A Comparison of Stent Implant versus Medical Treatment for Severe Symptomatic Intracranial Stenosis: A Controlled Clinical Trial

Impact of post-procedure stenosis on outcomes of patients with severe intracranial stenosis treated with intracranial stent placement

BACKGROUND

The optimal target post-procedure stenosis after percutaneous angioplasty and stent placement (PTAS) for intracranial stenosis is unknown. We determined the effect of post-procedure stenosis after intracranial PTAS on subsequent clinical events in patients with severe symptomatic intracranial stenosis.

METHODS

We categorized the severity of post-procedure stenosis as '<30%', '30-49%', and '≥50%' among 207 patients who underwent PTAS in a multicenter randomized clinical trial. Outcomes included stroke or death within 72 hours and within 30 days, ipsilateral stroke beyond 30 days of treatment, and stroke or death within 30 days or stroke in the qualifying artery beyond 30 days (primary endpoint of the trial). Cox proportional hazards analysis was performed with adjustments for age, initial severity of stenosis, location of stenosis, and qualifying event. Kaplan-Meier curves were generated for the primary endpoint stratified by post-procedure stenosis with log-rank analysis.

RESULTS

The severity of post-procedure stenosis was categorized as <30%, 30-49%, and ≥50% in 112, 73, and 22 patients, respectively. Compared with patients with post-procedure stenosis <30%, there was no difference in the risk of primary endpoint among patients with post-procedure stenoses of 30-49% (hazards ratio (HR) 0.85, 95% confidence interval (95% CI) 0.64 to 1.15) or those with ≥50% (HR 0.91, 95% CI 0.57 to 1.43). Log-rank analysis did not demonstrate a difference in rates of primary endpoint between groups stratified by post-procedure stenosis (P=0.70).

CONCLUSION

In the absence of any benefit on short- and long-term outcomes, strategies to achieve a low severity of post-procedure stenosis among patients with severe intracranial stenosis may not be warranted.

Comparative effect of stenting plus medical therapy vs medical therapy alone on the risk of stroke and death in patients with symptomatic intracranial stenosis: a systematic review and meta-analysis

BACKGROUND

Recently, several randomized controlled trials (RCTs) of stenting plus medical therapy versus medical therapy alone have been successfully conducted for the treatment of patients with symptomatic intracranial stenosis. This study aimed to evaluate differences between these two therapies in the risk of stroke and death.

METHODS

MEDLINE, EMBASE, the Cochrane Library, and ClinicalTrials.gov were systematically searched to identify relevant studies published before August 24, 2022. Review Manager 5.3 software was used to assess the data. The risk ratio (RR) was analysed and calculated with a random effect model or a fixed effects model.

RESULTS

We pooled 921 participants from three RCTs. Compared to the medical therapy alone group, the stenting plus medical therapy group had a higher risk of 30-day death or stroke (RR = 2.69 [1.64-4.41], P < 0.0001, I² = 0%). When the follow-up period exceeded 1 year (≥ 1 year), there was no significant difference in the risk of stroke or death between these two groups. The subgroup analysis showed that if the time from stroke onset to implantation was extended, additional stenting would have no effect on the risk of stroke or death, whether within 30 days or within 1 year (P = 0.16 and 0.78).

CONCLUSION

Medical therapy alone has a lower risk of stroke and death in the short term than stenting plus medical therapy, while no difference exists in the long term. More studies are still needed to further explore the precision strategy of stent implantation for symptomatic intracranial stenosis patients.

Medical and Endovascular Treatments for Intracranial Atherosclerotic Stenosis: A Network Meta-Analysis

Medical treatment and endovascular therapy are widely used for intracranial atherosclerotic stenosis, but the best treatment strategy remains uncertain. The goal of this study was to compare the safety and effectiveness of medical treatment, stenting, and primary balloon angioplasty (PBA). We searched PubMed, MEDLINE, and EMBASE for trials comparing these three treatments for intracranial stenosis up to December 24, 2020. We performed a network meta-analysis with random-effects models. The primary outcome was any stroke or death during a long-term follow-up. Secondary outcomes included ischemic stroke, intracranial hemorrhage, and death. This network meta-analysis included 14 trials with 1520 participants. No significant difference was found between the three groups in the primary outcome, while PBA was probably the best treatment according to the ranking plot. Medical treatment had significantly lower rate of any stroke or death (odds ratio (OR), 0.31; 95% CI, 0.17-0.56), ischemic stroke (OR, 0.43; 95% CI, 0.23-0.81), and intracranial hemorrhage (OR, 0.12; 95% CI, 0.02-0.71) within 30 days than stenting but did not differ from PBA. The ranking plot demonstrated that PBA was also most likely to rank the highest for ischemic stroke during the long-term follow-up and beyond 30 days, although no significant difference was identified. Medical treatment had lower risk of any stroke or death within 30 days than stenting but did not differ from PBA. All the treatments had similar effects on the prevention of long-term stroke, while PBA had the highest probability of being the most effective.

Japanese Postmarket Surveillance of Percutaneous Transluminal Angioplasty and Wingspan Stenting for Intracranial Atherosclerotic Disease

BACKGROUND

The Wingspan stent system was approved as a rescue device for angioplasty of intracranial atherosclerotic disease (ICAD) in 2012. We conducted the government-recommended Japanese Postmarket Surveillance of Percutaneous Transluminal Angioplasty and Wingspan Stenting for Intracranial Atherosclerotic Disease to monitor Wingspan safety and performance.

METHODS

In this open-label, single-arm study at 76 centers in Japan, ICAD subjects were treated with the Wingspan stent between 2014 and 2016. Efficacy end points were successful stent deployment and technical success, defined as stenosis improvement to <50%. Safety end points were ischemic stroke, modified Rankin Scale and National Institutes of Health Stroke Scale scores, adverse events, and mortality. Subjects were considered treated outside of current recommendations if not already receiving antithrombotics or if percutaneous transluminal angioplasty and stenting occurred within 7 days of onset.

RESULTS

The safety cohort included 305 subjects (mean age: 68.7 + 9.6; 83.3% male). Four subjects were removed due to being out of contract. Therefore, 301 subjects were included (mean age: 68.7 ± 9.7; 84.1% male). Successful stent placement was 96.7%. Technical success was observed in 86.8% of lesions. At 1 year, the rate of restenosis was 15.7%, ischemic stroke was 3.9%, and any stroke was 7.9%. Functionally independent outcome (modified Rankin Scale: 0-2) was 88.9% and mortality 3.0%. Significantly more serious adverse events occurred in subjects treated outside of current recommendations (17.9%) versus subjects treated per current recommendations (8.8%) (P = 0.045).

CONCLUSIONS

Endovascular treatment using the Wingspan stent for ICAD is safe and effective in the Japanese population.

Endovascular Therapy for Symptomatic Intracranial Artery Stenosis: a Systematic Review and Network Meta-analysis

Intracranial artery atherosclerotic stenosis (ICAS) is one of the most common causes of stroke. Endovascular therapy including balloon angioplasty alone (BA), balloon-mounted stent (BMS), or self-expanding stent (SES) was an important alternative to treat symptomatic ICAS refractory to medical treatment, while none of the three subtypes has been established to be the primary option. We conducted a systematic review and network meta-analysis to determine both the safety and efficacy and establish a hierarchy of different endovascular therapies on symptomatic ICAS. Major databases including MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for studies comparing outcomes of three different endovascular approaches and other comparable non-endovascular therapies for symptomatic ICAS patients published from 1 January 2000 to 1 November 2021. Primary outcomes included short-term mortality or stroke rate (peri-procedural, or mean follow-up ≤ 3 months), and long-term mortality or stroke rate (mean follow-up ≥ 6 months). Pairwise and network meta-analyses based on the above systematic review were conducted. A total of 19 eligible studies involving 3386 patients treated with 4 different approaches (BA, SES, BMS, and medical treatment) were analyzed. For primary outcome, BA had the highest ranking (SUCRA value 78), followed by BMS (SUCRA value 21.5) and SES (SUCRA value 13.1). The short-term mortality or stroke rate was significantly lower in the BA group compared to SES (OR = 2.50; 95% CI 1.12 to 5.57; p = 0.026) or BMS (OR = 0.43; 95% CI 0.19 to 0.96; p = 0.038). Other primary and secondary outcomes were no different among all three types of endovascular therapy. Overall, the studies were of good methodological quality and the consistency was acceptable across all network meta-analyses. BA offers the highest level of safety outcomes in terms of short-term mortality or stroke in treating symptomatic patients with intracranial artery stenosis, compared to SES and BMS, which needs to be confirmed in future studies. Trial registration in PROSPERO database: CRD42018084055.

Acupuncture Combined with Traditional Chinese Medicine and Drug Therapy for the Treatment of Cerebral Infarction (Phlegm-Blood Stasis Syndrome) and Carotid Atherosclerotic Plaque: A Preliminary Randomized Controlled Study

Carotid atherosclerotic plaque (CAP) is one of the leading causes of cerebral infarction. Western medicine usually uses lipid-lowering drugs to stabilize plaques. Currently, studies reporting on drugs that can reduce plaques are lacking. Here, we performed a randomized controlled study to investigate the effectiveness of acupuncture combined with drug therapy (TCM and Western) to treat cerebral infarction (phlegm-blood stasis syndrome) and CAP. The control group was treated with atorvastatin calcium tablets (20 mg/d, po for 15 days). The treatment group received atorvastatin calcium tablets 20 mg, traditional Chinese medicine (TCM) decoctions (two matured substance decoction plus peach kernel and Carthamus four substance decoction plus Chinese hawthorn fruit 20 g, gold theragran 20 g, and red yeast rice 3 g), and acupuncture therapy, once daily for 15 days as one treatment course. The patients' neurological deficit score, ultrasonic testing of the carotid artery, and lipoprotein-associated phospholipase A2 (Lp-PLA2) were evaluated. Our findings showed no significant difference in the evaluated indices between the two groups before treatment (P > 0.05). However, compared with the control group after 15 days of treatment and within each group before and after treatment, the differences were significant (P < 0.05). In conclusion, acupuncture combined with drug therapy demonstrated promising effectiveness in treating cerebral infarction (phlegm-blood stasis syndrome) and CAP.

Relationship between Serum FGF21 and vWF Expression and Carotid Atherosclerosis in Elderly Patients with Hypertension

Cardiovascular (CV) and cerebrovascular (CBV) diseases are common in the elderly and cause severe damage, with high morbidity, disability, and mortality. Hypertension, as a risk factor for a variety of CV and CBV diseases, also affects many elderly patients. This study aimed to investigate the relationship between serum FGF21 and vWF expression and carotid atherosclerosis (CAS) in elderly patients with hypertension. We recruited 143 elderly hypertensive patients admitted to our hospital from July 2017 to November 2019 to this study, including 75 patients with comorbid CAS (the observation group, OG) and 68 patients without CAS (the control group, CG). Enzyme-linked immunosorbent assay (ELISA) was used to test serum expression levels of FGF21 and vWF; receiver operating characteristic (ROC) curves to evaluate the value of FGF21 and vWF in diagnosing CAS and predicting the 6-month prognosis in elderly hypertensive patients; Pearson's correlation analysis to analyze the correlation of FGF21/vWF with the plaque thickness and stenosis area in hypertensive patients with CAS. The incidence of CV and CBV events was markedly higher in the high FGF21/vWF group than in the low FGF21/vWF group. Patients from OG were divided into the high FGF21/vWF group and the low FGF21/vWF group based on the median expression level of FGF21/vWF, then the incidence of cardiovascular (CV) and cerebrovascular (CBV) events was compared between the high and low expression groups. Serum levels of FGF21 and vWF were markedly higher in patients from OG than in patients from CG. Both FGF21 and vWF were in positive correlation with the plaque thickness and stenosis area in patients from OG. The area under the ROC curve (AUC) for diagnosing CAS was 0.790 by FGF21 and 0.807 by vWF; the AUC for predicting the occurrence of CV and CBV events was 0.771 by FGF21 and 0.754 by vWF. Serum levels of FGF21 and vWF are increased in elderly patients with hypertension and comorbid CAS, so they can be used for diagnosing CAS and predicting prognosis.

Efficacy and safety of endovascular treatment for patients with acute intracranial atherosclerosis-related posterior circulation stroke: a systematic review and meta-analysis

The benefit of endovascular treatment (EVT) for patients with intracranial atherosclerosis-related large vessel occlusion (ICAS-LVO) in posterior circulation stroke (PCS) is inconsistent. This systematic review and meta-analysis were conducted to estimate the effect of ICAS-LVO in PCS treated by EVT. A systematic review was completed, tracking studies from their date of inception until February 2020. Clinical studies which compared outcomes after EVT for ICAS-LVO and non-ICAS-LVO in PCS were included. Data were synthesized and interpreted from meta-analysis. A total of 688 patients (352 ICAS-LVO and 336 non-ICAS-LVO) in the eight studies were included. The successful reperfusion rate (odds ratio [OR], 0.58; 95% confidence intervals [95% CIs], 0.37-0.93; P = 0.02) was lower in PCS with ICAS-LVO than non-ICAS-LVO. And for other clinical outcomes, there were no differences between both groups. Moreover, there were no statistical differences of any clinical outcome among subgroups stratified by nations and target vessel occlusion location. With respect to patients' characteristics, age (mean difference [MD], -2.75; 95% CI, -4.62--0.88; P = 0.004), pc-Alberta Stroke Program Early CT Score (MD, -0.49; 95% CI, -0.94--0.05; P = 0.03), distributions of sex (male) (OR, 2.34; 95% CI, 1.53-3.56; P < 0.001), prior or current smoking (OR, 1.85; 95% CI, 1.12-3.07; P = 0.02), hypertension (OR, 2.06; 95% CI, 1.32-3.22; P = 0.002), coronary artery disease (OR, 0.27; 95% CI, 0.11-0.66; P = 0.004) and general anesthesia (OR, 2.89; 95% CI, 1.54-5.45; P = 0.001) were statistically different between both groups. In conclusion, more targeted assessments are warranted for patients with ICAS-LVO-related PCS during clinical strategies, and the benefit of EVT for PCS with ICAS-LVO deserves further research.

Medical and endovascular treatments of symptomatic intracranial stenosis. A Bayesian network meta-analysis

Intracranial stenosis is a well-established stroke risk factor with an increase of stroke recurrence or TIA up to 12.6% at 1 year. Treatments are different: medical and endovascular. We performed a multiple treatment comparison analysis to detect the best treatment in reducing the risk of stroke recurrence. We searched in Medline, Embase, Cochrane Central Register of Controlled Trials databases between 1979 and October 2017. Inclusion criteria were prospective randomized trials that evaluated patients with TIA or stroke due to intracranial stenosis and treated with different medical therapies and/or endovascular procedures. Primary endpoint was the recurrence of TIA or stroke in the territory of intracranial stenosis, while secondary endpoint was represented by any stroke or vascular death. Multiple treatment comparison meta-analysis based on a Bayesian fixed and random effects Poisson model was performed. Seven trials were included with a total of 1337 patients. At multiple treatment comparison, no significant differences between treatments were observed for both primary (median fixed effect standard OR: 0.40; 95%CI: 0.02-1.07) and secondary endpoints (median random effect standard OR: 1.17; 95%CI: 0.32-1.92). Treatment with aspirin alone ranked with high values both for primary and secondary endpoints (surface under the cumulative ranking curve of 70% and 82%, respectively). In patients with symptomatic intracranial stenosis, no differences between treatments were observed. However, aspirin alone was more effective than stenting in the reduction of TIA or stroke recurrences, with a better safety profile than oral anticoagulants.

Comparison of stent versus medical therapy for symptomatic patients with intracranial atherosclerotic stenosis: A meta-analysis

PURPOSE

To compare the outcomes of intracranial stent implantation and medical therapy for treatment of severe intracranial stenosis.

METHODS

Articles were identified from Medline, Cochrane, EMBASE, and Google Scholar published up to August 25, 2016. Eligible studies reported stroke occurrence, transient ischemic attack (TIA), and event-free survival rates in patients who suffered recent TIA or stroke caused by stenosis of a major intracranial artery and treated with either medical therapy or stenting. 4 studies enrolled a total 739 patients.

RESULTS

While no association between intracranial endovascular therapy and short-term stroke risk was found (pooled OR=1.349, 95% CI=0.541 to 3.367, P=0.521), significantly higher rate of stroke occurrence was observed in patients treated with stent therapy within 30days of treatment (pooled OR=3.143, 95% CI=1.755 to 5.628, P<0.001). No association was found between the type of treatment and TIA occurrence (pooled OR=0.702, 95% CI=0.277 to 1.781, P=0.457) and event-free survival rate (pooled HR=1.170, 95% CI=0.947 to 1.447, P=0.145).

CONCLUSION

Patients with symptomatic intracranial atherosclerotic stenosis undergoing stent therapy may have higher risk of short-term stroke.

The experiences of balloon-expandable stent in symptomatic stenosis of middle cerebral artery

Background

Stent placement for middle cerebral artery (MCA) stenosis remains a technical and clinical challenge. Our purpose was to assess the safety and feasibility of balloon-expandable stent (BES) for patients with symptomatic M1 stenosis of MCA, and to introduce our experience during the procedure.

Methods

In the study, we analyzed retrospectively 37 patients with M1 stenosis of the MCA ranged from 70 to 90 % in diameter reduction and refractory to medical therapy between January 2012 and January 2015. All the patients underwent angioplasty and stenting with BES, and followed up continuously.

Results

Thirty-five out of 37 patients were successfully followed up and available until now. The technical successful rate was 100 % for all the lesions. The complication rate was 0 during the procedure. Stroke occurred to one patient at 4th day after the procedure. There were two patients experiencing slight stroke after 8 months. Two patients were found re-stenosis >50 % without any symptom. The stroke rate of 12 months was 8.57 % (3/35).

Conclusions

Angioplasty associated with BES appears to be safe and feasible for the patients with symptomatic M1 stenosis of MCA. Our experiences about the BES may be valuable for decreasing the complication. However, further study is needed.

Hemodynamics in stented vertebral artery ostial stenosis based on computational fluid dynamics simulations

Hemodynamic factors may affect the potential occurrence of in-stent restenosis (ISR) after intervention procedure of vertebral artery ostial stenosis (VAOS). The purpose of the present study is to investigate the influence of stent protrusion length in implantation strategy on the local hemodynamics of the VAOS. CTA images of a 58-year-old female patient with posterior circulation transient ischemic attack were used to perform a 3D reconstruction of the vertebral artery. Five models of the vertebral artery before and after the stent implantation were established. Model 1 was without stent implantation, Model 2-5 was with stent protruding into the subclavian artery for 0, 1, 2, 3 mm, respectively. Computational fluid dynamics simulations based on finite element analysis were employed to mimic the blood flow in arteries and to assess hemodynamic conditions, particularly the blood flow velocity and wall shear stress (WSS). The WSS and the blood flow velocity at the vertebral artery ostium were reduced by 85.33 and 35.36% respectively after stents implantation. The phenomenon of helical flow disappeared. Hemodynamics comparison showed that stent struts that protruded 1 mm into the subclavian artery induced the least decrease in blood speed and WSS. The results suggest that stent implantation can improve the hemodynamics of VAOS, while stent struts that had protruded 1 mm into the subclavian artery would result in less thrombogenesis and neointimal hyperplasia and most likely decrease the risk of ISR.

Research on intracranial atherosclerosis from the East and west: why are the results different?

Intracranial atherosclerosis (ICAS) is a major cause of stroke worldwide and is more common in Asians than Caucasians. The study results from the East and West are generally similar, but notable differences exist. For example, studies from the East have reported that ICAS is associated with young age, whereas ICAS seems to be associated with old age in the West. Studies from the East have strongly suggested that mild ICAS associated with branch occlusion is one of the main causes of single subcortical infarction, whereas this aspect has not been considered in stroke classification systems developed in the West. While clopidogrel is commonly used in patients with large artery disease in the West, cilostazol has been more extensively studied and commonly used in ICAS patients in the East. A randomized controlled study from the West reported negative results regarding the efficacy of stenting in ICAS patients due largely to a relatively high rate of periprocedural adverse events, whereas research papers from the East have reported a relatively lower rate of complications. Studies to narrow these East-West gaps should be performed, including risk factor studies using homogenous ethnic populations, studies investigating appropriate classification systems, drug trials in different ethnic populations, and rigorous high standard randomized controlled studies on the efficacy of stenting in Eastern populations.

Role of stenting for intracranial atherosclerosis in the post-SAMMPRIS era

Introduction. The initial promise of endovascular stenting for the treatment of intracranial atherosclerotic disease (ICAD) has been tempered by the results of the SAMMPRIS trial which demonstrated better outcomes with medical management compared to stenting for symptomatic ICAD. We review post-SAMMPRIS ICAD stenting outcomes. Methods. A comprehensive literature search was performed using PubMed to identify all ICAD stenting series published after the SAMMPRIS in September 2011. The type and design of the stent, number of patients and lesions, inclusion criteria, and clinical and angiographic outcomes were noted. Results. From October 2011 to August 2013, 19 ICAD stenting series were identified describing the interventional outcomes for 2,196 patients with 2,314 lesions. Of the 38 different stents used, 87% were balloon-expandable stents (BESs) and 13% were self-expanding stents. The median minimum stenosis was 50%. The median rates of technical success rate, postprocedural ischemic events, and symptomatic in-stent restenosis (ISR) were 98% (range 87–100%), 9.4% (range 0–25%), and 2.7% (range 0–11.1%), respectively. The median follow-up durations were one to 67 months. Conclusions. The management of severe ICAD remains controversial. Future trials are needed to define the optimal patient, lesion, and stent characteristics which will portend the best outcomes with intervention.