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

2. 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

3. 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

4. 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%

5. 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 ??

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

7. 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

8. 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

9. 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

10. Could the answer come from an old solution?

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

12. 1.25 Balloon

13. 6 months post-plasty:
no symptoms

14. 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

15. UB Angioplasty Experience Compares Favorably to SAMMPRIS Data

16. Stroke-Free Survival: UB Data

17. 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

18. 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

19. 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

20. Sub-maximal angioplasty

21. 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

22. 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%

23. 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

24. Thank you!