Revisiting angioplasty without stenting for symptomatic intracranial atherosclerotic stenosis after the stenting and aggressive medical management for preventing recurrent stroke in intracranial stenosis (SAMMPRIS) study

BACKGROUND: The Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) study stopped recruiting patients because of higher-than-expected perioperative morbidity of primary stenting in patients with symptomatic intracranial stenosis. An alternative treatment, submaximal angioplasty without stenting, performed concurrently with SAMMPRIS, may offer revascularization benefits with a lower incidence of stenting-related risks. OBJECTIVE: To present the results of a consecutive case series of primary submaximal angioplasty procedures performed for symptomatic severe atherosclerotic intracranial stenosis refractory to medical treatment. METHODS: A database review identified primary submaximal angioplasty procedures performed in 41 patients for the treatment of >70% intracranial stenosis associated with an acute, symptomatic ischemic event in the distribution of the diseased vessel. For results analysis, 30-day events were reported as a percentage of patients treated. One-year periprocedural and ischemic event - free survival was reported as a percentage of all patients treated and displayed graphically with a Kaplan-Meier survival curve. RESULTS: Three events in 41 patients included 1 intraprocedural vessel perforation, 1 reperfusion hemorrhage <24 hours postoperatively, and 1 transient ischemic attack 3 months postprocedurally (30-day event rate, 2 of 41, 4.9%). Median clinical follow-up duration after submaximal angioplasty was 19 months, with ≥1 year of follow-up available for 32 patients. One-year perioperative and ischemic event-free survival was high (29 of 32 patients, 91%). CONCLUSION: In this series, periprocedural safety of submaximal angioplasty in the setting of acute, symptomatic atherosclerotic intracranial stenosis was demonstrated. Although direct comparison is impossible because many patients were ineligible for stenting procedures, the complication profile compares favorably with rates of identically defined event-free survival for patients randomized to the medical (88%) and surgical (77%) arms of SAMMPRIS despite the absence of aggressive medical management.