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Postdilation of the WINGSPAN- Stent instead of predilation is feasible and safe

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Postdilation of the WINGSPAN- Stent instead of predilation is feasible and safe. Andreas Ragoschke-Schumm 1 , Stephanie Schindhelm 1 , Peter Schmidt 1 , Sascha Schiffler 1 , Andreas Hansch 1 , Robert Drescher 1 , Martin Bokemeyer 1 , Albrecht Günther 2 , Jens Weise 2 , Thomas E. Mayer 1.

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slide1

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

symptomatic intracranial stenoses
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

risk of stroke recurrence
Risk of stroke recurrence

Chimowitz et al. NEJM, 2005

risk of stroke recurrence1
Risk of stroke recurrence
  • Subgroup analyses from WASID: 1 year risk
    • Stenoses 70-99 %  18 %
    • Stenoses 70-99 % and qualifying event within 30 d before study enrollment  23%!

Kasner et al. Circulation, 2006

Kasner et al. Neurology, 2006

need for more effective treatment
Need for more effective Treatment!

One Approach:Intracranial PTA and stenting

wingspan stent
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
wingspan stent mode of deployment
WINGSPAN-Stentmode of deployment

According to manufacturer and

WINGSPAN-Study

problem
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?
wingspan stent mode of deployment5
WINGSPAN-Stentmode of deployment

According to our

modification

study
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.
results
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)
subacute intracranial stenoses
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
technical results
technical results
  • 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%
subacute intracranial stenoses group
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
discussion
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.
conclusion
Conclusion
  • Post- instead of Predilation of the Wingspan-Stent in intracranial stenoses helps avoiding PTA and seems to be safe

??? Lower rate of restenoses ???

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