Abstract
Background:Extracranial–intracranial (EC-IC) bypass and intracranial stenting (ICS) are both revascularization procedures that have emerged as treatment options for intracranial atherosclerotic disease (ICAD). This study describes and compares recent trends in utilization and outcomes of intracranial revascularization procedures in the United States using a population-based cohort. It also investigates the association of ICS and EC-IC bypass with periprocedural morbidity and mortality, unfavorable discharge status, length of stay (LOS), and total hospital charges.Methods:The National Inpatient Sample (NIS) was queried for patients with ICAD who underwent EC-IC bypass or ICS during the years 2004–2010. Patient characteristics, demographics, perioperative complications, outcomes, and discharge data were collected.Results:There were 627 patients who underwent ICS and 249 patients who underwent EC-IC bypass. Patients who underwent ICS were significantly older (P < 0.001) with more comorbidities (P = 0.027) than those who underwent EC-IC bypass. Patients who underwent EC-IC bypass experienced higher rates of postprocedure stroke (P = 0.014), but those who underwent ICS experienced higher rates of death (P = 0.006). Among asymptomatic patients, the rates of postprocedure stroke (P = 0.341) and death (P = 0.887) were similar between patients who underwent ICS and those who underwent EC-IC bypass. Among symptomatic patients, however, there was a higher rate of postprocedure stroke in patients who underwent EC-IC bypass (P < 0.001) and a higher rate of death among patients who underwent ICS (P = 0.015).Conclusion:The ideal management of patients with ICAD cannot yet be defined. Although much data from randomized and prospective trials on revascularization have been collected, many questions remain unanswered. There still remain cohorts of patients, specifically patients who have failed aggressive medical management, where not enough evidence is available to dictate decision-making. In order to further elucidate the safety and efficacy of these intracranial revascularization procedures, further clinical trials are needed.
Highlights
We investigate the association of intracranial stenting (ICS) and EC‐IC bypass with periprocedural morbidity and mortality, rate of unfavorable discharge, length of stay (LOS), and total hospital costs
A significantly larger amount of patients who underwent ICS were symptomatic at presentation (61.2% versus 50.6%; P = 0.004) and were admitted nonelectively (67.5% versus 44.2%; P < 0.001)
The percentage of EC‐IC bypass procedures performed at teaching hospitals was significantly higher than ICS procedures (93.7% versus 85.5%; P = 0.012)
Summary
Successful management of patients with ICAD requires an intervention that is safe, effective, and has minimal complications.[32] Medical treatment can reduce the risk of ischemic stroke due to thromboembolic events, but it does not reduce the risk of ICAD progression and the associated patholophysiologic components of hypoperfusion and poor collateral circulation.[8,9,12,15,24,31] Technological advances in recent years have given rise to several surgical approaches to treating ICAD, which include extracranial–intracranial (EC‐IC) bypass and intracranial stenting (ICS).[2] These revascularization procedures were developed to reduce the risk of ischemic stroke in patients with impaired cerebral hemodynamics due to occlusive cerebrovascular disease by improving blood flow to the territory distal to the stenotic vessel.[26,29] These procedures may provide benefit to symptomatic patients with severe stenosis who are at the highest risk of ischemic stroke in the region of the stenotic artery,[6] but these patients pose the most procedural risks. It investigates the association of ICS and EC‐IC bypass with periprocedural morbidity and mortality, unfavorable discharge status, length of stay (LOS), and total hospital charges
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