Farhan Siddiq

Comparison of Primary Angioplasty With Stent Placement for Treating Symptomatic Intracranial Atherosclerotic Diseases A Multicenter Study

Background and Purpose— We sought to compare the clinical outcomes between primary angioplasty and stent placement for symptomatic intracranial atherosclerosis. Methods— We retrospectively analyzed the clinical and angiographic data of 190 patients treated with 95 primary angioplasty procedures and 98 intracranial stent placements (total of 193 procedures) in 3 tertiary care centers. Stroke and combined stroke and/or death were identified as primary clinical end points during the periprocedural and follow-up period of 5 years. The rates of significant postoperative residual stenosis (≥50% of greater stenosis immediately after the procedure) and binary restenosis (≥50% stenosis at follow-up angiography within 3 years) were also compared. The comparative analysis was performed after adjusting for age, sex, and center. Results— Fourteen procedures in the angioplasty-treated group (15%) and 4 in the stent-treated group (4.1%) had significant postoperative residual stenosis (relative risk [RR]=2.8, 95% CI, 0.85 to 9.5, P=0.09, for the adjusted model). There were 3 periprocedural deaths (1.5%), 1 in the angioplasty group (1.1%) and 2 in the stent-treated group (2.0%) and 14 periprocedural strokes (7.3%), 7 periprocedural strokes in each group (7.4% and 7.1%, respectively; hazard ratio=1.1; 95% CI, 0.57 to 1.9, P=0.85). Angiographic follow-up was available for 134 procedures (66 angioplasty-treated and 68 stent-treated cases). Forty-eight procedures (36.1%) had evidence of binary restenosis (25 of 66 angioplasties, 23 of 68 stents, P=0.85). Binary restenosis-free survival at 12 months was 68% for the angioplasty-treated group and 64% for the stent-treated group. There was no difference in follow-up survival (stroke, or stroke and/or death) between the angioplasty-treated and the stent-treated groups (hazard ratio=0.54; 95% CI, 0.11 to 2.5, P=0.44 and hazard ratio=0.50; 95%, CI 0.17 to 1.5, P=0.22, respectively, after adjusting for age, sex, and center). The stroke- and/or death-free survival at 2 years for the angioplasty-treated group and the stent-treated group was 92±4% and 89±5%, respectively. Conclusions— Stent treatment for intracranial atherosclerosis may lower the rate of significant postoperative residual stenosis compared with primary angioplasty alone. No benefit of stent placement over primary angioplasty in reducing stroke or stroke and/or death could be identified in this study.

Comparison between primary angioplasty and stent placement for symptomatic intracranial atherosclerotic disease: meta-analysis of case series.

OBJECTIVETo compare the short- and long-term rates of stroke-and/or-death associated with primary angioplasty alone and angioplasty with stent placement using a meta-analysis of published studies. Both primary angioplasty alone and angioplasty with stent placement have been proposed as treatment strategies for symptomatic intracranial atherosclerotic disease to reduce the risk of stroke-and/or-death with best medical treatment alone. However, it remains unclear which of these endovascular techniques offers the best risk reduction. METHODSWe identified pertinent studies published between January 1980 and May 2008 using a search on PubMed and Cochrane libraries, supplemented by a review of bibliographies of selected publications. The incidences of stroke-and/or-death were estimated for each report and pooled for both angioplasty alone and angioplasty with stent placement at 1 month and 1 year postintervention and then compared using a random-effects model. The association of year of publication and 1-year incidence of stroke-and/or-death was analyzed with meta-regression. RESULTSAfter applying our selection criteria, we included 69 studies (33 primary angioplasty-alone studies [1027 patients] and 36 studies of angioplasty with stent placement [1291 patients]) in the analysis. There were a total of 91 stroke-and/or-deaths reported in the angioplasty-alone–treated group (8.9%; 95% confidence interval [CI], 7.1%–10.6%), compared with 104 stroke-and/or-deaths in the angioplasty-with-stent–treated group (8.1%; 95% CI, 6.6%–9.5%) during a 1-month period (relative risk [RR], 1.1; P = 0.48). The pooled incidence of 1-year stroke-and/or-death in patients treated with angioplasty alone was 19.7% (95% CI, 16.6%–23.5%), compared with 14.2% (95% CI, 11.9%–16.9%) in the angioplasty-with-stent–treated patients (RR, 1.39; P = 0.009). The incidence of technical success was 79.8% (95% CI, 74.7%–84.8%) in the angioplasty-alone group and 95% (95% CI, 93.4%–96.6%) in the angioplasty-with-stent–treated group (RR, 0.84; P < 0.0001). The pooled restenosis rate was 14.2% (95% CI, 11.8–16.6%) in the angioplasty-alone group, as compared with 11.1% (95% CI, 9.2%–13.0%) in the angioplasty-with-stent–treated group (RR, 1.28; P = 0.04). There was no effect of the publication year of the studies on the risk of stroke-and/or-death. CONCLUSIONRisk of 1-year stroke-and/or-death and rate of angiographic restenosis may be lower in symptomatic intracranial atherosclerosis patients treated by angioplasty with stent placement compared with patients treated by angioplasty alone.

Risk factors for in-stent restenosis after vertebral ostium stenting.

Purpose: To determine whether vascular risk factors, underlying vessel diameter, and/or the type of stent affect restenosis rates for vertebral ostium stents. Methods: A single-center retrospective analysis was conducted of 44 patients (31 men; mean age 61 years, range 32–81) who underwent stenting of 48 ostial lesions in the vertebral arteries between 1999 and 2005. Only patients who underwent angiographic follow-up were included in the analysis. Cox regression analysis was utilized for risk factor association with binary restenosis (≥50% versus <50%). Stent types and stent categories were compared for differences in binary restenosis rates and lumen gain at follow-up angiography. Results: Twenty-three (48%) of 48 lesions had ≥50% stenosis at a mean follow-up of 7.7 months. Cigarette smoking was associated with higher binary restenosis rates (p=0.025), while hypertension, diabetes, hyperlipidemia, history of neck radiation, and known coronary artery and/or peripheral vascular disease were not. Reduced binary restenosis rates and improved lumen gain were seen in cobalt chromium balloon-expandable stents compared to non-cobalt chromium stents (p=0.002 and p=0.002, respectively), stainless steel balloon-expandable stents (p=0.005 and p=0.005), and the S670 stent (p=0.069 and p=0.069). The size of stent used was not associated with risk of restenosis (p=0.756). Conclusions: Cobalt chromium stents were associated with reduced restenosis, while smoking was associated with increased restenosis risk.

Factors and outcomes associated with early and delayed aneurysm treatment in subarachnoid hemorrhage patients in the United States.

BACKGROUND Recent studies from selected centers have shown that early surgical treatment of aneurysms in subarachnoid hemorrhage (SAH) patients can improve outcomes. These results have not been validated in clinical practice at large. OBJECTIVE To identify factors and outcomes associated with timing of ruptured intracranial aneurysm obliteration treatment in patients with SAH after hospitalization in the United States. METHODS We analyzed the data from the Nationwide Inpatient Sample (2005-2008) for all patients presenting with primary diagnosis of SAH, receiving aneurysm treatment (endovascular coil embolization or surgical clip placement). Early treatment was defined as aneurysm treatment performed within 48 hours and delayed treatment if treatment was performed after 48 hours of admission. RESULTS Of 32 048 patients with SAH who underwent aneurysm treatment, 24 085 (75.2%) underwent early treatment and 7963 (24.8%) underwent delayed treatment. Female sex (P = .002), endovascular embolization (P < .001), and weekday admission (P < .001) were independent predictors of early treatment. In the early treatment group, patients were more likely discharged with none to minimal disability (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.14-1.47) and less likely to be discharged with moderate to severe disability (OR 0.77, 95%CI 0.67-0.87) compared with those in the delayed treatment group. The in-hospital mortality was higher in the early treatment group compared with the delayed treatment group (OR 1.36 95%CI 1.12-1.66). CONCLUSION Patients with SAH who undergo aneurysm treatment within 48 hours of hospital admission are more likely to be discharged with none to minimal disability. Early treatment is more likely to occur in those undergoing endovascular treatment and in patients admitted on weekdays.

The effect of duty hour regulations on outcomes of neurological surgery in training hospitals in the United States: duty hour regulations and patient outcomes

OBJECT The effects of sleep deprivation on performance have been well documented and have led to changes in duty hour regulation. New York State implemented stricter duty hours in 1989 after sleep deprivation among residents was thought to have contributed to a patients death. The goal of this study was to determine if increased regulation of resident duty hours results in measurable changes in patient outcomes. METHODS Using the Nationwide Inpatient Sample (NIS), patients undergoing neurosurgical procedures at hospitals with neurosurgery training programs were identified and screened for in-hospital complications, in-hospital procedures, discharge disposition, and in-hospital mortality. Comparisons in the above outcomes were made between New York hospitals and non-New York hospitals before and after the Accreditation Council for Graduate Medical Education (ACGME) regulations were put into effect in 2003. RESULTS Analysis of discharge disposition demonstrated that 81.9% of patients in the New York group 2000-2002 were discharged to home compared with 84.1% in the non-New York group 2000-2002 (p = 0.6, adjusted multivariate analysis). In-hospital mortality did not significantly differ (p = 0.7). After the regulations were implemented, there was a nonsignificant decrease in patients discharged to home in the non-New York group: 84.1% of patients in the 2000-2002 group compared with 81.5% in the 2004-2006 group (p = 0.6). In-hospital mortality did not significantly change (p = 0.9). In New York there was no significant change in patient outcomes with the implementation of the regulations; 81.9% of patients in the 2000-2002 group were discharged to home compared with 78.0% in the 2004-2006 group (p = 0.3). In-hospital mortality did not significantly change (p = 0.4). After the regulations were in place, analysis of discharge disposition demonstrated that 81.5% of patients in the non-New York group 2004-2006 were discharged to home compared with 78.0% in the New York group 2004-2006 (p = 0.01). In-hospital mortality was not significantly different (p = 0.3). CONCLUSIONS Regulation of resident duty hours has not resulted in significant changes in outcomes among neurosurgical patients.

Effect of Carotid Revascularization Endarterectomy Versus Stenting Trial Results on the Performance of Carotid Artery Stent Placement and Carotid Endarterectomy in the United States.

BACKGROUND CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial) results, published in 2010, showed no difference in the rates of composite outcome (stroke, myocardial infarction, or death) between carotid artery stent placement (CAS) and carotid endarterectomy (CEA). OBJECTIVE To identify any changes in use and outcomes of CAS and CEA subsequent to the CREST results. METHODS We estimated the frequency of CAS and CEA procedures in the years 2009 (pre-CREST period) and 2011 (post-CREST period), using data from the National Inpatient Sample (NIS). Demographic and clinical characteristics and in-hospital outcomes of pre- and post-CREST CAS-treated and post-CREST CEA-treated patients were compared with pre-CREST CEA-treated patients. RESULTS A total of 225,191 patients underwent CEA or CAS in the pre- and post-CREST periods. The frequency of CAS among carotid revascularization procedures did not change after publication of the CREST results (12.3% vs. 12.7%, P = .9). In the pre-CREST period, the CAS group (compared with the CEA group) had higher rates of congestive heart failure (P < .001), coronary artery disease (P < .001), and renal failure (P < .001). The post-CREST CAS group had a higher frequency of atrial fibrillation (P = .003), congestive heart failure (P < .0001), coronary artery disease (P < .0001), and renal failure (P = .0001). Discharge with moderate to severe disability (P < .0001) and postprocedure neurological complications (P = .005) were more frequently reported in the post-CREST CAS group. After adjusting for age, sex, and risk factors, the odds ratio (OR) for moderate to severe disability was 1.0 (95% confidence interval [CI]: 0.8-1.2) in the pre-CREST CAS group and 1.4 (95% CI: 1.1-1.7) in the post-CREST CAS group compared with the reference group. The adjusted OR for neurological complications in the pre-CREST CAS group was 1.6 (95% CI: 1.2-2.1, P = .002), and 1.5 (95% CI: 1.1-2.0, P = .01) in the post-CREST CAS group. CONCLUSION The frequency of CAS and CEA for carotid artery stenosis has not changed after publication of the CREST. The demographics, pretreatment comorbidity profile, and in-hospital complication rates remained unchanged during the 2 time periods.

Rate of postprocedural stroke and death in SAMMPRIS trial-eligible patients treated with intracranial angioplasty and/or stent placement in practice.

BACKGROUND The SAMMPRIS (Stenting vs Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis) trial, comparing aggressive medical vs stent treatment in patients with symptomatic intracranial stenosis, was halted after a 14% stroke and death rate was observed in the stent-treated group. OBJECTIVE To study the 30-day stroke and death rate in intracranial angioplasty- and stent-treated patients meeting SAMMPRIS trial eligibility criteria. METHODS A retrospective analysis of 96 patients treated with intracranial angioplasty and stent placement at 3 university-affiliated institutions was performed. Patients were divided into SAMMPRIS trial eligible and ineligible groups based on inclusion and exclusion criteria for the SAMMPRIS trial. RESULTS Sixty-nine patients were determined to be SAMMPRIS eligible and 27 patients were ineligible. The SAMMPRIS-eligible group was divided into angioplasty- and stent-treated subgroups (30 and 39 patients, respectively). The overall 30-day postprocedure stroke and death rate was 7.2% in the SAMMPRIS-eligible group and 7.4% in the SAMMPRIS-ineligible group (P = .97). The 30-day postprocedure stroke and death rate was 3.3% in the SAMMPRIS-eligible, angioplasty-treated subgroup and 10.2% in the SAMMPRIS-eligible, stent-treated subgroup (P = .27). CONCLUSION The overall 30-day postprocedure stroke and death rate in our study was lower in both SAMMPRIS-eligible and -ineligible groups than the reported 14% stroke and death rate in the SAMMPRIS trial. We hypothesize that a more judicious use of primary angioplasty may be responsible for better postprocedure outcomes and should be considered an acceptable treatment in future trials.

Intracranial stenosis in young patients: Unique characteristics and risk factors

Background: Intracranial stenosis in young patients appears to have different characteristics from that observed in the older population. Objective: To study the differences in the pathogenesis of intracranial stenosis in younger patients as compared to the older population. Methods: The clinical characteristics of patients with angiographically confirmed intracranial stenosis were matched to a healthy population using the National Health and Nutrition Examination Study (NHANES). The study population was stratified into two age groups (≤45 and >45 years). The relative risk (odds ratios) and attributable risk of known cardiovascular risk factors were estimated. Results: A total of 17 (11%) patients from 153 patients with intracranial stenosis were aged ≤45 years. These patients were more likely to be women (53 vs. 28%, p < 0.05). The location of the lesion in the young patients was more likely to be in the internal carotid artery (65 vs. 29%, p < 0.05). When compared with the stroke risk factors from the NHANES control population, the attributable risk of hypertension, diabetes mellitus, and coronary artery disease for intracranial stenosis was lower among patients aged ≤45 years than that for patients aged >45 years (6.4 vs. 13.1%, 19.9 vs. 33.0% and 1.0 vs. 10.8%, respectively). Hyperlipidemia had a greater attributable risk of intracranial stenosis in patients ≤45 than in those >45 years of age (23.3 vs. 9.3%). Conclusions: Intracranial stenosis in young patients is predominantly located in the anterior circulation and more frequently occurs in young women. Even though the stroke risk factors appear to be strongly associated with intracranial stenosis in this age group, the impact of these risk factors is low due to the low prevalence.

Intracranial angioplasty and/or stent placement in octogenarians is associated with a threefold greater risk of periprocedural stroke or death.

Purpose: To compare the clinical and angiographic outcomes of endovascular treatment of symptomatic intracranial stenosis between octogenarian and younger patients. Methods: Data for 244 consecutive patients (173 men; mean age 61.6 years) who underwent angioplasty and/or stenting for intracranial atherosclerotic disease at 5 specialized centers were pooled. Baseline, 30-day, and follow-up clinical and angiographic information were collected. Rates of clinical and angiographic endpoints were compared between patients ≥80 years old versus those <80 years. Results: Patients ≥80 years (n = 15) were more likely to be hypertensive (87% versus 69%) and have underlying coronary artery disease (73% versus 36%, p<0.05) compared to younger patients (n=229). The rate of periprocedural stroke and/or death was 3-fold higher among patients aged ≥80 years compared with those <80 years (20% versus 7%, p=0.11). No recurrent stroke or death (excluding periprocedural events) was observed during follow-up in the octogenarian group. In patients who had follow-up angiography, a similar rate of ≥50% restenosis was observed among patients aged ≥80 years and those aged <80 years (25% versus 29%, p>0.1). Conclusion: The 3-fold higher periprocedural death and/or stroke rate suggests cautious use of intracranial angioplasty and/or stent placement in octogenarians.

The Emergence of Endovascular Treatment–Only Centers for Treatment of Intracranial Aneurysms in the United States

BACKGROUND Because of the availability of new technology, the spectrum of endovascular treatment for intracranial aneurysms has expanded widely. Some centers have started offering only endovascular treatment to patients with intracranial aneurysms (endovascular treatment-only centers [ETOCs]). Our objective was to identify the proportion and outcome of patients treated at ETOCs in the United States. METHODS We determined the proportion of ETOCs in the United States using Nationwide Inpatient Survey data files from 2010. We compared short-term outcomes between ETOCs and endovascular and surgical treatment centers (ESTCs). The outcomes studied were none to minimal disability, moderate to severe disability, in-hospital mortality, postprocedure complications, length of stay, and hospital charges. RESULTS Out of 85 hospitals performing endovascular treatment of unruptured aneurysms, 13 (15%) were categorized as ETOCs. Out of the 10,447 patients with unruptured aneurysms, 1245 (12%) were treated at ETOCs. ETOCs were more likely to be nonteaching hospitals (55% versus 45%, P=.02). The rates of in-hospital mortality (1.2% versus 1.8%) and none to minimal disability (88% versus 84%) were similar in patients treated at ETOCs and ESTC hospitals. The mean hospitalization charges were similar, but length of stay (4±7 days versus 6±10 days, P<.0001) was significantly shorter among patients treated at ETOCs. Only 2.7% patients required secondary neurosurgical procedures at the ETOCs compared with 5.8% in ESTCs (P=.09). CONCLUSION The recent emergence of ETOCs and provision of treatment with comparable outcomes and shorter length of stay at these hospitals may change the pattern of intracranial aneurysm treatment in the United States.