Percutaneous Transluminal Angioplasty with Stent Placement versus Best Medical Therapy Alone in Symptomatic Intracranial Arterial Stenosis: A Best Evidence Review

Abstract

Intracranial arterial stenosis (ICAS) is a common cause of stroke, and the risk of ischemic stroke from a stenotic intracranial artery remains high despite best medical therapy (BMT). As a result, clinicians have increasingly turned to percutaneous transluminal angioplasty and stenting (PTAS) over the last decade as an alternative therapy in high-risk patients with symptomatic ICAS. In this review, we will critically analyze multiple clinical trials to assess the safety and efficacy of PTAS with BMT versus BMT alone. The Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial reported a higher rate of stroke or death within 30 days in the PTAS plus BMT group (14.7%) than the BMT only group (5.8%, p = 0.002). The rate of any stroke during the follow-up period (mean = 32 months) was higher in the PTAS plus BMT group (22.3%) than the BMT only group (14.1%, p = 0.03). The Vitesse Intracranial Stent Study for Ischemic Stroke Therapy (VISSIT) trial reported a higher rate of stroke or death within 30 days in the PTAS plus BMT cohort (24.1%) than the BMT only cohort (9.4%, p = 0.05). There was also a higher rate of hard transient ischemic attack (TIA) or stroke within one year in the PTAS plus BMT group (36.2%) than the BMT only group (15.1%, p = 0.02). The Vertebral Artery Ischaemia Stenting (VIST) trial reported the rate of any stroke during the follow-up period to be two events in 50 person-years in the PTAS plus BMT cohort versus four events in 45 person-years in the BMT only cohort, with a calculated hazard ratio of 0.47 (p = 0.39). Vertebral Artery Stenting Trial (VAST) reported a higher incidence of stroke, MI, or vascular death in the PTAS with BMT cohort (22%) than the BMT only cohort (0%). Tang et al. reported no significant difference in the incidence of vascular events at one year and three years between the PTAS plus BMT and BMT only cohorts. However, the distribution of vascular events was more concentrated in the first postoperative week in the PTAS plus BMT cohort (75% of all vascular events) versus the BMT only cohort (17%). Feng et al. reported a lower periprocedural complication rate (9.1%) with the Enterprise stent in comparison to the Wingspan and balloon-expandable stents used in the SAMMPRIS and VISSIT trials. We conclude that PTAS should not be employed as first-line treatment in patients with symptomatic ICAS. However, PTAS should be considered in symptomatic ICAS patients that are hemodynamically unstable or have repeatedly failed BMT, especially at sites with lower rates of perioperative complications than those reported here.

Drug-coated Balloons in the Neurovascular Setting: A Comprehensive, Systematic Review of Current Use and Indications

“…[ 46 , 47 ] with promising results and was only revisited in 2018 [ 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 ]. However, despite good results and reviews continuing to advocate for the evaluation of DCB in the treatment and prevention of ECAS and ICAS in in-stent restenosis [ 57 , 58 , 59 ] and restenosis, data addressing the use of DCB and the evaluation of its possible benefits in the neurovascular setting remain rare; consequently, we believe that this field is under-investigated, and publications are lacking.…”

A randomized, double-blind, placebo-controlled, multicenter trial- DL-3-n-butylphthalide therapy for cerebral hypoperfusion from unilateral internal carotid system stenosis study: study protocol

“…[31][32] The current studies and guidelines do not support the percutaneous intracranial stenting and EC-IC employed as first-line treatment in patients with ICAS. 7,33 Therefore, it is reasonable to use the drug strategy to improve the cerebral hypoperfusion in the patients who are unfit for the surgical revascularization. This study expands the upper limit of eligible age to 85 years old and does not exclude the above high-risk conditions for the surgical revascularization as possible as we can.…”

Endovascular Recanalization of Non-acute Symptomatic Middle Cerebral Artery Total Occlusion and Its Short-Term Outcomes

“…However, Stenting and Aggressive Medical Management for Prevention of Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) investigators found that patients undergoing PTAS plus BMT for high-grade intracranial atherosclerosis have a significantly increased rate of recurrent stroke and death than patients receiving BMT alone (13). In a recent review, Padalia et al concluded that PTAS should only be considered in symptomatic ICAS patients that are hemodynamically unstable or have repeatedly failed BMT (18). Moreover, a recent study suggested that DCB is a viable alternative to drug-eluting stents, and the new advent of Neuro Elutax DCB further increased the feasibility of using DCB in intracranial arteries (19).…”