Search

As a means of preventing secondary ischaemic stroke, angioplasty and stenting are considered potentially beneficial for patients with severe intracranial atherosclerotic stenosis. However, the role of stenting has been challenged since the publication of the first randomised controlled trial on Stenting versus Aggressive Medical Management for Preventing Recurrent stroke in Intracranial arterial Stenosis (SAMMPRIS). This indicated that aggressive medical management was superior to stenting using Wingspan to prevent recurrent stroke, because stenting has a high peri-procedural stroke and death rate. In this paper, we review the management of intracranial atherosclerosis, revisit the skepticism on stenting, and state our position on the topic in the form of recommendations. These are based on the prevalence of the disease in Hong Kong, the high risk of recurrent stroke despite medical therapy in the presence of haemodynamic intracranial stenosis without sufficient collaterals, an analysis of the weak points of SAMMPRIS, and results of clinical studies in Hong Kong.

Objectives: To define the role of bypass surgery and percutaneous transluminal angioplasty to manage critical limb ischaemia due to infrainguinal arterial occlusive disease., Design: Retrospective review., Setting: Regional hospital, Hong Kong., Patients: Consecutive patients treated for critical limb ischaemia, for whom data were prospectively collected in those who underwent: (i) infrainguinal percutaneous transluminal angioplasty first, or (ii) infrainguinal bypass surgery., Results: Among patients with critical lower limb ischaemia, 364 consecutive individuals having infrainguinal bypass operations and 100 having percutaneous transluminal angioplasty first were compared. The latter patients were older (77 vs 74 years, P=0.014) and had more co-morbidities but higher ankle pressure than those having bypass surgery. In the angioplasty-first group, 74% had favourable lesions (classified as TransAtlantic Inter-Society Consensus A/B). In the bypass group, operative mortality was higher (4% vs 1%, P=0.03) than that in the angioplasty-first group. Hospital mortality was comparable (8% vs 3%, P=0.15). In the bypass group, median hospital stay was longer than that in the angioplasty-first group (24 vs 4 days, P<0.001), and postoperatively they also had a higher median ankle-brachial index (0.92 vs 0.70, P<0.001) and superior long-term patency. In the bypass group, American Society of Anesthesiologists class 4 patients suffered very high operative and hospital mortality (15% and 31%, respectively). Long-term patency of percutaneous transluminal angioplasty depended on the TransAtlantic Inter-Society Consensus class of the treated lesion. Limb salvage rates at 3 years were 89% and 78% for percutaneous transluminal angioplasty first and surgical bypass, respectively (P=0.046). Long-term survival was poorer in the percutaneous transluminal angioplasty-first group (21% vs 51% at 5 years, P=0.04)., Conclusion: Infrainguinal bypass and percutaneous transluminal angioplasty are complementary. For TransAtlantic Inter-Society Consensus A and B lesions, percutaneous transluminal angioplasty should be offered first. For American Society of Anesthesiologists class 4 patients, percutaneous transluminal angioplasty should be considered first, regardless of the TransAtlantic Inter-Society Consensus class.