Consensus of ICAD treatment Consensus of ICAD treatment after SAMMPRIS in Chinaafter SAMMPRIS in China

Zhujiang Hospital Zhujiang Hospital Nanfang Medical UniversityNanfang Medical University

Liu Yajie, MDLiu Yajie, MD

Pros &Cons of PTAS in ICAD Pros &Cons of PTAS in ICAD

Zhujiang Hospital Zhujiang Hospital Nanfang Medical UniversityNanfang Medical University

Liu Yajie, MDLiu Yajie, MD

Kasner SE, et al. Circulation. 2006;113:555-563

HR=2.03,P=0.0025

We will Continue with Clinical Trials

AMT superior to PTAS by 30-day rates of Stroke and Death

Chimowitz MI et al. N Engl J Med .365(11):993-1003

SAMMPRIS Results

• Whacan we learn from SAMMPRIS?

• Should we stop PTAS after SAMMPRIS?

• Should we consider future clinical trials?

Does PTAS do more harm ?

Operator

• 20 most recent consecutive cases of intracranial stenting or angioplasty.

1. Wingspan™ Stent System 2. Balloon-mounted coronary stent 3. Self-expanding stent for aneurysm 4. Angioplasty alone• A minimum of 3 Wingspan™ Stent System cases

was required to be considered for credentialing.• Average 3-4 procedures / enrolled doctor, when

SAMMPRIS was halted.

Chimowitz MI et al.J Stroke Cerebrovasc Dis 20(4):357-68

.

Chimowitz NEJM 2011

CAS Learning Curve – 72 CASES for Matured Operator

William A. Gray,et al.J Am Coll Cardiol Intv 2011;4:235– 46

Facilitate More Complex PTAS

23

14.3

17.2

26.9

9

3.2

6.8

9.5

0

5

10

15

20

25

30

low volume center( 1-8cases)

High volume center (14-19 cases)

Zaidat OO, et al. Neurology. 2008;70:1518–1524

Primary end point ： 30d Stroke or death/ ipsilateral stroke after 3 months

Primary end point(%

)

总体 24 小时 30 天 6 个月

• NIH Wingspan™ Stent System had lower event rate in low volume centers vs. high volume centers, operator skill is key factor in PTAS

P=0.022

Learning Curve for PTAS?

S GAO, et al .Front Neurol. 2011 Feb 15;2:6.

Pathogenesis and PTASPatient

PTAS not suitable for PA occluded patients

Hemodynamic impaired more suitable for PTAS

Pathogenesis and PTAS

Predictors of ischemic stroke in the territory of a symptomatic intracranial arterial stenosis. Kasner SE, Chimowitz MI, Lynn NJ, et al.: Circulation 2006, 113:555-563.

Timing

Chimowitz MI et al. N Engl J Med .365(11):993-1003

F. Nahab et al.Neurology. 2009 Jun 9;72(23):2014-9

Wingspan™ Stent System- Time Selection and Complication Rate

Patients enrolled Follow up

Clopidogrel™ 75mg day 1-5

AMT

PTAS

Clopidogrel™ 75mg day 1-5, with option of loading dose between 6 and 24 hours prior to PTAS

Clopidogrel™ 75mg daily

DAY 90

Randomized

Chimowitz Journal of Stroke and Cerebrovascular Diseases, Vol. 20, No. 4 (July - August), 2011: pp 357-368

Different Antiplatelet Therapy in 2 Groups

*Not all patients received the 600mg loading dose.

Medicine

Chimowitz MI, Lynn MJ, Derdeyn CP, et al. Stenting versusaggressive medical therapy for intracranial arterial stenosis.N Engl J Med 2011;365:993-1003.

DOI:10.3760/cma.j.issn.0578-1426.2013.03.00

Interventional therapy is one of the therapies to treat symptomatic ICAD patients. As inadequate evidence based, it should be a supplemental therapy for medical treatment, it can be conducted in selective patents.

Interventional therapy could be a supplemental therapy for ICAD patients whose vessels have ≥70% stenosis, and who are refractory to standard medical therapy with non/low collateral circulation.

Chinese Experts’ Consensus of Symptomatic ICAD PTAS Treatment

Summary

• PTAS performed by an experienced Operator in a hemodynamic impaired Patient at the right Timing with with adequate Medicine benefit all.

• Otherwise, it may harms everyone.