Percutaneous transluminal angioplasty or stenting of petrous and cavernous internal carotid artery stenosis - a systematic review

Percutaneous transluminal angioplasty (PTA) and stenting have been used for the treatment of internal carotid artery (ICA) stenosis over the past two decades. A systematic review was performed to understand the efficacy of PTA and/or stenting for petrous and cavernous ICA stenosis. In total, 151 patients (mean age 64.9) met criteria for analysis, 117 (77.5%%) were male and 34 (22.5%) were female. Of the 151 patients, 35 of them (23.2%) had PTA, and 116 (76.8%) had endovascular stenting. Twenty-two patients had periprocedural complications. There was no significant difference in the complication rates between the PTA (14.3%) and stent (14.7%) groups. Distal embolism was the most common periprocedural complication. Average clinical follow up for 146 patients was 27.3 months. Eleven patients (7.5%) out of 146 had retreatment. The treatment of petrous and cavernous ICA with PTA and stenting has relatively significant procedure related complication rates and adequate long-term patency.

COMPARISON BETWEEN PRIMARY ANGIOPLASTY AND STENT PLACEMENT FOR SYMPTOMATIC INTRACRANIAL ATHEROSCLEROTIC DISEASE

OBJECTIVE

To compare the short- and long-term rates of stroke-and/or-death associated with primary angioplasty alone and angioplasty with stent placement using a meta-analysis of published studies. Both primary angioplasty alone and angioplasty with stent placement have been proposed as treatment strategies for symptomatic intracranial atherosclerotic disease to reduce the risk of stroke-and/or-death with best medical treatment alone. However, it remains unclear which of these endovascular techniques offers the best risk reduction.

METHODS

We identified pertinent studies published between January 1980 and May 2008 using a search on PubMed and Cochrane libraries, supplemented by a review of bibliographies of selected publications. The incidences of stroke-and/or-death were estimated for each report and pooled for both angioplasty alone and angioplasty with stent placement at 1 month and 1 year postintervention and then compared using a random-effects model. The association of year of publication and 1-year incidence of stroke-and/or-death was analyzed with meta-regression.

RESULTS

After applying our selection criteria, we included 69 studies (33 primary angioplasty-alone studies [1027 patients] and 36 studies of angioplasty with stent placement [1291 patients]) in the analysis. There were a total of 91 stroke-and/or-deaths reported in the angioplasty-alone–treated group (8.9%; 95% confidence interval [CI], 7.1%–10.6%), compared with 104 stroke-and/or-deaths in the angioplasty-with-stent–treated group (8.1%; 95% CI, 6.6%–9.5%) during a 1-month period (relative risk [RR], 1.1; P = 0.48). The pooled incidence of 1-year stroke-and/or-death in patients treated with angioplasty alone was 19.7% (95% CI, 16.6%–23.5%), compared with 14.2% (95% CI, 11.9%–16.9%) in the angioplasty-with-stent–treated patients (RR, 1.39; P = 0.009). The incidence of technical success was 79.8% (95% CI, 74.7%–84.8%) in the angioplasty-alone group and 95% (95% CI, 93.4%–96.6%) in the angioplasty-with-stent–treated group (RR, 0.84; P < 0.0001). The pooled restenosis rate was 14.2% (95% CI, 11.8–16.6%) in the angioplasty-alone group, as compared with 11.1% (95% CI, 9.2%–13.0%) in the angioplasty-with-stent–treated group (RR, 1.28; P = 0.04). There was no effect of the publication year of the studies on the risk of stroke-and/or-death.

CONCLUSION

Risk of 1-year stroke-and/or-death and rate of angiographic restenosis may be lower in symptomatic intracranial atherosclerosis patients treated by angioplasty with stent placement compared with patients treated by angioplasty alone.

Angioplasty for intracranial artery stenosis

BACKGROUND

Intracranial artery stenosis causes up to 10% of all ischaemic strokes. The rate of recurrent vascular ischaemic events is very high. Angioplasty with or without stent placement is a feasible procedure to dilate the vessel affected. However, its safety and efficacy have not been systematically studied.

OBJECTIVES

To determine the efficacy and safety of angioplasty combined with best medical treatment compared with best medical treatment alone in patients with acute ischaemic stroke or transient ischaemic attack (TIA) resulting from intracranial artery stenosis for preventing recurrent ischaemic strokes, death, and vascular events.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched March 2006). In addition we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2006), MEDLINE (1966 to March 2006), EMBASE (1980 to February 2006) and Science Citation Index (1945 to March 2006). To identify further published, unpublished and ongoing trials we searched reference lists of relevant articles and contacted authors and experts in the field.

SELECTION CRITERIA

Randomised or otherwise controlled studies comparing best medical care plus angioplasty of the intracranial cerebral arteries, with or without stent placement, with best medical care alone. Studies were only included if data for clinical significant endpoints such as recurrent ischaemic stroke, haemorrhagic stroke and death were available.

DATA COLLECTION AND ANALYSIS

Two review authors selected trials for inclusion, and independently assessed trial quality and extracted data. Calculation of relative treatment effects with subgroup analysis was done if possible.

MAIN RESULTS

No randomised controlled trials were found. There were 79 articles of interest consisting of open-label case series with three or more cases. The safety profile of the procedure showed an overall perioperative rate of stroke of 7.9% (95% confidence intervals (CI) 5.5% to 10.4%), perioperative death of 3.4% (95% CI 2.0% to 4.8%), and perioperative stroke or death of 9.5% (95% CI 7.0% to 12.0%). No comments can be made on the effectiveness of the procedure.

AUTHORS' CONCLUSIONS

At present there is insufficient evidence to recommend angioplasty with or without stent placement in routine practice for the prevention of stroke in patients with intracranial artery stenosis. The descriptive studies show that the procedure is feasible although carries a significant morbidity and mortality risk. Evidence from randomised controlled trials is needed to assess the safety of angioplasty and its effectiveness in preventing recurrent stroke.