Intracranial In-Stent Restenosis Leads to Higher Risk of Recurrent Ischemic Events

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Patients who develop in-stent restenosis after undergoing treatment of intracranial atherosclerosis are at increased and earlier risk of ischemic events in the target artery, according to a study published online August 20, 2013, ahead of print in Stroke.

Wei-Jian Jiang, MD, of the Second Artillery General Hospital PLA (Beijing, China), and colleagues looked at 540 consecutive patients with symptomatic intracranial atherosclerosis who received stents at their institution between September 2001 and May 2009. A total of 226 patients with 233 stented arteries completed angiographic follow-up at 10.1±1.0 months, with 57 arteries (24.5%) found to have in-stent restenosis.

In-Stent Restenosis a Stand Alone Predictor

After a median of 38.9 months, there were 9 ischemic strokes and 18 TIAs, for a total of 27 primary endpoint events (11.6%). Events occurred on average at 25.3 ± 20.7 months after coronary angiography and happened earlier in those with in-stent restenosis (24.5%) than in those without the complication (9.9 vs. 26.6 months; P = 0.01).

An event was more likely to occur in arteries with in-stent restenosis at angiographic follow-up than in those without in-stent restenosis (21.1% vs. 8.5%; HR 2.94; 95% CI 1.37-6.30; P = 0.005). However, there was no difference in risk between arteries with symptomatic (26.3%) vs. asymptomatic in-stent restenosis (25% vs. 20%; HR 1.03; 95% CI 0.28-3.83; P = 0.96).

Multivariable analysis found that among 13 risk factors, in-stent restenosis was the only one associated with the occurrence of the primary endpoint (HR 2.79; 95% CI 1.20-6.49; P = 0.017).

The proportion of patients with diabetes was higher in the in-stent restenosis group (P = 0.03), while the proportions of men (P = 0.05) and smokers (P = 0.04) were higher in those without in-stent restenosis.

Smokers, Men May Be at an Advantage

Dr. Jiang and colleagues pointed out that their findings lend support to the “smoker’s paradox,” given that smokers were less likely to develop in-stent restenosis. Another “interesting finding,” they indicate, is that women were at an increased risk of in-stent restenosis. While the sex difference is not readily explainable, “women may have smaller intracranial arteries, which could pose a greater [in-stent restenosis] risk,” they note, adding that this aspect deserves further study.

In addition to the limited statistical capabilities of the study, the authors note that most of the patients who met the primary endpoint “were not investigated with telemetry and echocardiography to rule out other potential causes for stroke/TIA, which would lead to the overestimation of the rate of lesion-related events.”

Stents a Viable Option?

In a telephone interview with TCTMD, John R. Laird Jr, MD, of the University of California, Davis Medical Center (Sacramento, CA), commended the researchers on including a “remarkably large” number of patients.

Because “we know that these patients are at very high-risk for future strokes and TIAs, there is much interest in interventions that may improve clinical outcomes. Most of the studies to date have shown no real strong benefit for stenting of these intracranial lesions,” so the paper touches on a controversial issue, he said. “And now we see when stents are placed and restenosis occurs, the likelihood of future events is quite high.”

This risk raises several questions about intracranial stenting, Dr. Laird continued. To begin with, he asked, “should we really be doing this?” The paper does not provide enough information to accurately answer either way. Additionally, since the study included 1 self-expanding and 2 balloon-expandable stents, none of which were drug-eluting, the optimal device in this situation also remains unknown, he added.

Future trials should focus on comparing “advanced stenting with some of the newer and better stents with medical therapy to determine whether stenting makes sense for intracranial atherosclerotic lesions. We also need more information about which patients are most likely to benefit from stenting,” Dr. Laird concluded.

Study Details

The majority (83.4%) of patients were male, and the mean age was 52.9 years. Three device types were used:

• Coronary balloon-expandable stents
• Apollo balloon-expandable intracranial stents (MicroPort Medical, Shanghai, China)
• Wingspan self-expanding stents (Stryker Neurovascular, Kalamazoo, MI)

 

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Source:
Jin M, Fu X, Wei Y, et al. Higher risk of recurrent ischemic events in patients with intracranial in-stent restenosis. Stroke. 2013;Epub ahead of print.

 

 

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