Rescue intracranial stenting for acute large vessel occlusion using an Orsiro Mission drug-eluting balloon-mounted stent.

Intracranial atherosclerotic disease (ICAD) is one of the most common causes of acute ischemic stroke and accounts for 33-50% of strokes in Asian, Hispanic, and black populations.(1) In patients with ICAD undergoing thrombectomy for large vessel occlusion (LVO), some may demonstrate obstinate inability of recanalization, immediate re-occlusion of the target vessel, and/or underlying high-grade stenosis preventing adequate perfusion. Bailout endovascular strategies for suspected ICAD include angioplasty and/or acute intracranial stenting with self-expandable stents (SES). Balloon-mounted stents (BMS), such as the Orsiro Mission, are increasingly being used by neurointerventionalists rather than SES given the relative ease of deployment and avoidance of an exchange maneuver to re-cross the lesion after angioplasty. Furthermore, BMS have higher radial force compared to SES, lending to advantageous dilatation.(2) Finally, the use of BMS may be associated with lower rates of in-stent restenosis compared with SES.(2, 3) However, BMS deployment can be technically challenging given the length and stiffness of the systems, especially in patients with tortuous anatomy and/or with distal occlusions. We present two cases of LVO complicated by immediate re-occlusion necessitating acute Orsiro Mission stent placement, which has not been described in the neurointerventional literature. The cases demonstrate the brevity of deployment and the importance of intermediate catheter selection and positioning, which allows easier navigation of the stiff BMS systems.