Stenting Versus Medical Therapy For Intracranial And Extracranial Arterial Stenosis

Background: The incidence of stroke is120~180/100000.The main type is ischemicstroke[4]. Intracranial and extracranial arterial atherosclerotic stenosis is one of the mainfactors of ischemic stroke.It accounts for39%-49%acute stroke[2,3]. Intracranial orextracranial vascular stenosis or occlusion accounts for70%Transient IschemicAttacks(TIA)[1].Effective treatment of intracranial and extracranial arterial stenosis hassignificant social and economic benefits which can prevent the occurrence of stroke, reducethe disability and mortality rates.The recognised treatment methods of intracranial andextracranial arterial stenosis contain Carotid Endarterectomy(CEA)and PercutaneousTransluminal Angioplasty(PTAS)present.CEA was limited to be used to common carotidartery and initial segment of internal carotid artery.It lack a better way for the treatment ofcerebral artery stenosis except PTAS.It has a rapid development.However,PTAS has notbeen compared with medical management in a large multicenter and randomizedtrial.SAMMPRIS,the only trial,published in the New England Journal of Medicine in2011,showed that aggressive medical management was superior to similar therapy plusangioplasty and stenting.However the follow-up time of study was only11.9months.It cannot answer which is better in the more long time.Our study was focuses on short-term andlong-term clinical efficiency and the hemodynamic changes of the two therapies forintracranial and extracranial vascular stenosis.Objective: Retrospectively review the curative effect of cerebral artery stenosis withsingle medical management or medical management plus PTAS.Observe the hemodynamiceffects of the two therapies using Transcranial Doppler Ultrasound (TCD).Methods: Selected patients in accordance with the requirement of Digital subtractionangiography (DSA) to be moderate or severe stenosis.There are421cases, including256cases underwent PTAS and165cases only received conservative treatment.We analysis itsprimary end point of during hospitalization (stroke or death events).Follow up them andanalysis the primary end point beyond hospitalization (stroke in the territory of thequalifying artery).There are106patients be followed up,including60patients receivedmedical management plus PTAS and46patients received single medical management.Meanwhile,we chose Middle Cerebral Artery (MCA) to analysis the hemodynamic effects of the two therapies using TCD.There are23cases met the requirement,including10patientsreceived medical management plus PTAS and13patients received single medicalmanagement.Results:(1)256patients underwent PTAS and165patients with conservative treatmentrespectively has28patients (10.94%) and2patients (1.21%) with primary endpoint eventsduring hospitalization,it differed significantly(p≤0.01); There are respectively16patients(6.25%) and0patients with serious endpoint events (disabling or fatal endpoint events),italso differed significantly (p≤0.01).(2)60patients received medical management plus PTASwith an average follow-up time889.60days and46patients received single medicalmanagement with an average follow-up time682.17days respectively have5cases (8.33%)and10cases (21.74%) with primary endpoint events beyond hospitalization.It hassignificant difference (p≤0.05).There are respectively2cases (3.33%) and6cases (13.04%)with severe end point.It has no significant differences (p>0.05).(3)Under the premise offollow-up time has no significant difference (p>0.05),the flow velocity of stent vascularincreased and it has significant difference (p≤0.05) after an average follow-up time of496.10days.The flow velocity of diseased vascular of the patients received medical treatment onlyhas no significant difference change (p>0.05) ofter an average follow-up time of223.00days.(4)Under the premise of flow velocity of diseased vascular and follow-up time has nosignificant difference (p>0.05),the flow velocity of medical management plus PTAS groupis larger than the single medical management group.It has significant difference (p>0.05).(5)The flow velocity of medical management plus PTAS group has a declining trend in the firstmouth.It increased quickly in the period of1-3months and6-12month,it increased slowly inthe period of3-6month.Conclusion:(1)The perioperative complications of PTAS is high.(2)From the long-termbenefits, medical management plus PTAS can effectively prevent the occurrence of strokein the territory of the qualifying artery.(3) From the view of hemodynamics,single medicalmanagement can effectively prevent the progress of vessel becoming narrower.AlthoughPTAS leads the progress,the vessel diameter of the medical management plus PTAS group isstill larger than the single medical management group eventually.The reconstruction ofPTAS is effective.(4)The rate of vascular becoming narrower is uneven of the medicalmanagement plus PTAS group.We consider that this trend has a relation to physiological andpathologic reaction and oral medications.It may prevent the progress effectively to continueto apply the relatively large doses of anti-platelet drugs.