ABSTRACT NUMBER: ESOC2026A1912 NOVEL “SUBMAXIMAL” STENTING STRATEGY FOR RESCUE THERAPY IN ICAD-RELATED LVO STROKE

Abstract Background and aims Intracranial atherosclerotic disease (ICAD) is a leading cause of acute ischemic stroke. When endovascular thrombectomy (EVT) fails due to underlying ICAD-related large vessel occlusion (LVO), rescue stenting becomes necessary. We introduce "submaximal" stenting—deliberate balloon-mounted stent deployment at sub-nominal pressures (6-7 atmospheres)—to minimize vessel wall trauma during emergency revascularization. This study evaluates the feasibility and safety of this novel technique. Methods This single-center retrospective cohort study evaluated patients undergoing acute rescue stenting with Resolute OnyxTM and Onyx FrontierTM drug-eluting stents from January 2020 to July 2025. Primary outcomes were technical success (patency without adjacent vessel occlusion) and procedural safety (absence of intraprocedural vessel rupture). Secondary outcomes included in-stent thrombosis, symptomatic intracranial hemorrhage (sICH), and functional status (mRS and NIHSS) at discharge and follow-up. Results Among 37 patients (median age 59.0 years; 67.6% male; 78.4% Black), all had severe (70-99%) stenosis. Most treated vessels were M1 MCA (37.8%), basilar artery (27.0%), and intracranial ICA (16.2%). Technical success was achieved in all cases (100%) with immediate post-procedural vessel patency. No intraoperative vessel rupture or bleeding occurred. sICH occurred in 8.1% and in-stent thrombosis in 16.2%. Median discharge NIHSS was 11.0 and mRS 4.0. Conclusions "Submaximal" stenting—deliberate under-expansion at sub-nominal pressures—with Resolute OnyxTM and Onyx FrontierTM drug-eluting stents appears technically feasible and safe as an acute rescue strategy for ICAD-LVO stroke refractory to EVT. This novel approach warrants further investigation in larger, prospective, multicenter studies. Conflict of interest Archit Bharathwaj Baskaran: nothing to disclose Rami Z. Morsi: nothing to disclose Khalid Trad: nothing to disclose Taraf S. Jaro: nothing to disclose Shyam Patel: nothing to disclose Jorie Singer: nothing to disclose Julia Iourinets: nothing to disclose Ahmad Chahine: nothing to disclose Rushabh Shah: nothing to disclose Tareq Kass-Hout: nothing to disclose