Long-term outcomes of resolute Onyx Zotarolimus-eluting stents for symptomatic intracranial stenosis: A multicenter propensity score-matched comparison with stenting versus aggressive medical management for preventing recurrent stroke in intracranial stenosis trial

Background: Intracranial atherosclerotic disease (ICAD) is a leading cause of ischemic stroke. The Medtronic Resolute Onyx Zotarolimus-eluting stents (RO-ZES) are promising in preventing stroke recurrence compared with medical management (MM) and percutaneous angioplasty and stenting (PTAS) at both 30-day and one-year follow-ups. We evaluated long-term outcomes for patients treated with RO-ZES, PTAS, or MM. Methods: A retrospective multicenter study was conducted including patients who underwent RO-ZES stenting for symptomatic ICAD between March 2018 and May 2023, with follow-up through October 2024. Propensity score-matched control groups, representing MM and PTAS, were derived from the SAMMPRIS trial. Primary outcomes included recurrence rates of transient ischemic attack, stroke, intracerebral hemorrhage (ICH), and mortality. Time-to-event after intervention was evaluated. Results: Patients who underwent stenting with RO-ZES and two propensity-matched cohorts from the SAMMPRIS trial who underwent MM and PTAS were included. Mean follow-up was 27.9 ± 17.0 months. The RO-ZES group demonstrated significantly fewer recurrent strokes (11.3%) compared with MM (27.0%) and PTAS (27.8%) (p =.003). The MM group experienced the lowest recurrence rate of ICH (0.9%) (p =.018). Multivariable regression revealed that RO-ZES experienced lower odds of recurrent strokes (OR =.40, 95% CI [0.17–0.92], p =.031) than PTAS throughout follow-up. Multivariable Cox regression demonstrated that RO-ZES stenting lowered the hazard of recurrent strokes compared with PTAS (hazard ratio =.36, 95% CI [0.16–0.80], p =.012). Conclusion: Treatment of severe, symptomatic ICAD using RO-ZES was associated with lower odds of recurrent strokes compared with PTAS in this long-term follow-up study. Further prospective trials comparing MM with novel stent technologies are necessary.