Friedrich-Schiller-University, Jena, Germany
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Transcript of Friedrich-Schiller-University, Jena, Germany
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Postdilation of the WINGSPAN-Stent instead of predilation is
feasible and safe
Andreas Ragoschke-Schumm1, Stephanie Schindhelm1, Peter Schmidt1, Sascha Schiffler1, Andreas Hansch1, Robert Drescher1, Martin
Bokemeyer1, Albrecht Günther2, Jens Weise2, Thomas E. Mayer1 Friedrich-Schiller-University, Jena, Germany
1Department of Neuroradiology, 2Department of Neurology
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Symptomatic intracranial stenoses
• Important cause of stroke, especially in blacks, Asians, and Hispanics. – 10% in the white population– 30% in the chinese population
• WASID trial: no benefit of warfarin over ASS but more complications ASS conventional therapy of choice
Chimowitz et al. NEJM, 2005
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Chimowitz et al. NEJM, 2005
Risk of stroke recurrence
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• Subgroup analyses from WASID: 1 year risk
– Stenoses 70-99 % 18 %– Stenoses 70-99 % and qualifying event within
30 d before study enrollment 23%!
Risk of stroke recurrence
Kasner et al. Circulation, 2006Kasner et al. Neurology, 2006
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Need for more effective Treatment!
One Approach:Intracranial PTA and stenting
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WINGSPAN-Stent
• Self expanding Nitinol-Stent, Over-The-Wire• Indication: symptomatic intracranial stenoses• Diameter: 2.5 mm – 4.5 mm, length 9, 15, 20 mm
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According to manufacturer and
WINGSPAN-Study
WINGSPAN-Stentmode of deployment
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WINGSPAN-Stentmode of deployment
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WINGSPAN-Stentmode of deployment
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WINGSPAN-Stentmode of deployment
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WINGSPAN-Stentmode of deployment
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Problem• Predilation poses potential risk of unprotected dissection, vessel occlusion or vessel
rupture
• There are cases where stenting alone could lead to sufficcient treatment of the stenosis
Questions
• Does primary Stent-deployment help avoid dilation at all?
• Does postdilation harm the stent or the patient?
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According to our
modification
WINGSPAN-Stentmode of deployment
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WINGSPAN-Stentmode of deployment
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WINGSPAN-Stentmode of deployment
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WINGSPAN-Stentmode of deployment
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WINGSPAN-Stentmode of deployment
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Study
• Retrospective• All Patients that were treated with wingspan stents were
assessed for technical success• All Patients treated for symptomatic intracranial stenoses
were assessed for treatment assocciated complications, periprocedural outcome and restenoses.
• Indication: interdisciplinary with a neurologist• Postprocedural follow-up (DSA after 6 months,
Doppler/Duplex-Sonography and neurological examination every 3 months during the first year.
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results
• Observation time 02/2008 - 09/2010• 34 Patients (25 m, 9 f), Wingspan N=40• 24 patients were treated with subacute
symptomatic stenoses (>24 hrs.)• 9 with acute vessel occlusion (all
vertebrobasilar)• 1 with acute aneurysmal SAH (dissection during
endovascular embolisation)
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Subacute intracranial stenoses
• Average stenosis rate 75% (55%-99%)• Age: average 60.7 yrs, (ranging from 43 to
80 yrs.)• Postinterventional follow-up (max. 158 d,
median 133 d)• No follow-up in 1 patient
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• Stent localisation (28/40) 70% anterior – (12/40) 30% posterior circulation
• Technical success (40/40) 100%• Predilation (2/40) 5%• Postdilation (21/40) 52.5%• Dissection C2-Segment during postdilation
(asymptomatic but treated with a stent)• Stent deformation (2/40) 5%
technical results
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Preinterventional
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Treatment of stenosis, postdilation
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Follow up after 3 months
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Subacute intracranial stenoses-Group
• 1 major stroke (basilar artery) with extensive new infarcts in the brainstem and posterior circulation. Death
• 1 Patient (proximal MCA) with mild transient neurologic impairment and small new DWI-Lesions in postprocedural MRI
(2/24) 8.3%• 1 Patient with mild hyperperfusion Syndrome
(headaches) 4.2%• Restenoses (3/24) 12.5%• No intracranial bleedings
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Discussion
• In 42.5% of Stents no dilation was needed
• The rate of 8.3% of periprocedural strokes is within the range of complications reported for intracranial stenting
• Restenosis-rate of 12.5% is remarcably low but could increase with longer follow-up.
• Visible Stent deformation in 5% but did not impair clinical outcome.
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Conclusion
• Post- instead of Predilation of the Wingspan-Stent in intracranial stenoses helps avoiding PTA and seems to be safe
??? Lower rate of restenoses ???