Published on October 29, 2007
NIH-Funded Multi-center Registry: NIH-Funded Multi-center Registry The Use of Wingspan® Intracranial Stent for High Risk Patients with Symptomatic Intracranial Arterial Stenosis Zaidat O, et. al. American Stroke Association, San Francisco, CA Presented February 9, 2007. Notice: Notice We have created this slide deck based on the cited study. We have done our best to ensure the slides are accurate and convey the relevant information in a fair and balanced manner. If you believe these slides would be helpful in your practice (for use with staff or referring doctors, for example), feel free to use them, as is or as modified as you see fit in your medical judgment. We respectfully request that any use of these slides is made in a fair and balanced manner. Acknowledgements & Disclosures: Acknowledgements & Disclosures Honoraria/Consultants for Boston Scientific: • Dr. Michael Alexander • Dr. Stan Barnwell • Dr. John Chaloupka • Dr. Sam Zaidat NIH Registry Overview: NIH Registry Overview Study Characteristics • Retrospective • Multi-center • Single-arm • Not CEC Adjudicated or Core Lab Reviewed • Consecutive Note: The analysis presented was restricted to patients with 70–99% stenosis NIH Registry Overview: NIH Registry Overview Baseline Characteristics Number of Patients: 131 Mean Age (SD): 64.2 (12) Gender: Male: 55% | Female: 45% Ethnicity: White: 78% | Black: 14% | Hispanic: 4% Lesion Location: ICA: 25% | VA: 25% MCA: 33% | BA: 17% Qualifying Event: TIA: 30% | Stroke: 60% Non-specified cerebral ischemic event: 10% NIH Registry Overview: NIH Registry Overview Baseline Characteristics (continued) • All lesions exhibited intracranial stenosis 70–99% • Mean days from event to stenting: 34 (SD: 51) NIH Registry Results: NIH Registry Results Technical Results * Technical success is defined as baseline deployment of the Wingspan® stent at the target lesion with <50% residual stenosis NIH Registry Results: NIH Registry Results Clinical Outcomes NIH Registry Results: NIH Registry Results Angiographic Outcomes * Based on intent to treat **49 angiographic follow-ups were performed at mean of 4.7 months from procedure (range: 3.3 months—6.2 months) NIH Registry Results: NIH Registry Results Follow-up Angiographic Outcomes • 49 angiographic follow-ups were performed at an average of 4.7 months from procedure NIH Registry Results: NIH Registry Results Any Stroke or Death <30 Days or Ipsilateral Stroke >30 Days Kaplan-Meier Estimates of Event Rates at 3 Months NIH Registry Conclusions: NIH Registry Conclusions Based on the data from this series: • Wingspan stenting in patients with 70–99% intracranial stenosis is associated with high technical success (97.6%) • Wingspan stenting is associated with a low periprocedural stroke or death rate (4.6%) • Wingspan stenting resulted in a low rate of symptomatic restenosis (4.1%) • Comparison of the confidence intervals of the stroke rates in this registry and WASID do not rule out that stenting has no advantage over medical therapy or could be associated with up to a 50% reduction in stroke risk • A randomized multi-center trial is needed to determine whether stenting is superior to medical therapy in high-risk patients with intracranial stenosis Wingspan® Stent System: Wingspan® Stent System See package insert for complete indications, contraindications, warnings, and instructions for use. Humanitarian Device. The Wingspan Stent System with Gateway PTA Balloon Catheter is authorized by United States Federal law for use in improving cerebral artery lumen diameter in patients with intracranial atherosclerotic disease, refractory to medical therapy, in intracranial vessels with >50% stenosis that are accessible to the system. The effectiveness of this device for this use has not been demonstrated. Wingspan Stent System Indications for Use The Wingspan Stent System with Gateway PTA Balloon Catheter is indicated for use in improving cerebral artery lumen diameter in patients with intracranial atherosclerotic disease, refractory to medical therapy, in intracranial vessels with >50% stenosis that are accessible to the system. Contraindications • Patients in whom antiplatelet and/or anticoagulation therapy is contraindicated. • Lesions that are highly calcified or otherwise could prevent access or appropriate expansion of the stent. Potential Adverse Effects The potential adverse events listed below, as well as others, may be associated with the use of the Wingspan Stent System with Gateway PTA Balloon Catheter or with the procedure: Observed adverse events: infection; TIA; stroke; hematoma; vasospasm; hemorrhagic event; hypertension; peripheral vascular diseases; neurological symptoms; pain; AMI; angina; arrhythmia; creatinine increase; hematuria; hypoglycemia/hyperglycemia; asymptomatic thromboembolic event; bradycardia (35 min); broken middle-foot left/V-fracture; chronical antrum gastritis; death; elevated bilirubin, GOT, GPT; fever; hiatus hernia; hypervolemia; new distal in stent stenosis; pulmonary edema; respiratory failure; seizure; syncope. Potential adverse events: cerebral aneurysm; coagulopathy; emboli (air, tissue, or thrombotic tissue); intimal dissection; pseudoaneurysm; stent migration; stent misplacement; stent occlusion; stent embolization; stent thrombosis; vessel perforation; vessel rupture; vessel thrombosis; vessel trauma requiring repair or surgical intervention. Please be aware that potential adverse effects may arise even with the proper use of medical devices. Accordingly, this device should only be used by persons qualified in the procedures for which it is indicated. Warnings • The Wingspan Stent System with Gateway PTA Balloon Catheter should only be used by physicians who have received appropriate training in interventional neuroradiology and treatment of intracranial atherosclerotic disease. • The Wingspan Stent System is not designed or intended for contrast injections or injections other than heparinized saline. • If excessive resistance is encountered during the use of the Wingspan Stent System or with the Gateway PTA Balloon Catheter at any time during the procedure, discontinue use of the system. Movement of the system against resistance may result in damage to the vessel, or a system component. • In animal evaluations, the severity of vessel stenosis/neointimal thickness appears to be correlated with the degree of trauma inflicted on the arterial walls by stent placement or stent radial expansion. • Experience with stent implants indicates that there is a risk of restenosis. Subsequent restenosis may require repeat dilation of the vessel segment containing the stent. The risks and long-term outcome following repeat dilation of endothelialized stents is unknown at present. • If the stent is implanted adjacent to or contacting other implanted metal, such as another stent or embolic coil, the metals should be of similar composition to avoid galvanic corrosion potential. Cautions/Precautions • The Wingspan Stent System and the Gateway PTA Balloon Catheter are provided STERILE for single use only. Do not resterilize. Store in a cool, dry place. • Use the Wingspan Stent System and Gateway PTA Balloon Catheter prior to the “Use By” date printed on the package. • Select a stent size (length and diameter) that extends a minimum of 3 mm on both sides of the lesion. • Carefully inspect the sterile package and Wingspan Stent System prior to use to verify that neither has been damaged during shipment. Do not use kinked or damaged components. • Typical antiplatelet and anticoagulation regimen used for interventional intracranial procedures is an important adjunct to stent treatment. Patients must be advised to take their prescribed medications after the stent is implanted and should be counseled on the risk of not complying with medical therapy. In-stent thrombosis may occur during the procedure if proper antiplatelet and anticoagulation therapy is not administered. • Do not steam shape the tip of the Wingspan Stent System because it could damage the stent or delivery system. • Implanting a stent may lead to dissection of the vessel distal or proximal to the stent and may cause other complications (vasospasm/acute closure) of the vessel requiring additional intervention (i.e., further dilation, placement of stents). • Do not deploy the stent if it is not properly positioned in the vessel. • Placement of the stent may compromise side branch patency. • Follow the Wingspan Stent System preparation and use instructions carefully. • Previous studies have shown that some metal stents may be incompatible with MRI scanning. The Wingspan Stent System has been shown to be MRI compatible in MRI systems operating at field strengths of 3.0 Tesla or lower. MRI laboratory evaluation demonstrated that no significant image distortion or heating was created by the presence of the stents at scanning sequences commonly used during MRI procedures. • Do not use the Wingspan Stent System or the Gateway PTA Balloon Catheter for repositioning or recapturing the stent. • Exercise caution when crossing the deployed stent with guidewires or other devices. • In tortuous vessels, a stiff guidewire may cause binding within the Wingspan Stent System or the Gateway Balloon Catheter during deployment. In such cases, use only soft guidewires, and position the floppy section of the guidewire within the stent. • After deployment, the stent may foreshorten up to 2.4% in 2.5 mm stents and up to 7.1% in 4.5 mm stents. • Stent retrieval methods (use of additional wires, snares and/or forceps) may result in additional trauma to the vasculature and/or the vascular access site. Complications may include bleeding, hematoma, or pseudoaneurysm. GatewayTM PTA Balloon Catheter: GatewayTM PTA Balloon Catheter See package insert for complete indications, contraindications, warnings, and instructions for use. Gateway PTA Balloon Catheter Indications for Use The Gateway PTA Balloon Catheter is indicated for balloon dilation of the stenotic portion of intracranial arteries prior to stenting for the purpose of improving intracranial perfusion. Contraindications The Gateway PTA balloon catheter is contraindicated for use in: • Patients in whom antiplatelet and/or anticoagulation therapy is contraindicated. • Patients who are judged to have a lesion which prevents effective angioplasty. Potential Adverse Effects Adverse events (in alphabetical order) may be associated with the use of an intracranial angioplasty in stenotic lesions of the intracranial arteries: death; dissection; drug reactions to antiplatelet agents/contrast medium; distal emboli (air, tissue, orthrombotic emboli); hematoma; hemorrhage, requiring transfusion; hypotension/hypertension; infection and pain at insertion site; ischemia/infarct; perforation; pseudoaneurysm, (femoral and intracranial); restenosis of the dilated vessel; spasm; stroke/TIA; total occlusion of the intracranial artery. Please be aware that potential adverse effects may arise even with the proper use of medical devices. Accordingly, this device should only be used by persons qualified in the procedures for which it is indicated. Warnings • Since the use of this device carries the associated risk of subacute thrombosis, vascular complication and/or bleeding events, judicious selection of patients is necessary. • Only physicians who have received training should perform intracranial angioplasty. • Angioplasty and stenting procedures should only be performed at hospitals where emergency intracranial surgery can be readily performed in the event of a potentially injurious or life-threatening complication. Cautions/Precautions • Store in a dry, dark, cool place. Do not resterilize. • Note product “Use By” date. • Follow the Gateway PTA Balloon Catheter preparation and use instructions carefully. • Do not prepare or pre-inflate the balloon other than as directed. Use the balloon purging technique described in this Instructions for Use. • Typical antiplatelet and anticoagulation regimen used for interventional intracranial procedure is an important adjunct to balloon angioplasty treatment. Do not use the Gateway PTA Balloon Catheter in patients in whom antiplatelet and/or anticoagulation therapy is contraindicated. Vessel thrombosis may occur during the procedure if proper antiplatelet and anticoagulation therapy is not administered. • Angioplasty may lead to dissection of the vessel and may cause other complications (vasospasm/acute closure) of the vessel requiring additional intervention (i.e., further dilation, placement of stents). • Use only the appropriate balloon inflation media. Do not use air or any gaseous medium to inflate the balloon because it may cause uneven inflation and complications. • If unexpected difficulty is experienced during inflation, do not continue; remove the device and do not attempt to use it. • To reduce the potential for vessel damage, the inflated diameter of the balloon should approximate the lesser of the vessel diameters just proximal and distal to the stenosis. • Do not use a guidewire having a diameter greater than 0.014 in/0.36 mm. • When the delivery catheter is exposed to the vascular system, it should be manipulated while under high-quality fluoroscopic observation. If resistance is met during manipulation, determine the cause of the resistance before proceeding. • Infusion of any medium other than a flush of heparinized normal saline through the guidewire lumen may compromise device performance. • Do not attempt to reposition a partially deployed balloon. Attempted repositioning of a partially deployed balloon may result in severe vessel damage. • Balloon pressures should be monitored during inflation. Do not exceed rated burst pressure indicated on the product label. Use of pressures higher than those specified on the product label may result in a ruptured balloon and potential intimal damage and dissection. The rated burst pressure is based on the results of in vitro testing. At least 99.9% of the balloons (with a 95% confidence interval) will not burst at or below their rated burst pressure. Use of a pressure monitoring device is recommended to prevent over-pressurization. • Before withdrawing the device, visually confirm complete balloon deflation by fluoroscopy. If the balloon has already been inflated and difficulty is experienced deflating (a non-deflate), connect a large-barrel syringe and manually attempt to deflate the device. • In order to achieve optimal performance of Gateway Catheters and Boston Scientific steerable guidewires and to maintain the lubricity of the Bioslide surface, it is critical that a continuous flow of appropriate flush solution be maintained between a) the Gateway catheter and guide catheter, and b) the Gateway catheter and any intraluminal device. In addition, flushing aids in preventing contrast crystal formation and/or clotting on both the guidewire and inside the catheter lumen. • The recommended continuous flush set up requires two stopcocks and two rotating hemostatic valves (RHV); the RHV’s provide a fluid tight seal and are attached to the guide catheter and Gateway Catheter. The stopcocks attach to the RHV sidearms, which become infusion ports for appropriate flush or contrast medium injection.