Friedrich-Schiller-University, Jena, Germany 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

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

Risk of stroke recurrence Chimowitz et al. NEJM, 2005

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

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

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

WINGSPAN-Stent mode of deployment According to manufacturer and WINGSPAN-Study

WINGSPAN-Stent mode of deployment

WINGSPAN-Stent mode of deployment

WINGSPAN-Stent mode of deployment

WINGSPAN-Stent mode of deployment

Does primary Stent-deployment help avoid dilation at all? 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?

WINGSPAN-Stent mode of deployment According to our modification

WINGSPAN-Stent mode of deployment

WINGSPAN-Stent mode of deployment

WINGSPAN-Stent mode of deployment

WINGSPAN-Stent mode of deployment

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.

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)

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

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%

Preinterventional

Treatment of stenosis, postdilation

Follow up after 3 months

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

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.

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

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