Stenting for Intracranial Atherosclerosis: Who, When, and How Alex - - PowerPoint PPT Presentation

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Stenting for Intracranial Atherosclerosis: Who, When, and How Alex - - PowerPoint PPT Presentation

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Stenting for Intracranial Atherosclerosis: Who, When, and How Alex Abou-Chebl, MD, FSVIN Stroke Medical Director Baptist Health Louisville Disclosure Statement of Financial Interest Within the past 12 months, I or my spouse/partner have had a

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SLIDE 1

Stenting for Intracranial Atherosclerosis: Who, When, and How

Alex Abou-Chebl, MD, FSVIN Stroke Medical Director Baptist Health Louisville

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SLIDE 2

Disclosure Statement of Financial Interest

  • Consulting Fees/Honoraria
  • Consulting Fees/Honoraria
  • Silk Road Medical
  • Angiodynamics

Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below.

Affiliation/Financial Relationship Company

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SLIDE 3

Alex Abou-Chebl, MD

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SLIDE 4

SAMMPRIS Criticisms

  • 20 Cases Vetting

Only 3 Wingspan, no need for atherosclerosis experience

  • General Anesthesia
  • Cross lesion with

microcatheter and exchange for balloon

  • Initially no post-dilation

allowed, protocol changed after

  • SBP<150mmHg post-op

SBP<120 reduced risk of ICH with CAS

  • No assessment of ASA/Plavix

response

  • Average 7days to

randomization

½ patients w ICH Tx 17days after event- Low WASID risk

  • No assessment of

cerebrovascular reserve

  • No angiographic collateral

criteria

  • Perforator strokes included
  • Stenting vessels <2.5mm
  • Lesion characteristics not

considered

Mori Classification

Alex Abou-Chebl, MD

Abou-Chebl A, Steinmetz H. Stroke 2012:43(2):616-620

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SLIDE 5

Pathophysiology

  • Thrombotic occlusion

Acute plaque rupture  Thrombosis  Vessel Occlusion  Ischemia

  • Artery-to-artery embolism

Acute plaque rupture/Turbulence/Sheer Stress  Thrombosis  Embolism  Ischemia

  • Hypoperfusion

Flow-limiting stenosis  Autoregulation Failure  Hypoperfusion  Ischemia

  • Branch Origin Occlusion- Perforator Syndromes

Atherosclerotic plaque buildup  Encroachment/Occlusion

  • stia of perforators  Ischemia
  • Combination- Impaired “Washout of Emboli”

Alex Abou-Chebl, MD

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SLIDE 6

Determinants of Risk & Severity of Clinical Manifestations

  • Stenosis Characteristics
  • Collateral Blood Flow

Cerebrovascular Reserve

  • Freq & Size of Embolism
  • Severity of Hypoperfusion
  • Duration of Ischemia
  • Underlying Brain

Substrate

Neuronal Reserve

  • Age
  • Medical Co-morbidities

Hyper/Hypoglycemia

  • CRP & Fibrinogen predictors
  • f recurrent CAD and stroke
  • Bang OY teal. JNNP 2005
  • Arenillas JF et al. Stroke.

2003;34:2463-2468.

% Survival free of ILOD-related events Months after inclusion

Patients with CRP  1.41 mg/dl Patients with CRP > 1.41 mg/dl

P< .0001

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SLIDE 7

Why Differentiating Hemodynamic

  • vs. Perforator Ischemia Matters
  • Volume of Territory at Risk
  • Eloquence of Tissue at Risk
  • Maximizing Benefit from

Revascularization

  • Reducing Risk of Revascularization

Alex Abou-Chebl, MD

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SLIDE 8

Importance of Collaterals

WASID Angiographic Dataset N=287 (of 569)

  • “Across all stenoses extent of collaterals was a predictor for

subsequent stroke in the symptomatic arterial territory”

None vs. good HR 1.14, CI 0.39-3.30

Poor vs. good HR 4.36; 95% CI, 1.46-13.07; p < 0.0001

  • 70-99% stenoses, more extensive collaterals risk of territorial stroke

None vs. good HR 4.60; 95% CI, 1.03-20.56

Poor vs. good HR 5.90; 95% CI, 1.25-27.81, p = 0.0427

  • 50-69%, presence of collaterals associated with likelihood of stroke

None vs. good HR 0.18; 95% CI, 0.04-0.82

Poor vs. good HR 1.78; 95% CI, 0.37-8.57; p < 0.0001

  • Multivariate analyses: extent of collaterals independent predictor for

subsequent stroke

None vs. good HR 1.62; 95% CI, 0.52-5.11

Poor vs. good, 4.78; 95% CI, 1.55-14.7; p = 0.0019

Alex Abou-Chebl, MD

Liebeskind D, et al. Ann Neurolo 2011;69:963-74

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SLIDE 9

Decreased Flow Reserve in Coronary Circulation

  • Stenting of non-ischemic stenoses has no benefit

compared to Med Rx only

  • Stenting of ischemia-related stenoses improves

Sx and outcome

  • In multivessel CAD, identifying which stenoses

cause ischemia difficult:

 Non-invasive tests often unreliable  Coronary angiography often results in under- or

  • verestimation of functional stenosis severity
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SLIDE 10

Assessment of Cerebrovascular Reserve

  • Acetazolamide SPECT

 Useful in combination with an anatomical study  Measures hemodynamic significance of stenosis  Identify pts. who may benefit from

revascularization

 Annual Stoke Rates as high 25%

  • Eskey & Sanelli Neuroimag Clin N Am 2005;15
  • Ozgur H, et al. AJNR 2001
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SLIDE 11

Natural History of ICAD: A Dynamic Process

  • Wong et al. Stroke 2005;33:532-6.

 Serial TCD study of 143 symptomatic MCA stenoses

  • At 6 month TCD

– 29% Normalized 4.8% Recurrent Events – 62% Stable 12.5% Recurrent Events – 9% Progressed 38.5% Recurrent Events – Total 10.5% Recurrent Events

  • Arenillas et al. Stroke 2001;32:2898-2904

 26.5month TCD study of 40 symptomatic MCA

  • 32.5% Progressed
  • 20% recurrent events

 Predictor of Stroke

  • Tandem stenosis in cervical ICA
  • Lesion Progression

Alex Abou-Chebl, MD

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SLIDE 12

Mori Classification

  • Lesion based
  • Length
  • Eccentricity
  • Predicts complications and reocclusion
  • Type A: concentric, <5mm, smooth

8%

  • Type B: eccentric, 5-10mm, angulated, irregular 26%
  • Type C: >10mm, extreme angulation, total occl. 87%

Mori T, Kazita K, Chokyu K, Mima T, Mori K. Short-term arteriographic and clinical outcome after cerebral angioplasty and stenting for intracranial vertebrobasilar and carotid atherosclerotic occlusive disease. AJNR Am J Neuroradiol 2000 Feb;21:249-254.

Alex Abou-Chebl, MD

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The Less Than Ideal ICAD Patient

 42yo woman with coital headache and stroke

Alex Abou-Chebl, MD

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SLIDE 14

Technical Result

Alex Abou-Chebl, MD

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SLIDE 15

Indications

  • >70% symptomatic stenosis

Focal, concentric, non-angulated, away from bifurcation

Distal territory Sx- no perforator Sx

  • Failed medical Rx

Antiplatelet- dual

Statin

ACE-I

  • Abnormal cerebrovascular reserve

Radiographic

Clinical

  • Pressure dependent
  • Orthostatic Sx
  • Progressive stenosis despite medical Rx

Alex Abou-Chebl, MD

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SLIDE 16

Timing of Intervention

  • Hyperperfusion syndrome can complicate CEA

and CAS ~1.1% with 0.6% risk of ICH

 80% fatality rate

Abou-Chebl A, et al. J Am Coll Cardiol 2004;43(9):1596-1601

  • Small (N=18) series suggested high complication

rates ~50% w early intracranial intervention

Gupta R, et al. Neurology 2003;61:1729–1735

  • Significant risk with delay in Tx- 56% recurrent

events in 28days

Kozak O, et al. Neurosurgery 2011;69:334–343

  • SAMMPRIS- risk of ICH independent of timing of

intervention relative to index event

Fiorella D, et al. Stroke 2012;43:2682-2688

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SLIDE 17

Approach

  • Local anesthesia

 Intraprocedural neurological assessments guide

therapeutic approach

  • Primary stenting for vessels >2.5mm diameter

 PTA for smaller vessels  Bailout stenting

  • No wire exchanges or crossing with microcatheter

 Cross with wire in balloon

  • Slowly predilate all lesions

 NTG  Size balloon 0.8:1  Never oversize or use stiff wires and balloons

Alex Abou-Chebl, MD

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SLIDE 18

Intra-procedural Patient Monitoring

  • 67% Developed Headache

Balloon Inflation 79.2%

Wire Positioning 62.5%

Stent Delivery 20.9%

Stent Deployment 16.7%

  • 4.8% Developed Sx of Ischemia

2/3 Brainstem Hypoperfusion during PTA

  • Decrease Inflation Duration

1/3 Hemispheric after Completion of Intervention

  • Repeat Angiogram  Stent Thrombosis
  • GPIIb/IIIa Inhibitor
  • Successful Recanalization  Recovery

Abou-Chebl A, et al. J Neuroimaging 2006;16(3): 216-223

Alex Abou-Chebl, MD

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SLIDE 19

Clopidogrel Response and Risk of Peri- procedural Thrombotic Complications with Cerebrovascular Interventions

  • Unpublished data

 N=71 (2000-2002)  Optical Platelet Aggregometry

  • ADP and Arachidonic Acid

Total Patients without Thrombotic Complication Patients with Thrombotic Complication Endovascular 60 53 7 ADP %- aggregation (mean±SD) 33±16.3% 31±14.8% 54.6±16.2% p=0.008 AA %- aggregation 22.6±10.2 22.3±10.3% 26±8.7% p=0.32

ADP- adenosine diphosphate, SD- standard deviation, AA- arachidonic acid

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SLIDE 20

Smout J, Macdonald S, Stansby G International Journal of Stroke. Vol5, Dec 2010; 477-482 Gray et al: JACC Interv 2011

Importance of Experience

Alex Abou-Chebl, MD

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SLIDE 21

U.S.-China Multicenter Balloon Expandable vs. Self-Expanding Stent Registry

  • 670 lesions treated in 637 patients
  • Mean age 57±13 years
  • Location of stent placement:

 MCA 270 (40%)  Posterior circulation 263 (39%)  Intracranial ICA 137 (21%).

  • Stent type:

 BMS 68%, DES 5%, SES 32%  Technical failure rate: BMS 7.1% and SES 1.4%, (p<0.001) Jiang W, Cheng-Ching E, Abou-Chebl A , et al. Neurosurgery 2011

Alex Abou-Chebl, MD

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SLIDE 22

Results

  • 30 day peri-procedural stroke or death

6.1%

  • Deaths

0.94%

  • Independent Predictors of Stroke or Death

Variable OR 95% CI p

Treatment < 24 hrs 4.0 1.6 -6.7 < 0.001 Mori Type A 0.31 0.13 – 0.72 0.007

Alex Abou-Chebl, MD

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SLIDE 23

Summary

  • Intracranial Atherosclerosis is Common
  • With Med Tx Recurrence Rates are ~12-22%/yr

 Aspirin+clopidogrel+atorva/rosuvastatin is “Best”

Medical Therapy

  • No role for Warfarin
  • PTA/Stenting safe and effective in selected symptomatic

patients

 Most effective in patients with decreased

cerebrovascular reserve

  • Treatment should not be delayed in non-disabled

patients

  • Operator experience and appropriate technique are

critical for success

Alex Abou-Chebl, MD