% (12.7% Primary vs 1.4% Elective; P = .017), driven by intraprocedural in-stent thrombosis (9.9% vs 0%; P = .013). At last follow-up (median 9 months), restenosis ≥50% was observed in 14.3% (7.8% vs 19.7%; P = .10) and mRS <3 in 84.7% (82.1% vs 87.1%; P = .61). New diffusion-weighted imaging lesions were seen in 39.2% of 79 patients with early MRI, without group differences.
Discussion
In this multicentre cohort, pEGASUS-HPC PTAS provided substantial luminal gain, moderate restenosis and good mid-term functional outcomes overall. Elective use in medically refractory sICAS was associated with very low major complication rates, whereas primary use during AIS carried significantly higher thrombotic and haemorrhagic risk.