1. 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

2. 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

3. Risk of stroke recurrence
Chimowitz et al. NEJM, 2005

4. Risk of stroke recurrence
Subgroup analyses from WASID: 1 year risk
Stenoses %  18 %
Stenoses % and qualifying event within 30 d before study enrollment  23%!
Kasner et al. Circulation, 2006
Kasner et al. Neurology, 2006

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

6. 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

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

8. WINGSPAN-Stent mode of deployment

9. WINGSPAN-Stent mode of deployment

10. WINGSPAN-Stent mode of deployment

11. WINGSPAN-Stent mode of deployment

12. 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?

13. WINGSPAN-Stent mode of deployment
According to our
modification

14. WINGSPAN-Stent mode of deployment

15. WINGSPAN-Stent mode of deployment

16. WINGSPAN-Stent mode of deployment

17. WINGSPAN-Stent mode of deployment

18. 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.

19. 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)

20. 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

21. 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%

22. Preinterventional

23. Treatment of stenosis, postdilation

24. Follow up after 3 months

25. 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

26. 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.

27. ??? 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 ???

28. Thank you for your attention!