Transluminal angioplasty and stenting versus conservative treatment in patients with symptomatic basilar artery stenosis: Perspective for future clinical trials

PURPOSE: Two recent randomized controlled trials (RCT) consistently showed superiority of aggressive medical treatment versus percutaneous transluminal angioplasty and stenting (PTAS) in patients with intracranial artery stenosis. Patients with symptomatic basilar stenosis have a higher long-term risk of recurrent stroke compared to patients with anterior circulation stenosis but no study has specifically focused on the role of PTAS in this subgroup. The aim of our study was to investigate the subgroup of patients with symptomatic basilar artery stenosis to find evidence for the feasibility of a future clinical trial.

METHODS: Patients with ischemic stroke caused by a symptomatic basilar stenosis and admitted to five German tertiary care hospitals were included in this multicenter effectiveness study. Primary outcome was a composite endpoint of stroke recurrence, clinically relevant restenosis, progression and death. Shared frailty Cox regression models were used to compare outcome rates between groups.

RESULTS: Of the 139 patients included in the study 79 (57 %) underwent PTAS and 60 (43 %) conservative treatment alone. The median follow-up period was 300 (IQR 18-738) days. Risks of the primary composite outcome (hazard ratio HR 0.49, 95 % confidence interval CI 0.25-0.97, p = 0.039) and of the key secondary outcomes recurrent stroke (HR 0.42, 95 % CI 0.19-0.95, p = 0.037) and clinically relevant restenosis/progression (HR 0.12, 95 % CI 0.03-0.59, p = 0.009) were lower in patients with PTAS compared to conservative treatment. There was no difference in all-cause mortality between groups (HR 0.98, 95 % CI 0.19-5.09, p = 0.979).

CONCLUSION: In this retrospective study we could not reproduce the findings from large RCTs on intracranial stenting. Our data could be considered as a basis for a prospective study on patient selection for PTAS in the basilar artery.