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

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

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  1. 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

  2. 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

  3. Risk of stroke recurrence Chimowitz et al. NEJM, 2005

  4. 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

  5. Need for more effective Treatment! One Approach:Intracranial PTA and stenting

  6. 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

  7. WINGSPAN-Stentmode of deployment According to manufacturer and WINGSPAN-Study

  8. WINGSPAN-Stentmode of deployment

  9. WINGSPAN-Stentmode of deployment

  10. WINGSPAN-Stentmode of deployment

  11. WINGSPAN-Stentmode of deployment

  12. 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?

  13. WINGSPAN-Stentmode of deployment According to our modification

  14. WINGSPAN-Stentmode of deployment

  15. WINGSPAN-Stentmode of deployment

  16. WINGSPAN-Stentmode of deployment

  17. WINGSPAN-Stentmode of deployment

  18. 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.

  19. 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)

  20. 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

  21. 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%

  22. Preinterventional

  23. Treatment of stenosis, postdilation

  24. Follow up after 3 months

  25. 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

  26. 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.

  27. Conclusion • Post- instead of Predilation of the Wingspan-Stent in intracranial stenoses helps avoiding PTA and seems to be safe ??? Lower rate of restenoses ???

  28. Thank you for your attention! E-mail: andreas.ragoschke-schumm@med.uni-jena.de

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