Outcomes of tailored angioplasty and/or stenting for symptomatic intracranial atherosclerosis: a prospective cohort study after SAMMPRIS

Abstract

Background and purpose High periprocedural complication rate is a key limitation of endovascular treatment of intracranial atherosclerotic disease (ICAD), despite potential risk reduction of recurrent stroke. Taking lessons from the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Arterial Stenosis (SAMMPRIS) trial, targeting a selected patient population, we prospectively evaluated the feasibility and safety of tailored angioplasty and/or stenting for patients with ICAD. Methods From November 2011 to October 2012, 158 patients with symptomatic ICAD caused by hypoperfusion combined with poor collateral flow were consecutively recruited into a prospective single center study. Patients were divided into three groups based on arterial access and lesion morphology: balloon mounted stent group (group BS) for smooth access and Mori A lesion, angioplasty plus self-expanding stent group (group AS) for tortuous access and Mori B or C lesion, and angioplasty group (group AG) for tortuous access and Mori A lesion. The primary endpoints were successful procedure rate and any vascular event within 30 days. Results Overall technical success rate was 96.3% (154/158). There were significant differences in the technical success rate: 89.7% (35/39) in group AG compared with 97.5% (79/81) in group BS and 100% (38/38) in group AS (p=0.042). The 30 day composite stroke, myocardial infarction, or death rate was 4.4% (7/158). Stroke within 30 days occurred in four patients in group BS and in three patients in group AS. Conclusions Individualized treatment of ICAD using tailored devices according to arterial access and lesion morphology was feasible and safe in symptomatic patients caused by hypoperfusion with poor collateral flow.

Thirty-Day Outcome of a Multicenter Registry Study of Stenting for Symptomatic Intracranial Artery Stenosis in China

“…The tailored endovascular treatment strategy used in this trial may thus contribute to a low complication rate at 30 days when compared with the SAMMPRIS and VISSIT trials when the operators were forced to use a single device. 16,27 In this study, the demographic differences between the balloon-mounted stent and the self-expanding stent groups may be related to operator experience and expected time of the procedure. For elderly patients, or patients with intracranial vertebral artery stenosis, or patients with Mori A lesion, operators preferred balloon-mounted stent because of its features of rapid exchange and shorter procedure time.…”

“…In addition, after the SAMMPRIS, a 30-day composite stroke or death rate of 4.5% was reported in 156 patients enrolled in a prospective study using a tailored endovascular treatment in a high-volume center in China. 16 Nonetheless, the weight of these studies do not compare with that of randomized clinical trials. 17 A randomized clinical trial with careful selection of patients is thus warranted in the Chinese population such that these patients are not deprived of a potentially beneficial treatment.…”

Multicenter Prospective Trial of Stent Placement in Patients with Symptomatic High-Grade Intracranial Stenosis

“…Our results are comparable with the recent data (1-month stroke and/or death rate of 4.4%-6.2%) derived from some high-volume centers (Ͼ100 cases per year). [17][18][19] A retrospective analysis of 96 patients treated with intracranial angioplasty and stent placement at 3 university-affiliated institutions in the United States reported that the overall 1-month stroke and/or death rate was 7.2% in the 69 SAMMPRIS-eligible group and 7.4% in the 27 SAMMPRIS-ineligible group. 20 The 30-day stroke and/or death rate was 3.3% and 10.2% in the SAMMPRIS-eligible, angioplasty-treated subgroup and the stent-treated subgroup, respectively.…”

“…The longer time interval may have allowed plaque stabilization and spontaneous lysis of overlying thrombus and probably also reduced the risk of hemorrhagic transformation for patients with recent ischemic stroke (Ͻ3 weeks). 17,[21][22][23] An analysis of the National Institutes of Health Multicenter Wingspan Intracranial Stent Registry Study found that stent placement performed within 10 days of a qualifying ischemic event was associated with a higher rate of 30-day stroke and/or death compared with procedures performed after 10 days (8% versus 17%, P ϭ .06). 21,24 In the SAMMPRIS trial, the rates of ischemic stroke, symptomatic hemorrhagic stroke, or any death within 1 month were 15.7% and 13.8% in the patients enrolled within 7 days or after 7 days of their qualifying event, respectively.…”

Internal Carotid Artery Stenting for Intracranial Atherosclerosis

“…6,7,32,33 Device manufacturers and scientists will have to reevaluate stent design and develop new products with superior safety and efficacy profiles. Many have called for different materials to be used and suggested potential drug-eluting models that have thus far been used with varying success worldwide.…”