Stenting Versus Aggressive Medical Therapy for Intracranial Arterial Stenosis
What is the role of percutaneous transluminal angioplasty and stenting (PTAS) for intracranial arterial stenosis?
The investigators randomly assigned patients who had a recent transient ischemic attack or stroke attributed to stenosis of 70-99% of the diameter of a major intracranial artery to aggressive medical management alone, or aggressive medical management plus PTAS with the use of the Wingspan stent system. The primary endpoint was stroke or death within 30 days after enrollment or after a revascularization procedure for the qualifying lesion during the follow-up period, or stroke in the territory of the qualifying artery beyond 30 days.
Enrollment was stopped after 451 patients underwent randomization, because the 30-day rate of stroke or death was 14.7% in the PTAS group (nonfatal stroke, 12.5%; fatal stroke, 2.2%) and 5.8% in the medical-management group (nonfatal stroke, 5.3%; non–stroke-related death, 0.4%) (p = 0.002). Beyond 30 days, stroke in the same territory occurred in 13 patients in each group. Currently, the mean duration of follow-up, which is ongoing, is 11.9 months. The probability of the occurrence of a primary endpoint event over time differed significantly between the two treatment groups (p = 0.009), with 1-year rates of the primary endpoint of 20.0% in the PTAS group and 12.2% in the medical-management group.
The authors concluded that in patients with intracranial arterial stenosis, aggressive medical management was superior to PTAS.
This study suggests that aggressive medical therapy was superior to PTAS in high-risk patients with intracranial stenosis, because the rate of periprocedural stroke after PTAS was higher than expected and the rate of stroke in the medical-management group was lower than estimated. Essential elements of the aggressive medical regimen used in this trial can readily be adopted in clinical practice, including adding clopidogrel to aspirin for the first 90 days and lowering blood pressure and low-density lipoprotein cholesterol to achieve target levels based on national guidelines. Until additional data are available, there does not appear to be a role for PTAS in the management of patients with intracranial stenosis.
Keywords: Stroke, Ischemic Attack, Transient, Dietary Proteins, Vascular Diseases, Ticlopidine, Blood Pressure, Constriction, Pathologic, Angioplasty, Stents, Cholesterol, Coronary Angiography, Cardiology, Suicide
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