Gates Vascular Institute Kaleida Global Vascular Center Jacobs Institute UB Translational Research Center Gates Vascular Institute

Intracranial Atherosclerotic Disease Techniques for Safe Intervention L. Nelson Hopkins, MD, FACS Professor of Neurosurgery Department of Neurosurgery – University at Buffalo President, Gates Vascular Institute, Buffalo, NY Vernard Fennell, MD, MSc Endovascular Fellow

Disclosure Statement of Financial Interest 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 Grant/Research Support Consulting Fees/Honoraria Major Stock Shareholder/Equity Royalty Income Ownership/Founder Intellectual Property Rights Other Financial Benefit1 Toshiba, Medtronic, Microvention None Claret, Boston Scientific, Medina, Ostial, Apama, Ocular, Silk Road, TSP TSP

Intracranial Stenosis Common … Dangerous…Treatable with Risk Natural Hx (Sx stenosis) is Poor Med therepy 12-24% 1 Yr M&M Coumadin is dangerous (WASID) Primary Stenting high risk Restenosis is common (25-40% BMS) 7-10% of Ischemic CVA’s 70-90,000 CVA’s 15-20% Recurr Rate Warning TIA- 20%

Pts with 70-99% symptomatic stenosis highest risk of stroke WASID Trial Aspirin = Coumadin for AIS prevention, BUT… Coumadin caused more hemorrhage Pts with 70-99% symptomatic stenosis highest risk of stroke 18-22% at 1 year …an opportunity for endovascular treatment ??

Rapid stenting of symptomatic 70-99% intracranial stenosis Randomized 451 patients to Wingspan Stent or Aggressive medical therapy, 2008-2013 Rapid stenting of symptomatic 70-99% intracranial stenosis All patients dosed aspirin and plavix ++ Biweekly checks & counseling

SAMMPRIS Results: 30-day rate of the primary endpoint 14.7% PTAS vs. 5.8% AMM 1-year rate of the primary endpoint 20.0% PTAS vs. 12.2% AMM

SAMMPRIS: What Happened? Recently sx “Hot” plaques stented acutely A little goes a log way Wire perforation & Dissection Reperfusion hemorrhage “Snow plow” Perforator infarction “Cheesegrater” effect = infarction or perforation Vessel Rupture

SAMMPRIS Trial What Did We Learn Wingspan stent for recently symptomatic intracranial stenosis is dangerous Really aggressive medical therapy is somewhat effective (12% at one year) but not practical in general population SAMMPRIS stopped intervention for intracranial stenosis… A disaster for patients

Could the answer come from an old solution?

Case 45 year old man presents with left hand numbness TIA. Cardioembolic workup was negative, but angiography confirmed right MCA near-occlusive stenosis.

1.25 Balloon

6 months post-plasty: no symptoms

Submaximal Angioplasty: UBNS Experience 2007-2011 41 patients: 1 year stroke-free survival 93% 2 perioperative complications Vessel perforation: pt died POD 4 Reperfusion hemorrhage: MRS 3 -> 4 1 30 day – 1 year ischemic event

UB Angioplasty Experience Compares Favorably to SAMMPRIS Data

Stroke-Free Survival: UB Data

Complication 1: Reperfusion Hemorrhage Case 8: A 76 year old woman presented with a large MCA infarction, MRS score of 3 on presentation. Submaximal angioplasty of the right MCA was performed without incident. On postoperative day 1, she was found to have a neurological decline with diminished level of arousal. Noncontrast CT revealed a right frontal reperfusion hemorrhage. MRS at discharge Lesson Less dilitation is better

Complication 2: Vessel Perforation Case 10: A 67 year old woman underwent right MCA angioplasty. Intraoperatively, with microwire manipulation, extravasation was noted. Postoperative noncontrast CT revealed diffuse subarachnoid hemorrhage. She died of complications from the hemorrhage on postoperative day 4. Lesson Extreme care Soft wires

Complication 3: 30-day to 1 year Delayed stroke -A 50 year old man developed confusion four months after initial angioplasty. -Lost to FU…No 3 Month angio… -MRI was consistent with subacute ischemic event (arrows) ipsilateral to prior MCA angioplasty. -Revision angioplasty with placement of stent was performed. -No further sx Lesson Meticulous follow up

Sub-maximal angioplasty

Endovascular Treatment Symptomatic Intracranial Atherosclerotic Disease Our Approach Staged Angioplasty and Stent Submaximal Angioplasty (2/3 Reference vessel) Allow Healing 2-3 months Repeat imaging Delayed Stent (undersized) PRN

Sub-Maximal Angioplasty Safe and Effective 65 patient s w/ ICAD 75% w/ anterior circulation stenosis Stroke rate post sub max angioplasty 0% at 30d 5.5% at 1 year Mortality + hemorrhage 0%

Conclusions ICAD carries a high risk of stroke Stenting “hot” lesions is dangerous Sub-maximal angioplasty carefully performed is safe and effective Subsequent recurrent stenosis can be safely treated with slightly undersized stents

Thank you!