Abstract DP228: Impact of Balloon Sizing and Procedural Factors in Emergent Angioplasty for Intracranial Atherosclerotic Large Vessel Occlusion

Background: Percutaneous transluminal angioplasty (PTA) is an established rescue option for intracranial atherosclerotic disease–related large-vessel occlusion (ICAD-LVO); however, the procedural factors influencing angiographic results, safety, and clinical outcomes remain uncertain. Objective: To identify procedural factors associated with residual stenosis, hemorrhagic complications, and clinical outcomes after emergency PTA for ICAD-LVO. Methods: We retrospectively analyzed consecutive patients with acute ischemic stroke who underwent PTA for ICAD-LVO at our center between 2015 and 2025. Target lesions were intracranial internal carotid artery, middle cerebral artery, vertebral artery, or basilar artery. Patient and procedural characteristics were collected. The balloon-to-vessel (BV) ratio was calculated as balloon diameter divided by parent-vessel diameter. The primary outcome was residual stenosis <50% at the end of the procedure. The secondary outcome was a favorable outcome at 90 days (mRS 0–2 or unchanged from baseline). The safety outcome was intracranial hemorrhage, including subarachnoid hemorrhage and hemorrhagic infarction. Results: Fifty-two patients were included (median age 75 years; 44% women). For the primary outcome, 16 patients (30.8%) achieved residual stenosis <50%. Compared with ≥50%, residual stenosis <50% had smaller parent vessel diameters (median 2.08[95% CI, 1.56-2.53] vs 2.54 mm [2.22-2.91], p=0.01) and higher BV ratios (0.92[0.78-1.26] vs 0.73[0.61-0.91], p=0.01), while inflation pressure and number of inflations did not differ. For the secondary outcome, 26 patients (50.0%) achieved favorable outcomes at 90 days. The favorable outcome group showed a trend toward a higher BV ratio (0.88[0.74-1.13]vs 0.67[0.61-0.90], p=0.09), but no other procedural factors differd. As the safety outcome, intracranial hemorrhage occurred in 14 patients (26.9%). Patients with intracranial hemorrhage had a higher number of inflations compared with those without hemorrhage (3.5[2.25-4.00] vs 2.0[1.50-3.00], p=0.04), whereas the BV ratio and inflation pressure did not differ. Conclusion: In emergent PTA for ICAD-LVO, a higher BV ratio was associated with reduced residual stenosis without increasing hemorrhagic risk, while a greater number of inflations increased hemorrhagic complications. A larger balloon with fewer inflations may represent a more effective and safer strategy.