Disclosures Your Patient Has Carotid Bulb Stenosis and a Tandem Intracranial Stenosis: How Do SAMMPRIS and Other Evidence Inform Your Treatment? UCSF Vascular Symposium 2015 Steven W. Hetts, MD Associate Professor of Radiology Interventional Neuroradiology University of California, San Francisco Chief Medical Officer: ChemoFilter Scientific advisory: Medina Medical Consulting: Stryker Neurovascular, Silk Road Medical Data Safety and Monitoring Committee: DAWN trial Core Imaging Lab: MAPS, FRED, SURMOUNT, and ATLAS trials Grant support: NIBIB, NCI, Siemens I will discuss off-label uses of devices (stents, balloons) I have borrowed liberally from my colleagues and acknowledge their kind help: Christopher Dowd, MD, Joey English, MD, PhD, Daniel Cooke, MD, Peter Jun, MD, Van Halbach, MD, Randall Higashida, MD Lecture Outline Cervical Atherosclerotic Disease Scope of disease Trials Practical considerations Intracranial Atherosclerotic Disease Scope of disease Trials Practical considerations Future directions CREST Trial: Summary Brott et al, NEJM 2010 363:11-23 Composite death, stroke, and MI does not differ between CAS and CEA in sxs and asx patients Paradoxically, in patients under 70 years, CAS may be more advantageous than in patients over 70 years Higher periprocedural stroke risk with CAS Higher periprocedural MI risk with CEA 1
CAS: Patient Selection Hemodynamically Significant > 50-70% Failed Medical Therapy Clinically Symptomatic Stroke TIA Focal Neurological Signs Amaurosis Fugax Carotid Stenting Indications High Risk Surgical Patients Severe Coronary or Pulmonary Disease Recent MI, Stroke Surgically Difficult Access Lesions arising off Aortic Arch Lesions above the Mandible >C2 All Intracranial Lesions Traumatic or Spontaneous Dissections Relative Carotid Stenting Indications Multiple Vessel Disease Occlusion of Contralateral Carotid or Vertebral Tandem Stenosis with Intracranial Lesion Recurrent Stenosis Post Endarterectomy History of Cervical Radiation Long Segment Lesions >4 cm Traumatic Carotid Pseudoaneurysms Pre Treatment Assessment Complete Neurological Assessment Brain MRI/CT Scan Anti-Platelet Medications Cerebral Blood Flow Studies Complete Angiographic Assessment 2
53 yo F with progressive stepwise L hemiparesis Case Example Tandem cervical ICA and MCA stenoses Treatment options Medical management Stent cervical ICA under conscious sedation Stent cervical ICA under MAC Stent cervical ICA under GA Stent cervical ICA and PTA MCA under GA Stent cervical ICA and stent MCA under GA ECA-ICA bypass Run the other way 3
Cervical ICA stenting Cerebral diagnostic DSA pre ICA stent Cerebral DSA pre and post ICA stent Initially no change in HP post ICA stenting, then worsening HP 4
Original DWI before ICA stenting New areas of temporal ischemia Now what would you do? CT Perfusion Medical management ICU pressor challenge PTA MCA Stent MCA ECA-ICA bypass Run the other way Get more imaging rcbv MTT 5
CT Perfusion M2 MCA severe stenosis rcbv MTT ICAD: Scope of Disease 8-10% of strokes and TIAs in USA due to ICAD 70,000-90,000 strokes/tias per year Recurrent stroke risk 15-25% per year Higher ICAD rate in Black, Asian, and Hispanic populations Medical Therapy for ICAD Anticoagulation for ICAD described in 1955 Retrospective studies suggested warfarin was superior to ASA for ICAD stroke prevention WASID (2005): landmark prospective trial comparing ASA to warfarin for recurrent stroke/tia prevention WASID showed no benefit of warfarin over ASA and increased risk of bleeding 6
ECA-ICA Bypass for ICAD Described in 1967 to prevent stroke in patients with symptomatic ICA or MCA stenoses Prospective ECIC bypass trial (NEJM 1985) 1377 pts randomized to bypass or medical tx ECIC bypass no better for ICA lesions ECIC bypass worse for severe MCA stenoses COSS Trial (stopped in 2010 by NIH) ECIC bypass for carotid occlusion patients with increased oxygen extraction fraction by PET PTA and Stenting for ICAD WASID trial suggested that best medical therapy for ICAD still had high risk for recurrent stroke Reasonable to research PTA and stenting as well as new medications for ICAD Off label use of coronary PTA balloons since 1980s Off label use of coronary stents since 1990s SAMMPRIS Trial Randomized symptomatic ICAD patients to medical therapy (ASA/clopidogrel) or stent designed for ICAD plus ASA/clopidogrel M2 MCA severe stenosis MCA PTA 7
Stenting catheter navigation MCA stenting DSA post MCA revascularization DSA before ICA and MCA stenting 8
DSA post MCA revascularization Intracranial Atherosclerosis: Ischemic Stroke Mechanisms 1. Flow-limiting -> Hypoperfusion -> Deep Watershed Ischemia 2. Distal Emboli -> Wedged-Shaped Cortical Infarcts 3. Perforator Injury -> Deep Lacunar Infarcts SAMMPRIS TRIAL SAMMPRIS TRIAL Predicted Event Rates: 30 day 1 year Predicted Event Rates: 30 day 1 year Medical Arm 11% 25% Stenting Arm 5-9% 8-15% Medical Arm 11% (5.8%) 25% Stenting Arm 5-9% (14.7%) 8-15% 9
WINGSPAN STENT SYSTEM Important SAMMPRIS Information to Follow 1. Influence of Presenting Pattern of Ischemia and/or Location of Stenosis on the Risk of Procedural Ischemia 2. Extent/Location of Infarction and Timing of Revascularization Potential Complications 1. Flow-limiting -> Hypoperfusion -> Deep Watershed Ischemia 2. Distal Emboli -> Wedged-Shaped Cortical Infarcts 3. Perforator Injury -> Deep Lacunar Infarcts 4. Reperfusion Injury -> Edema and/or Hemorrhage 5. Procedural -> Wire Perforation, SAH/IPH Future Directions in Cervical and Intracranial Atherosclerosis Medical new antiplatelets statins Surgical CEA for many, CAS for some Endovascular: optimization of stenting Distal emboli Perforator occlusion Patient selection based on stroke type Thank You steven.hetts@ucsf.edu 10