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

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%!

Risk of stroke recurrence

Kasner et al. Circulation, 2006Kasner 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

According to manufacturer and

WINGSPAN-Study

WINGSPAN-Stentmode of deployment

WINGSPAN-Stentmode of deployment

WINGSPAN-Stentmode of deployment

WINGSPAN-Stentmode of deployment

WINGSPAN-Stentmode of deployment

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?

According to our

modification

WINGSPAN-Stentmode of deployment

WINGSPAN-Stentmode of deployment

WINGSPAN-Stentmode of deployment

WINGSPAN-Stentmode of deployment

WINGSPAN-Stentmode 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

• 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%

technical results

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.

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