Endovascular Neurovascular Procedures: How Far Should We Go?
Pub Date: Monday, April 6, 2009
Author: E. Sander Connolly, MD
Meyers PM, Schumacher HC, Higashida RT, et al. Indications for the performance of intracranial endovascular neurointerventional procedures: a scientific statement from the American Heart Association Council on Cardiovascular Radiology and Intervention, Stroke Council, Council on Cardiovascular Surgery and Anesthesia, Interdisciplinary Council on Peripheral Vascular Disease, and Interdisciplinary Council on Quality of Care and Outcomes Research. Circulation 2009. Published online before print April 6, 2009. 10.1161/CIRCULATIONAHA.109.192217.
Meyers and colleagues provide an erudite review of the current status of endovascular procedures for cerebrovascular applications, complete with levels of evidence. Despite the proliferating application of endovascular techniques to a broad variety of cerebrovascular diseases, these guidelines show that the levels of evidence for many cerebral procedures remain quite limited. No longer in its infancy, interventional neuroradiology has become a multidisciplinary endeavor, and the number of participants continues to grow. Particularly as physicians without specific neuroscience training redirect their catheters from the body to the brain, we must ask if the data support dissemination of these procedures to interested physicians without the requisite neuroscience training. Should the cardiologist, vascular surgeon, or peripheral interventional radiologist perform cerebrovascular procedures? The levels of evidence suggest these endovascular neurovascular procedures are not ready to be popularized pending the results of several important ongoing trials. For instance, angioplasty and stenting have been successfully applied to a number of vascular beds outside the head. While these procedures are performed on an experimental basis inside the head to treat or prevent stroke, ongoing studies such as SAMMPRIS  are necessary to determine their relevance. A recent systematic review of the literature on intracranial stent-angioplasty for atherosclerotic disease by Groeschel and associates did not find benefit and warned against the procedure outside of randomized trials or at inexperienced centers. The brain presents challenges not encountered in the treatment of other organ systems. Recognition of our limitations is the first step toward mastery of these obstacles.
- Chimowitz M. Stenting and aggressive medical management for preventing recurrent stroke in intracranial stenosis. NIH R01NS058728-01A1, R01NS058728-01A1, December 7, 2007; updated February 12, 2009. http://ClinicalTrial.gov. Identifier: NCT00576693. http://clinicaltrials.gov/ct2/show/NCT00576693?term=SAMMPRIS&rank=1
- Groeschel K, Schnaudigel S, Pilgrim SM, et al. A systematic review on outcome after stenting for intracranial atherosclerosis. Stroke 40, 2009. [Epub ahead of print]
-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association --