Advances in the treatment of posterior cerebral circulation symptomatic disease

Transcription

1 Advances in the treatment of posterior cerebral circulation symptomatic disease Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery Faculty of Medicine, School of Health Sciences, University of Thessaly, Greece Chairman, Dept. of Vascular Surgery, University Hospital of Larissa Larissa, Greece

2 Disclosure Speaker name: Athanasios Giannoukas I have the following potential conflicts of interest to report: Consulting Employment in industry Stockholder of a healthcare company Owner of a healthcare company Other(s) x I do not have any potential conflict of interest 2

3 Introduction One-fifth of all transient ischemic attacks (TIAs) and ischemic strokes are in the territory of the vertebro-basilar (VB) Arteries (Posterior circulation) Attract less attention than those in the carotid artery territory Bogousslavsky J, et al. Stroke 1988;19:1083e92. Markus HS, et al. Lancet Neurol. 2013;12:

4 Causes of vertebrobasilar stroke/tia Similar to those affecting the anterior circulation, including: Cardioembolism Thromboembolism Large and small artery disease Atherosclerosis (accounts for 20-25% of strokes) Stenosis mostly occur at the VA origins, but they can affect the distal VA and basilar arteries. Markus HS, et al. Lancet Neurol. 2013;12:

5 Slide with headline only TIAs due to VB circulation ischemia may be overlooked among clinically non-focal transient neurological attacks Less effective in the diagnosis and identification of high-risk posterior circulation ischemic events than carotid artery events. FAST (face arm speech test) ABCD2 score (age, blood pressure, clinical features, duration, and diabetes) Paul NL, et al Lancet Neurol. 2013;12: Hoshino T, et al. J Neurol Sci. 2013;325: Gulli G, et al. J Neurol Neurosurg Psychiatry. 2012;83:

6 Prevalence of >50% VB stenosis in patients suffering from posterior circulation TIA or minor stroke has been associated with multiple TIAs at presentation and a high early risk of recurrent stroke. 6

7 Evidence suggests that the 90-day risk of recurrent stroke is: 7% in patients with no VA Stenoses 16% in patients with extracranial VA stenoses 33% in those with intracranial VA or basilar artery stenoses 7 7

8 What about evidence on the treatment?? 8

9 Open reconstruction Access to the VA is less easy than for the ICA. Available data available are from non-controlled studies. Naylor AR et al Clinical Guidelines of ESVS. Eur J Vasc Endovasc Surg (2017) -, 1e79 9

10 A total of 27 articles were identified that met inclusion criterion, with a total of 980 patients treated with stents. Stenting and angioplasty of ECVAS appear to have a low rate of peri-procedural stroke (1.1%) or transient ischemic attack (0.8%) and restenosis rates that may not be as high as suspected (11%-30%) 10

11 Forty-two selected studies reported endovascular treatment (angioplasty or stenting, or both) of 1,117 vertebral arteries in 1,099 patients There is limited comparative evidence on the efficacy of medical, surgical, and endovascular treatment of proximal vertebral artery disease. Percutaneous transluminal angioplasty and stenting has low peri-procedural TIA events (1.5%) and combined stroke and death rate was 1.1%. Recurrent symptoms of vertebrobasilar insufficiency developed in (8%) 11

12 Ten comparative trials involving 672 patients were identified. Within 30-day follow-up and in follow up period > 1 year there was no significant difference between PTA plus MT and MT alone in vascular death, any stroke, posterior circulation TIA, posterior circulation infarction, and ischemic stroke PTA plus MT may be not superior to MT alone for SVAS treatment. 12

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14 Randomised 16 patients with symptomatic VA stenoses to angioplasty or BMT. None developed recurrent symptoms, but many patients were recruited months last TIA/stroke, that is well beyond the high-risk period for recurrent stroke. 14

15 Compared stenting (Wingspan stent) against BMT in 450 patients with symptomatic intracranial stenoses, of whom 60 (13%) had stenoses of the VA or basilar arteries Basilar artery stenoses were associated with high rates of periprocedural ischaemic stroke following stenting (21% vs. 7% for other arteries) Aggressive medical treatment was superior to angioplasty and stenting in patients with recent TIA or stroke (within past 30 days) and 70% to 99% atherosclerotic VB stenosis. 15

16 Randomised 115 symptomatic patients with >50% intra- or extracranial VA stenosis (57 stenting 58 BMT) VAST stopped prematurely due to regulatory issues and it was underpowered to show significant difference between stenting and BMT Stenting (3: stroke, MI, or vascular death) vs. BMT (1) within 30 days Stenting 12% stroke vs. BMT 7% during a median 3-year follow-up 16

17 The 30-day primary safety end point occurred in more patients in the stent group (24.1%) vs the medical group (9.4%) (P =.05) Intracranial hemorrhage within 30 days occurred in more patients in the stent group (8.6%) vs. none in the medical group (5.5%) (P =.06) The 1-year primary outcome of stroke or hard TIA occurred in more patients in the stent group (36.2%) vs. the medical group (15.1%) (P =.02) Worsening of baseline disability score (modified Rankin Scale) occurred in more patients in the stent group (24.1%) vs. the medical group (11.3%) (P =.09) 17

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22 Thank you 22

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