Comprehensive Risk Analysis of the Wingspan Stent in Relation to Target Vessels.

Objective: To facilitate understanding for the safe use of the Wingspan stent, a comprehensive literature analysis was conducted, and incidence rates of 30-day stroke or death before and after the Stenting versus Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial were compared. We also investigated the associations between 30-day stroke or death rate and four lesion vessels, the internal carotid artery (ICA), middle cerebral artery (MCA), basilar artery (BA), and vertebral artery (VA). Methods: We searched MEDLINE, Embase, Web of Science, and Cochrane Library databases. The incidence rates of 30-day stroke or death in pre- and post-SAMMPRIS were compared using forest plots and funnel plots. Results: Thirty studies (15 before and 15 after the SAMMPRIS) were identified, comprising 2071 patients. Post-SAMMPRIS studies showed lower incidence rates of 30-day stroke or death compared to the pre-SAMMPRIS studies (8.5% vs. 5.6%, p = 0.014). The odds ratio of 30-day stroke or death of the post-SAMMPRIS group compared to that of the pre-SAMMPRIS group was 0.64 (95% confidence interval: 0.45-0.92, p = 0.014). The average 30-day stroke or death rates of overall, pre-, and post-SAMMPIS studies were 1.1%, 1.1%, and 1.1% for ICA; 6.2%, 8.8%, and 5.3% for MCA; 0.9%, 6.0%, and 2.7% for VA; and 13.5%, 15.1%, and 12.5% for BA, respectively. The post-SAMMPRIS study group showed significantly lower event rates for the treatment of MCA and VA than the pre-SAMMPRIS group did (p = 0.003 and p = 0.006, respectively). The incidence rates of ischemic and hemorrhagic stroke were 3.5% and 2.0%, respectively. Conclusion: This systematic surveillance study indicated that the modification of the indications for use based on the results of the SAMMPRIS trial for the Wingspan stent was effective in reducing 30-day stroke or death.

Technique for Treatment of a Symptomatic Intracranial Stenosis With Balloon Angioplasty and Wingspan Stent Placement: 3-Dimensional Operative Video.

Intracranial angioplasty and stenting is an increasingly common modality to treat intracranial atherosclerosis, which accounts for 80 000 strokes annually. Early trials showed there to be a high complication rate1,2 associated with stenting but with improved technique this complication rate has dramatically decreased.3 The following video details the procedure of intracranial balloon angioplasty and stenting for a high-grade stenosis of the right internal carotid artery. The risks and benefits of the procedure were discussed with the patient and they consented to the procedure.

Quantitative Magnetic Resonance Angiography Fails to Screen In-Stent Restenosis but Predicts Good Long-Term Outcome.

Wingspan stent in the setting of symptomatic intracranial atherosclerotic disease (ICAD) has shown to be associated with in-stent restenosis (ISR). Conventional angiography is typically used to detect ISR, but quantitative magnetic resonance angiography (QMRA), a non-invasive measure of blood hemodynamics, has also been used to screen for ISR. This report highlights a case where QMRA failed to screen for ISR in a patient who received a Wingspan stent for symptomatic intracranial vertebral artery stenosis but predicted good long-term outcome. The patient remained asymptomatic and had robust vertebrobasilar flow at long-term follow-up despite developing ISR.

Isolated Focal Basilar Artery Stenosis with Acute Stroke Treated with Emergency Thrombectomy and Stenting.

Strokes due to basilar artery (BA) stenosis/occlusion are devastating. As it is an uncommon cause of stroke, its optimal management is not clearly defined. We present the case of a 68-year-old male with a background history of hypertension, hyperlipidaemia, and smoking who developed a sudden onset of reduced consciousness, myoclonic jerks, generalised weakness, and nausea due to an occluded mid-segment BA with right occipital and left cerebellar infarcts. Emergent cerebral angiography was performed and he was immediately treated by clot retrieval and, due to underlying arterial stenosis, the immediate placement of a stent within 3 h of symptom onset. He had complete neurological recovery within 1 week, with no neurological deficits. He remained well at follow-up 3 months later. Emergency revascularisation of stroke due to BA occlusion should be considered as a treatment option.

Regression of in-stent restenosis after using a Wingspan stent to treat intracranial atherosclerotic stenosis: A case report and 5-year follow-up

In-stent restenosis occurs in approximately 30% of patients after receiving a Wingspan stent to treat symptomatic intracranial atherosclerosis. This report describes a 55-year-old man with intracranial atherosclerotic internal carotid artery terminus stenosis who developed significant in-stent restenosis. Follow-up angiogram 5 years later demonstrated the regression of restenosis without invasive intervention.

Changes of high-resolution magnetic resonance imaging before and after Wingspan stent in patients with intracranial large artery stenosis / 中国脑血管病杂志

Objective To evaluate the imaging changes of the arterial wall and lumen at the site of intracranial large artery lesions with high-resolution magnetic resonance imaging (HR-MRI) before and after Wingspan stent implantation.Methods From December 2013 to December 2014,9 patients with symptomatic intracranial arterial stenosis (stenosis rate:70%-99%) admitted to the Department of Interventional Neuroradiology,Xuanwu Hospital,Capital Medical University were enrolled retrospectively.The sites of the lesions included middle cerebral arteries,basilar artery,and intracranial segment of vertebral artery.Head 3D HR-MRI technique was used to analyze and compare the changes of the tube-wall enhancement areas in the lesion sites through image registration and matching.The consistency of stenosis rates measured by HR-MRI and DSA was compared through Pearson correlation analysis and Bland-Altman Plot.Results The success rate of technique was 100% without related complications.(1) After Wingspan stent implantation,the gadolinium enhancement in the vascular walls of the stenosis sites was decreased significantly compared with that before procedure.The area of enhancement decreased was 87±16% after stent implantation compared with before implantation,and the difference was statistically significant (t=2.325,P=0.049).(2) Before stent implantation,the mean stenosis rates of the HR-MRI and DSA measurements were 82±6% and 82±8% respectively,and the difference was not statistically significant (t=0.051,P=0.961);after procedure,the mean stenosis rates of HR-MRI and DSA measurements were 16±12% and 21±12% respectively,and the difference was not statistically significant (t=1.345,P=0.216).(3) The Pearson correlation coefficients of HR-MRI and DSA for stenosis rate measurement before and after stent implantation were 0.347 (P=0.361) and 0.545 (P=0.129) respectively.Bland-Altman statistical images showed that most of the data points were within the consistency limit (x-±1.96 s).Conclusions As an in vivo noninvasive imaging means,HR-MRI can be used to assess the changes of vascular walls of the lesion sites,the vascular lumen,and the original plaques after the intracranial stent release.It can also be used to evaluate the reconstruction of intracranial arterial walls.

Endovascular reconstruction of internal carotid artery dissection in patients with acute ischemic stroke using the Wingspan stent.

OBJECTIVE: The purpose of this study is to demonstrate our experience in endovascular reconstruction of carotid dissections using the Wingspan Stent System™ (Boston Scientific, Natick, MA, USA), a device we use because of its high radial force and its navigation in extreme curves. METHODS: We treated 11 consecutive patients with acute ischemic stroke due to carotid dissection with the Wingspan stent, in the cervical carotid artery. RESULTS: Functional evaluation revealed that 10 of the 11 patients were independent at 3 months post surgery and that the 11 stents used were found to be patent at the 6-month follow-up digital subtraction angiography (DSA). CONCLUSIONS: The Wingspan stent is an alternative to classic carotid stents and flow diverters for the treatment of cervical internal carotid artery (ICA) dissection associated with ectasias or large loops. The device remains patent over the long term and it is not associated with arterial wall complications.

Safety and Efficacy of Wingspan Stenting for Severe Symptomatic Atherosclerotic Stenosis of the Middle Cerebral Artery: Analysis of 278 Continuous Cases.

OBJECTIVE: Our objective is to investigate the safety and long-term efficacy of the Wingspan stent (Boston Scientific, Natick, MA, USA) for treating severe atherosclerotic stenosis of the middle cerebral artery (MCA). METHODS: A total of 278 consecutive patients from our stroke database with clinical symptoms within the prior 90 days and intracranial atherosclerotic stenosis of 70% or above of the MCA were enrolled in this study between September 2012 and November 2014, and these patients were followed until the end of June 2015. The endpoint events included any stroke or death within 30 days after stenting and any subsequent ipsilateral ischemic stroke. RESULTS: Among the 278 enrolled patients, 277 patients (99.6%) successfully underwent stenting. The mean rate of stenosis decreased from 82.5 ± 7.9% to 9.0 ± 3.2% following treatment. Within 30 days after stenting, 12 patients (4.3%) experienced endpoint events, including 8 cases (2.9%) of hemorrhagic stroke and 4 cases (1.4%) of ischemic stroke; 2 perioperative deaths occurred. During 8-33 months of follow-up, 19 patients developed endpoint events. The 1- and 2-year endpoint event rates were 5.8% (95% confidence interval [CI], 5.0%-15.7%) and 7.2% (95% CI, 4.3%-10.1%), respectively. CONCLUSIONS: From this study, we can conclude that the treatment of severe symptomatic atherosclerotic stenosis of the MCA using the Wingspan stent was safe and effective and that the long-term stroke recurrence rate after stenting was low.

Wingspan stenting can effectively prevent long-term strokes for patients with severe symptomatic atherosclerotic basilar stenosis.

OBJECTIVE: To investigate the safety and long-term effect of using the Wingspan stent for severe symptomatic atherosclerotic basilar artery stenosis (≥70%). MATERIALS AND METHODS: Between July 2007 and April 2013, we had 91 consecutive patients (age range 41-82 years old) with symptomatic severe basilar stenosis (70-99%) who underwent Wingspan stenting at our center. All patients had stenosis-related temporary ischemic attack or strokes. We analyzed the demographic data, pre- and post-procedural cerebral angiography, technical success rate, peri-procedural complications, and clinical and imaging follow-ups. RESULTS: The Wingspan stenting procedure was successful in all patients: The stenosis was reduced from 82.2% ± 5.8% pre-stenting to 15.9% ± 5.7% post-stenting. The 30-day peri-operative rate for stroke or death was 14.3%, which included ischemic stroke in 12 cases (12/91 = 13.2%) and subarachnoid hemorrhage in one case (1/91 = 1.1%), with a fatal or disabling stroke rate of 2.2%. Among the 77 patients with clinical follow-up assessment within 7-60 months (mean 31.3 ± 15.1 months) after stenting, four patients (5.2%) had posterior ischemia, including one patient with disabling ischemic stroke (1.3%) and three patients (3.9%) with temporary ischemic attack. The 2-year cumulative stroke rate was 16% (95% CI: 8.2-23.8%). Among 46 patients with imaging assessments at 3-45 months (mean, 9.5 ± 8.3) post-stenting, six (13.0%) patients had restenosis, including two (2/46 = 4.3%) with symptomatic restenosis. CONCLUSIONS: The benefit of stenting for patients with severe basilar artery stenosis (> 70%) may lie in lowering the long-term fatal and disabling stroke rate; and as long as the peri-operative stroke rate can be kept at a relatively lower level, patients with severe basilar stenosis can benefit from basilar artery stenting.

Symptomatic intracranial vertebral artery atherosclerotic stenosis (≥70%) with concurrent contralateral vertebral atherosclerotic diseases in 88 patients treated with the intracranial stenting.

PURPOSE: To investigate the safety, effect and instent restenosis rate of Wingspan stenting in treating patients with intracranial vertebral artery atherosclerotic stenosis (70-99%) concurrent with contralateral vertebral artery atherosclerotic diseases. MATERIALS AND METHODS: Eighty-eight patients with severe symptomatic intracranial vertebral artery atherosclerotic stenosis (≥70%) combined with contralateral vertebral artery atherosclerotic diseases were treated with the Wingpsan stent. All the baseline, cerebral angiography, success rate, perioperative complications, clinical and imaging follow-up data were prospectively analyzed. RESULTS: The success rate of stenting was 100%, and the mean stenotic rate was reduced from prestenting (84.9±6.8)% to poststenting (17.2±5.9)%. The perioperative stroke rate was 1.1%. Among eighty patients (90.9%) with clinical follow-up 8-62 months (mean 29.3±17.2) poststenting, five (6.3%) had posterior circulation TIA only, three (3.8%) had mild stroke in the posterior circulation but recovered completely, and another five patients greater than 70 years old died of non-ischemic stroke. Imaging follow-up in 46 patients (52.3%) 5-54 months (mean 9.9±9.9) following stenting revealed instent restenosis in 12 patients (26.1%) including 7 (58.3%) symptomatic restenosis. Age and residual stenosis were the two factors to significantly (P<0.05) affect instent restenosis. CONCLUSION: Wingspan stenting in the intracranial vertebral artery atherosclerotic stenosis combined with contralateral vertebral artery atherosclerotic diseases has a low perioperative stroke rate and a good preventive effect on long-term ischemic stroke, but the instent restenosis rate is a little high.

Reviving Intracranial Angioplasty and Stenting "SAMMPRIS and beyond".

We review the methods and results of Stenting and Aggressive Medical Management for Preventing Recurrent Stroke (SAMMPRIS) and provide a critical review of its strengths and limitations. In SAMMPRIS, the aggressive medical treatment arm (AMT arm) did substantially better than the Wingspan Stenting plus aggressive medical management arm (WS+ arm). Complications in the first 30 days post intervention led to the disparity between treatment arms. A major contribution of SAMMPRIS was the added value that AMT and lifestyle change may provide, when compared to a precursor trial, Warfarin-Aspirin Symptomatic Intracranial Disease (WASID), designed to prevent stroke in persons with high-grade symptomatic intracranial occlusive disease, however, the results of neither of these two trials have ever been reproduced. On the other hand, we argue that technical limitations of the Wingspan stent system (WS System) and lack of an angioplasty only intervention arm may have led to a premature launch of the trial and early termination of the study. Future randomized trials with different devices and modified patient selection criteria are warranted.

Comparison of simulated structural deformation with experimental results after Wingspan stenting.

OBJECTIVES: Biomechanical stress distribution correlates with the biological responses after stenting. Computational analyses have contributed to the optimization of stent geometry. In particular, structural analysis based on pre-operative angiography can be used to predict the stent-artery interaction before endovascular treatments. However, the simulated results need to be validated. In this report, we compared the simulated arterial structure with post-operative images after an intracranial Wingspan stent. METHODS: A Wingspan stent was deployed at a slightly curved ascending pharyngeal artery (APA) in the swine. Using a finite element method (FEM), the configuration after stenting was simulated and quantitatively compared with post-procedural 3D angiography. RESULTS: The finite element analysis demonstrated arterial straightening after stenting. The simulated images were similar to the experimental results with respect to the curvature index of the center line and the cross-sectional areas. CONCLUSION: We assessed the simulated structural deformation after Wingspan stenting, by comparison with experimental results.

Clinical study of Wingspan stents for symptomatic atherosclerotic stenosis of the basilar artery / 实用放射学杂志

Objective To assess the efficacy and feasibility of Wingspan stents for symptomatic atherosclerotic stenosis of the bas-ilar artery.Methods Clinical data of 40 patients with symptomatic atherosclerotic stenoses in the basilar artery were analyzed retro-spectively.The operative successful rate,the degree of stenosis,perioperative complications and the results of clinical and imaging follow-up were analyzed.Results The technical success rate was 95.35%.The rate of procedure-related complications during the perioperative period (30 days)was 20.0% (eight of 40 patients).There were two patients with no permanent neurological sequelae. Ipsilateral stroke or death occurred in six patients(1 5%).Thirty-six patients(92.3%)were available for a clinical follow up.The mean follow-up period was 36.3 months (range 12-75 months).Seventeen patients (47.2%)were available for follow-up imaging with DSA or CTA.The mean imaging follow-up period was 9.4 months (range 4-41 months).Symptomatic in-stent restenosis (ISR)was documented in two (1 1.76%)of these patients.Three ischemic events occurred during the follow-up period in 12 months.The adverse event rate was 8.33% at 1 year.Conclusion Wingspan stents for symptomatic atherosclerotic stenosis of the basilar artery was an effective and feasible technique,but we should carefully grasp the operation indications.

Clinical and angiographic outcomes of wingspan stent placement for treatment of symptomatic intracranial stenosis: single center experience with 19 cases.

OBJECTIVE: The limitations of medical management of symptomatic intracranial arterial stenosis (ICS) have prompted development of new strategies, including endovascular treatment. However, stenting of symptomatic ICS remains investigational. Here, we have reported and analyzed a series of 19 endovascular procedures involving placement of a Wingspan stent. METHODS: We conducted a retrospective review of a series of ICS in which patients were treated with percutaneous transarterial balloon angioplasty and stent placement (PTAS). Patients included in the study were diagnosed as symptomatic ICS between May 2010 and September 2011. RESULTS: Nineteen patients (median age, 65 years; 12 males, seven women) were treated with the Wingspan stent system for symptomatic ICS ranging from 50% to 99%. The technical success rate was 100%. The location of ICS included the internal carotid (n = 5; 1 petrous, 3 cavernous, and 1 clinoid segments), vertebral (n = 1; V4 segment), basilar (n = 1), and middle cerebral (n = 12; 9 M1, 3 M2) arteries. There was no occurrence of procedure-related mortality. Periprocedural morbidity occurred in two cases (10.5%), including carotid-cavernous fistula (n = 1) and subarachnoid hemorrhage (n = 1). No ipsilateral stroke was recorded beyond 30 days during a mean follow-up period of 13.2 months (range 9-19 months). Restenosis (> 50%) was observed in one patient (6.3%), who was asymptomatic, on follow-up imaging. CONCLUSION: Wingspan stent for symptomatic ICS can be performed with a high rate of technical success and acceptable periprocedural morbidity rates. Our initial experience indicates that this procedure represents a viable treatment option for this patient population.

Anesthetic management for Wingspan stent.

BACKGROUND: The bare metal self-expanding Wingspan stent (Boston Scientific, Natick, MA) was approved by the Food and Drug Administration under the Humanitarian Device Exemption in August 2005 for patients with intracranial atherosclerotic disease (ICAD) who are refractory to medical therapy. Relatively low rates of periprocedural morbidity and mortality have been reported. METHODS: After receiving institutional review board approval, we conducted a retrospective chart review to examine the anesthetic management and perioperative mortality and morbidity for all Wingspan stent insertions performed at our institution from 2005 to 2007. RESULTS: A total of 72 patients with a history of intracranial stenosis had angioplasty and Wingspan stent insertion: 34 male and 38 female, with an average age of 64 ± 11.6 years. Preoperative systolic blood pressure was 200 ± 45 mmHg, and diastolic blood pressure was 100 ± 23 mmHg. All patients received general anesthesia for stent insertion. Five patients died (6.9%), 4 had perioperative stroke (5.5%), and 9 had recurrent stenosis (12.5%). CONCLUSIONS: Anesthetic management for Wingspan stent insertion for ICAD is challenging. Maintenance of hemodynamic stability with optimum brain perfusion during the stent deployment is crucial to patient safety. A prospective study is warranted to assess the optimal anesthetic choice during Wingspan stent insertion.

Coincidental Occurrence of Acute In-stent Thrombosis and Iatrogenic Vessel Perforation During a Wingspan Stent Placement: Management with a Stent In-stent Technique.

We presented a case that an acute in-stent thrombosis after the deployment of a Wingspan stent was successfully managed with a stent in-stent technique. Because vessel perforation and subarachnoid hemorrhage were iatrogenically developed during the procedure, we were unable to use the thrombolytic agents to correct the in-stent thrombosis. When a thrombotic complication following an intracranial stent placement occurs with a coincidentally hemorrhagic complication, the stent in-stent technique should be considered as a treatment option.

Clinical and Angiographic Outcomes of Wingspan Stent Placement for Treatment of Symptomatic Intracranial Stenosis: Single Center Experience with 19 Cases

OBJECTIVE: The limitations of medical management of symptomatic intracranial arterial stenosis (ICS) have prompted development of new strategies, including endovascular treatment. However, stenting of symptomatic ICS remains investigational. Here, we have reported and analyzed a series of 19 endovascular procedures involving placement of a Wingspan stent. METHODS: We conducted a retrospective review of a series of ICS in which patients were treated with percutaneous transarterial balloon angioplasty and stent placement (PTAS). Patients included in the study were diagnosed as symptomatic ICS between May 2010 and September 2011. RESULTS: Nineteen patients (median age, 65 years; 12 males, seven women) were treated with the Wingspan stent system for symptomatic ICS ranging from 50% to 99%. The technical success rate was 100%. The location of ICS included the internal carotid (n = 5; 1 petrous, 3 cavernous, and 1 clinoid segments), vertebral (n = 1; V4 segment), basilar (n = 1), and middle cerebral (n = 12; 9 M1, 3 M2) arteries. There was no occurrence of procedure-related mortality. Periprocedural morbidity occurred in two cases (10.5%), including carotid-cavernous fistula (n = 1) and subarachnoid hemorrhage (n = 1). No ipsilateral stroke was recorded beyond 30 days during a mean follow-up period of 13.2 months (range 9-19 months). Restenosis (> 50%) was observed in one patient (6.3%), who was asymptomatic, on follow-up imaging. CONCLUSION: Wingspan stent for symptomatic ICS can be performed with a high rate of technical success and acceptable periprocedural morbidity rates. Our initial experience indicates that this procedure represents a viable treatment option for this patient population.

Coincidental Occurrence of Acute In-stent Thrombosis and Iatrogenic Vessel Perforation During a Wingspan Stent Placement: Management with a Stent In-stent Technique / 신경중재치료의학

We presented a case that an acute in-stent thrombosis after the deployment of a Wingspan stent was successfully managed with a stent in-stent technique. Because vessel perforation and subarachnoid hemorrhage were iatrogenically developed during the procedure, we were unable to use the thrombolytic agents to correct the in-stent thrombosis. When a thrombotic complication following an intracranial stent placement occurs with a coincidentally hemorrhagic complication, the stent in-stent technique should be considered as a treatment option.

Gateway-Wingspan stent system assisted angioplasty for treatment of chronic basilar artery stenosis / 中国脑血管病杂志

Objective: To assess the feasibility and safety of Gateway-Wingspan stent system assisted angioplasty for treatment of basilar artery stenosis. Methods: The operative strategy, efficiency, successful rate, the degree of stenosis and periprocedural neurological complications were analyzed retrospectively in 20 patients after Gateway-Wingspan stent system assisted angioplasty for treatment of chronic basilar arterial stenosis. Results: 20 patients of basilar artery stenosis using stent assisted angioplasty were implanted 20 Wingspan stents. The stent implantation was successful in all patients. The mean degree of stenosis decreased from (79.0 ± 6.0)% before the procedure to (13.0 ± 3.4)% after stenting. One patient advent brain stem infarction because of AICA occlusion. During the follow-up of 1, 3 and 6 month, according to Malek scale, twelve patients (60%) belonged to scale 1, two patients (10%) belonged to scale 3, and one patient (5%) belonged to scale 1. All of 15 patients were in stable condition. Among them, the treatment efficiency of twelve patients were very successful. In addition, 5 patients treatment effect was very good in the early postoperative period, but the treatment effect was gradually decreased. Among them, 3 patients (15%) belonged to scale 1 after one month, but belonged to scale 2 after three months. In addition, 2 patients (10%) belonged to scale 2 in 1, 3 month, but belonged to scale 2 after six months. Conclusion: Gateway-Wingspan stent system assisted angioplasty is safe and feasible for treatment of basilar artery stenosis.