Submaximal angioplasty in the treatment of patients with symptomatic ICAD: a systematic review and meta-analysis

Abstract

IntroductionManagement approaches for intracranial atherosclerosis include medical, surgical, or endovascular treatment. Among endovascular treatments, recent studies have stated that submaximal angioplasty (SA) may offer considerable benefits and be a promising alternative to aggressive medical therapyand/or stenting in the treatment of intracranial atherosclerotic disease (ICAD).ObjectiveTo investigate the rates of periprocedural and long-term cerebrovascular accidents, mortality, and restenosis in patients with symptomatic ICAD who were treated with SA.MethodsAn electronic database search was performed for relevant studies that reported clinical outcomes of patients with ICAD following SA. Outcomes of interest were incidence of transient ischemic attack, intracerebral hemorrhage, stroke, and mortality in the periprocedural period and at 1 year. The periprocedural period was defined as the time from SA until 30 days after the procedure. Technical success and restenosis rates after the procedure were also analyzed.ResultsA total of 19 studies with 777 patients were identified. The technical success rate was 93% (95% CI 85% to 98%). The incidence of 30-day and 1-year stroke (all types) was 3% (95% CI 1% to 5%) and 5% (95% CI 4% to 8%), respectively. Thirty-day and 1-year mortality was found to be 1% (95% CI 0% to 2%) and 2% (95% CI 0% to 4%), respectively. The combined incidence of stroke or death was 5% (95% CI 3% to 8%) at 30 days, and 9% (95% CI 7% to 12%) at 1 year.ConclusionThe findings suggest that SA might be a promising alternative treatment in the treatment of symptomatic ICAD due to its favorable technical profile, periprocedural safety, and long-term efficacy. A randomized clinical trial is warranted to compare the safety and efficacy of SA with 'gold standard' medical treatment.

Rescue Endovascular Treatment for Emergent Large Vessel Occlusion With Underlying Intracranial Atherosclerosis: Current State and Future Directions

“…A meta-analysis by Seyedaadat et al evaluated 19 studies with 777 patients who underwent submaximal angioplasty for ICAS. The authors found 93% success rate with 3% stroke rate at 1 month ( 44 ), significantly lower rates than what were reported in SAMMPRIS ( 33 ) and VISSIT ( 5 ). In cases of re-occlusion, our practice has been to repeat MT and give a weight-based intra-arterial dose of tirofiban followed by stenting.…”

Proximal basilar artery hemorrhage after submaximal angioplasty for intracranial atherosclerotic disease presenting as a large vessel occlusion treated with pipeline embolization device

“…ICAD is a well-documented risk factor for ischemic stroke and is reported to be the underlying cause of ischemic stroke in 5-10% of cases. 12) Vertebrobasilar ICAD is believed to be associated with a higher morbidity…”

“…Intracranial atherosclerotic disease (ICAD) is becoming an increasingly well-recognized cause of ischemic stroke. 12) To date, treatment for symptomatic ICAD starts with maximal medical therapy (MMT) involving dual antiplatelet agents (aspirin and clopidogrel), statin therapy, and smoking cessation. Endovascular intervention for symptomatic ICAD refractory to MMT has been a topic of debate in recent years after the results of large randomized controlled trials showed higher periprocedural stroke and mortality rate for angioplasty and stenting.…”

“…5)13) Submaximal balloon angioplasty has arisen as a possible therapeutic intervention for symptomatic ICAD refractory to MMT. 12) Iatrogenic vessel perforation, either from an open surgical or www.the-jcen.org night prior. The following morning the patient was unarousable and demonstrated acute symptoms of vomiting and seizure-like activity prompting emergency medical services.…”

“…5)13) More recently, however, 19 studies incorporated into a meta-analysis with 777 patients documented stroke and death rate reduction at 30 days and 1-year associated with submaximal angioplasty (SA) for ICAD, providing support for SA in combination to aggressive medical therapy involving dual antiplatelet medications and statin therapy as a viable treatment option for symptomatic ICAD. 12) An advantage of SA is related to the decreased radial force applied to the diseased vessel wall reducing the risk of iatrogenic injury to that vessel. 7) There are case reports that document the utility of endovascular intervention for iatrogenic injuries to the intracranial vessels.…”