1. Consensus of ICAD treatment after SAMMPRIS in China Zhujiang Hospital Zhujiang Hospital Nanfang Medical University Liu Yajie, MD Pros &Cons of PTAS in ICAD Zhujiang Hospital Zhujiang Hospital Nanfang Medical University Liu Yajie, MD

2. Kasner SE, et al. Circulation. 2006;113:555-563 HR=2.03,P =0.0025 We will Continue with Clinical Trials

3. AMT superior to PTAS by 30-day rates of Stroke and Death Chimowitz MI et al. N Engl J Med.365(11):993-1003 SAMMPRIS Results

4. Whacan we learn from SAMMPRIS? Should we stop PTAS after SAMMPRIS? Should we consider future clinical trials? Does PTAS do more harm ?

5. Operator 20 most recent consecutive cases of intracranial stenting or angioplasty. 1. Wingspan ™ Stent System 2. Balloon-mounted coronary stent 3. Self-expanding stent for aneurysm 4. Angioplasty alone A minimum of 3 Wingspan ™ Stent System cases was required to be considered for credentialing. Average 3-4 procedures / enrolled doctor, when SAMMPRIS was halted. Chimowitz MI et al.J Stroke Cerebrovasc Dis 20(4):357-68. Chimowitz NEJM 2011

6. CAS Learning Curve – 72 CASES for Matured Operator William A. Gray,et al.J Am Coll Cardiol Intv 2011;4:235– 46

7. Facilitate More Complex PTAS

8. Zaidat OO, et al. Neurology. 2008;70:1518–1524 Primary end point ： 30d Stroke or death/ ipsilateral stroke after 3 months Primary end point (%) 总体 24 小时 30 天 6 个月 NIH Wingspan ™ Stent System had lower event rate in low volume centers vs. high volume centers, operator skill is key factor in PTAS P=0.022 Learning Curve for PTAS?

9. S GAO, et al.Front Neurol. 2011 Feb 15;2:6. Pathogenesis and PTAS Patient

10. PTAS not suitable for PA occluded patients

11. Hemodynamic impaired more suitable for PTAS Pathogenesis and PTAS

13. Predictors of ischemic stroke in the territory of a symptomatic intracranial arterial stenosis. Kasner SE, Chimowitz MI, Lynn NJ, et al.: Circulation 2006, 113:555-563. Timing

14. Chimowitz MI et al. N Engl J Med.365(11):993-1003

15. F. Nahab et al.Neurology. 2009 Jun 9;72(23):2014-9. Wingspan ™ Stent System- Time Selection and Complication Rate

16. Patients enrolled Follow up Clopidogrel™ 75mg day 1-5 AMT PTAS Clopidogrel™ 75mg day 1-5, with option of loading dose between 6 and 24 hours prior to PTAS Clopidogrel™ 75mg daily DAY 90 Randomized Chimowitz Journal of Stroke and Cerebrovascular Diseases, Vol. 20, No. 4 (July - August), 2011: pp 357-368 Different Antiplatelet Therapy in 2 Groups *Not all patients received the 600mg loading dose. Medicine

17. Chimowitz MI, Lynn MJ, Derdeyn CP, et al. Stenting versus aggressive medical therapy for intracranial arterial stenosis. N Engl J Med 2011;365:993-1003.

18. DOI:10.3760/cma.j.issn.0578-1426.2013.03.00 Interventional therapy is one of the therapies to treat symptomatic ICAD patients. As inadequate evidence based, it should be a supplemental therapy for medical treatment, it can be conducted in selective patents. Interventional therapy could be a supplemental therapy for ICAD patients whose vessels have ≥70% stenosis, and who are refractory to standard medical therapy with non/low collateral circulation. Chinese Experts’ Consensus of Symptomatic ICAD PTAS Treatment

19. Summary PTAS performed by an experienced Operator in a hemodynamic impaired Patient at the right Timing with with adequate Medicine benefit all. Otherwise, it may harms everyone.