ฝึกพูดภาษาอังกฤษด้วยเทคนิค Shadowing จากวิดีโอ: SVINutes: Intracranial Atherosclerotic Disease: Key Considerations for Stenting

Hello, I am Amir Hassan, and on Zvinitz today we will be talking about intracranial atherosclerotic disease, key considerations for stenting.

ICAT is a significant cause of ischemic stroke, responsible for 10% of ischemic strokes in the US and up to 50% in Asia.

In South Texas, we have a 20-30% incidence.

The disease process, you have a lot of plaque buildup, which leads to stenosis, increasing stroke risk.

The key stroke mechanisms include hemodynamic compromise, artery embolism, in-situ thrombosis, and perforator strokes.

Current treatment approaches include medical management with anticoagulants, antiplatelets, and or statin therapy.

Interventions that include stenting and angioplasty.

On cases with hemodynamic compromise, stenting has significant superiority over medical therapy.

In a patient with a basilar stenosis, as you see here on the CT correlating CT perfusion, would benefit this patient much more than medical therapy.

Versus a perforator stroke alone, as you can see here, this patient would do much better with medical therapy than intracranial stenting.

Quick overview of the Sampras trial.

There was a significant risk of instant stenosis.

There was a significant risk of ischemic strokes

and what you had was the medical management arm doing significantly better than the intervention arm

and the trial was prematurely terminated then fast forward several years

and we have the weave trial

and the weave trial results were published in stroke in april 2019

and the main findings were

if you stuck to the on-label primary analysis findings you had a 2.6 percent event rate of stroke

or death within 72 hours versus

if you were off-label those patients were collected in a registry

and they had up to 23.9 percent risk of stroke or death within 72 hours.

One of the lessons learned were adjacent perforators.

You had to undersize the balloon in those lesions and your goal was 60 to 80 percent true lumen diameter.

Also experience mattered.

In studies where the enrollment sites had the experience of treating three cases or on on average 10 cases like in Sampras, you had a much higher event rate.

Whereas in Weave, the average interventionist had placed 37 wingspan stents prior to enrollment.

Those who had high experience, greater than 50 wingspan stents prior to their first patient enrollment in Weave had a 0% event rate.

We have several studies that looked at our initial experience with the Resolute Onyx stent, balloon-mounted stent that is drug-coded, and then we looked at 30-day outcomes,

comparing them to the Sampras medical arm patients with propensity score matching, and we had a multi-center study that included other balloon-mounted stents.

And what we found was that most of these patients did significantly better if you were on label, meaning you had to treat the patient and wait for seven days,

maximize medical management with dual anti-plitotherapy and statin therapy, and And we also found significant decreased restenosis rates,

long-term restenosis, compared to the Wingspan study.

And here are the publications so you can look at them yourselves.

The main points here are your tips and your setup for support based on our experience.

And a key point here is patient selection.

Patients with severe tortuosity, type 3 arches, an M for a carotid artery,

common carotid, those cases probably be much more aggressive with your medical therapy before approaching stenting.

In patients that you do select for stenting, we are very aggressive with P2Y12 testing on all patients.

If that P2Y12 number is greater than 200, switch the patients to Berlinta 90mg BID.

My partner does use 60mg BID and we have not found a significant difference between my patients and his patients.

We always use a bolt ballast or a BMX guide catheter.

We find that's much more supportive.

If treating anterior circulation, you will have a lot of difficulty with the radial approach, so we primarily prefer femoral access.

If you're treating lesions proximal to the periclinoid segment of the carotid, Navian 058-115 is the most supportive DAC.

If you're treating an MCA lesion, it doesn't cross the periclinoid ophthalmic segments, so a Cat5 or Sophia EX 115 cm is the preferred distal axis catheter.

We always use Zoom 14 support wire, that is our preferred O14 wire, Synchro 2 support if you don't have the Zoom 14,

or you can use the Aristotle 14 support wire.

Regular Synchro 2 and Traxxas just don't have enough support.

We highly recommend the Resolute Onyx 2x8 mm device because it can comfortably increase in size to about 3.25 with post-dilatation.

And for all our MCA M1 lesions and our mid-bazilar lesions,

your perforator-rich teratoids, I don't care if your MCA or your basilar already measures 3-3.5mm, we always use our Resolute Onyx 2x8.

Thank you very much and have a great day.

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ฝึกพูดภาษาอังกฤษด้วยเทคนิค Shadowing จากวิดีโอ: SVINutes: Intracranial Atherosclerotic Disease: Key Considerations for Stenting

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