Wingspan Stenting For Symptomatic Intracranial Atherosclerotic Artery Stenosis

Part one; A Systematic review on outcome after angioplasty for intracranial atherosclerotic artery stenosisPurpose:Primary angioplasty and stenting is increasingly being used for the treatment of intracranial stenoses. Based on a literature search we sought to determine the immediate and long-term outcomes, as well as the durability of this procedure.Methods:We identified pertinent studies published between January 1980 and December 2010 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 pooled analysis.Results: After applying our selection criteria, we included 73 studies : 33 primary angioplasty studies (1088 patients) and 40 studies of angioplasty with stent placement (1631 patients) in the analysis. There were a total of 95 stroke-and/or-deaths reported in the primary angioplasty group (8.73%), compared with 99 stroke-and/or-deaths in the stent–assisted group (6.07%) during a 1-month period (OR:1.48, 95%CI:1.11-1.98). Compared to primary angioplasty, there were at higher technical success rates in the stent–assisted group (86.3±11.1% vs 97.1±2.1%, P<0.05). Periprocedural complications were significantly higher in the posterior versus the anterior circulation, there were higher residual stenosis with self-expadable stents. Restenosis > 50% occurred more frequently after the use of a self-expandable stent than a balloon-mounted stent, However, there were not statistic difference. The pooled incidence of 1-year stroke-and/or-death in patients treated with angioplasty alone was 15.3%, compared with 9.1% in the angioplasty- with-stent–treated patients (OR:1.63; P =0.000).Conclusions: Although intracranial stenting appears to be feasible, adverse events vary widely. Against the background of the results of this review yielding no clear impact of long-time outcome, the widespread application of intracranial stenting outside the setting of randomized trials and in inexperienced centers currently does not seem to be justified. Part two; Wingspan stenting with modified predilation for symptomatic middle cerebral artery stenosisPurpose: Wingspan stenting of MCA remains a technical challenge, and rates of residual stenosis and restenosis must be lowered. Our purpose was to assess the feasibility, safety and effectiveness of a modified predilation for MCA stenosis.Methods: A series of 48 patients with symptomatic MCA stenosis greater than 50% and refractory to medical therapy underwent Wingspan stenting with different balloon/artery ratios before (Group 1, Boston guidelines predilation) or after (Group 2, modified predilation) July of 2008. Technical success, periprocedural complications, recurrent symptoms and restenosis were assessed retrospectively, and risk factors for restenosis were analyzed using logistic regression.Results: Successful stenting occurred in 48 of 49 lesions (98%). Primary endpoints within 30 days included 1 (2.12%) minor stroke and 2 (4.26%) TIAs. Stenoses were reduced from 77.11±10.09% to 27.50±6.91% in Group 1 versus from 72.56±10.46% to 8.20±5.41% in Group 2. A total of 43 patients were followed for 12.92±5.08 months, and recurrent stroke or TIA occurred in 2 patients (4.65%). Vessels were followed with TCD (43 vessels), angiography (23 vessels), or CTA (1 vessel). The restenosis rate was 8/18 (44%) in Group 1 and 3/25 (12%) in Group 2. Restenosis was associated with residual stenosis and diabetes.Conclusions: Wingspan stenting for symptomatic MCA stenosis can be performed with high success and low complication rates, and modified predilation with the Gateway balloon can reduce the rates of residual stenosis and restenosis. Part three: Wingspan stent for high grade symptomatic vertebrobasilar artery atherosclerotic stenosisPurpose: To present the treatment outcomes with Wingspan stent angioplasty of high grade intracranial VBA stenosis in symptomatic patients.Methods: Between 2007 and 2010, the notes were retrospectively reviewed of 30 patients with 31 intracranial high-grade VBA stenoses (all≥70%) who underwent elective stenting due to the failure of medical therapy. Clinical evaluation was performed based on the modified rankin scale and the National Institutes of Health Stroke Scale.Results: In all cases, the stent deployment was technically successful. The mean stenosis decreased significantly from 82.28%±8.02% (range, 72% to 99%) to 11.18%±7.28% (range, 0 to 25%) after stent-assisted angioplasty (P < 0.05). Periprocedure complications occurred in three (10%) out of 30 patients: there were two cases of perforator strokes and one case of retrievable flow insufficiency with stent overlap. Clinical follow-up (mean, 17.81±11.49 mo; range, 5 to 40 mo) was available for 27 patients, and Angiographic follow-up (mean, 9.95±5.74 mo, range, 5 to 20 mo) was available for 19 patients. Only one case demonstrated recurrent symptoms with restenosis (≥50%). There were no recurrent ischemic events and no cases of restenosis in the other patients.Conclusion: According to our data, the Wingspan stent for symptomatic intracranial VBA stenoses is a safe and efficacious treatment alternative in cases with recurrent symptoms despite medical therapy. However, the improvement of outcome requires the reduction in the rate of procedure-related complications and long-term outcomes still have to be demonstrated.