The Study Of Perioperative Period Safty About Angioplasty And Stenting Rof Symptomatic Intracranial Arterial Stenosis

Atherosclerotic intracranial arterial stenosis (ICAS) is the most common vascular lesion in patients suffering from strokes and transient ischemic attacks (TIA), especially in ethnic Asians. Angioplasty and stenting is a new technology, developed in the past two decades for the treatment of symptomatic ICAS. The average incidence of perioperative stroke and death was 7.7%. However, according to a 2011 multi-center study entitled "Stenting and Aggressive Medical Management for Preventing Recurrent Stroke" (SAMMPRIS), in which patients were enrolled who had a transient ischemic attack (TIA) or non-disabling stroke attributed to 70%-99% stenosis of a major intracranial artery within 30 days prior to enrollment, the incidence of primary endpoint in the Wingspan stenting group was significantly higher than that of the medical treatment group (14.7% vs 5.8%). In this paper, we aim to investigate whether the selection of the appropriate anesthesia method can reduce the stroke incidence within thirty days after an angioplasty and stenting procedure.Object:This study sought to find criteria which could help to choose the appropriate anesthesia method in order to reduce the incidence of stroke within thirty days of angioplasty and stenting procedures for symptomatic intracranial arterial stenosis (ICAS).Methods:1. After receiving the approval of the institutional review board, we conducted a retrospective review to assess the anesthetic management of all angioplasties and stent insertions performed on patients with ICAS at the Neurology Department of Linyi People’s Hospital between 2005 and 2012. The following information were recorded in an Excel chart: epidemiological characteristics, type of events (stroke or TIA), location of the stenosis, morphology and severity of stenosis, operation time, type of stents used, anesthetic method, and incidence of postoperative complications or primary endpoints. The primary endpoints were defined as ischemic stroke in the target-lesion artery territory, symptomatic brain hemorrhage or death within 30 days of operation.2. All ICAS diagnoses were based on transcranial color Doppler (TCD), magnetic resonance angiography (MRA), or computed tomographic angiography (CTA) findings and confirmed by digital subtraction angiography (DSA). From the seventh day before and thirtieth day after operation the patients received aggressive medical treatment—a combination of antiplatelet therapy (aspirin 100 mg/d+ Clopidogrel 75 mg/d) and intensive management of risk factors, including statins (Atorvastatin or Rosuvastatin to decrease the LDL-C level below 70 mg/L) and blood glucose-lowering drugs. The patients were also advised to quit smoking.Definition of the sites of stenosis:The anterior circulation consists of the petrous segment, cavernous segment, and clinoid segment of internal carotid artery and of the Ml segment of middle cerebral artery (M1). The posterior circulation consists of the intradural vertebral arteries (V4), basilar artery (BA), and P1 segment of posterior cerebral arteries (PCA,). The baseline percentage stenosis were measured using WASID criteria[4], which measures the narrowest diameter of the stenosed artery as compared with the diameter of the most proximal, normal portion of the artery.Inclusion criteria:1. Patients underwent angioplasty and stenting at the Neurology Department of Linyi Municipal Hospital between 2005 and 2012; 2. Patients suffered from ischemic events (including stroke and TIA) within one year of stenosis; 3. Ischemic events were caused by stenotic arteries (more than seventy percent), confirmed by DSA; 4. Patients had at least one risk factor for atherosclerosis, including hypertension, diabetes, high cholesterol, smoking, and carotid artery plaque; 5. Ischemic symptoms or radiographic stenosis did not improve after three months of aggressive medical treatment with antiplatelet and blood cholesterol lowering drugs and management of other risk factors; 6. In case of acute stroke, the time interval between surgery and stroke onset was at least two weeks; 7. The modified Rankin Scale (mRS) of patients were three or less.3. Selection of anesthesia methods:Before the angioplasty and stenting procedure, two or more surgeons discussed the patients’ conditions and decided whether to use GA or LA. The factors considered included location of the stenosis, Mori type of the lesion [5], severity of the stenosis, proximal vessel conditions, and the type of stent used in the procedure. In certain circumstances, such as middle cerebral artery (MCA) or basilar artery stenosis, seriously tortuous vessels, Mori type B or C lesions, more than ninety percent stenosis, or placement of Wingspan stent, GA was prefered. In other circumstances, such as stenosis at ophthalmic artery or proximal of it, stenosis of the vertebral artery, less tortuous vessels, Mori type A lesions, stenosis between seventy to ninety percent, and placement of Apollo stent, LA was prefered.4. A 6 French (Fr) guiding catheter was delivered to the distal cervical internal carotid or vertebral artery through a 6-Fr or 8-Fr sheath via the right femoral artery. A 6-Fr long sheath may be used to provide extra strength when necessary. The intraoperative heparin regimen was used to maintain an activated clotting time of longer than 250 seconds (a bolus of 2/3 mg/kg body weight was administered, followed by one-half of the previous dose every other hour; when the dose was lowered to 10 mg, a consistent dose of 10 mg was administered every other hour). When using Wingspan self-expanding stents, angioplasty was typically performed with a slow, graded inflation of the Gateway balloon to predilate the vessel. The balloon diameter was 80% of the target vessel’ s diameter. For the Apollo stent, a 0.014-inch microwire was carefully steered through the target lesion under roadmap guidance. The stent system was then advanced to the lesion over the microwire, without a balloon predilation. The stent was released by gradual balloon inflation to target pressure, and maintained for fifteen to thirty seconds. After the stent was installed the microwire and guiding catheter were removed.5. Angio-Seal (St. Jude Medical, St. Paul, Minnesota) or suture-based devices such as Proglide (Abbott Vascular; Redwood City, California) were used to close the femoral artery at the end of the procedure. Brain CT was performed to exclude intracranial hemorrhage (ICH). If no hemorrhage occurred the patients were administered low-molecular-weight heparin (0.4 ml subcutaneously every twelve hours for three days). The blood pressure of the patients’was controlled below 130/80 mmHg. Vital signs and neurological status were closely monitored throughout the perioperative period.Results:1.183 stenotic lesions were found in 178 patients, including 72 MCA M1 segments,22 ICA ophthalmic segments and 21 below ophthalmic segments, 40 VA V4 segments,27 BA and one PCA PI segment.2. Among the 178 patients,179 stents were successfully placed in 174 patients. The procedural success rate was 97.7%. The average stenosis was 79.8±8.3 percent and 11.3±10.5 percent before and after the procedure, respectively. A total of 11 patients (6.2%) had primary end points within thirty days, of which two died (1.1%).3. Among the 178 patients,80 patients had intubation and GA and 98 patients had LA. The primary end points within thirty days between the two groups had no significant differences (8.8% versus 4.1%, P=0.19).4.88 wingspan self-expanding stents (one failed) and 95 balloon-expanding stents (three failed) were used. The primary end points within thirty days between the two groups had no significant differences (8.0% versus 4.4%, P=0.25).Conclusion:1.Angioplasty and stenting for the treatment of ICAS is safe in total, the perioperative complications can be controlled at a relatively low level.2. Self-expandting stent and balloon-expanding stent can also be used for the treatment of ICAS and have similar perioperative safty.3. When selecting the appropriate anesthesia method for angioplasty and stenting procedure in patients with ICAS, the location, morphology, and severity of the stenosis, the proximal vessel conditions, as well as the type of stent used need to be taken into account. If the procedure can be finished with LA, LA is preferred. Otherwise, GA should be considered, and the blood pressure should be closely monitored and managed during the procedure to prevent prolonged hypotension.