February 18, 2011 (Los Angeles, California) — The largest national review of endovascular treatment for intracranial stenosis is showing nearly triple the cost compared with usual care and unclear safety and efficacy.
"In-hospital charges were an average of $88,223 for those who had angioplasty and $60,711 in angioplasty-plus-stent patients compared with $24,208 for patients who had neither procedure," Adnan Qureshi, MD, from the Minnesota Stroke Initiative, told reporters attending a news conference here at the International Stroke Conference 2011.
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| Dr. Adnan Quresht |
Session moderator Ralph Sacco, MD, from the Miller School of Medicine at the University of Miami in Florida and president of the American Heart Association complimented the size and quality of the review, calling this "a national snapshot."
The study is part of the Nationwide Inpatient Survey of 1000 hospitals. This is the largest all-payer inpatient care database in the United States.
Investigators saw more than 370,061 admissions for ischemic stroke or transient ischemic attack between 2005 and 2007. Among these, 158 (0.042%) underwent primary angioplasty and another 169 (0.045%) had a combination of angioplasty and stenting. Stenting alone was performed in 12 patients.
Most of these procedures, 80% or more in each group, were performed at urban teaching hospitals. The investigators report that outcomes for patients undergoing primary angioplasty were worse than patients who also had stents put in.
Table 1. Outcomes of Intracranial Intervention in the Nationwide Inpatient Sample
| Discharge | Primary Angioplasty, % (n = 791) | Angioplasty and Stents, % (n = 837) | P Value |
| Home | 45 | 76 | <.0001 |
| Care facility | 39 | 20 | .0007 |
| In-hospital death | 17 | 4 | .0037 |
Besides lower costs, ischemic stroke patients who underwent neither procedure also had lower in-hospital mortality at 3%.
Table 2. Predictors of Death and Disability in Patients With Intracranial Angioplasty or Stents
| Predictor | Odds Ratio (95% Confidence Interval) | P Value |
| Congestive heart failure | 3.1 (1.2 – 7.7) | .0119 |
| Pneumonia | 10.4 (1.4 – 77.5) | .0215 |
| Urinary tract infection | 3.5 (1.6 – 7.4) | .001 |
| Intracranial hemorrhage | 10.8 (1.1 – 109.7) | .0433 |
"Our findings show these procedures still carry high immediate complication rates and evidence of their efficacy is sketchy and ambiguous," lead investigator Yousef Mohammad, MD, from Rush University in Chicago, Illinois, said in a news release.
Dr. Mohammad was scheduled to present the study findings but was unable to attend due to a family emergency, and coauthor Dr. Qureshi, also president of the International Society of Interventional Neurology, stepped in.
Current guidelines recommend that endovascular treatment for intracranial stenosis be considered after all medications have failed.
Dr. Qureshi told the meeting that he believes the way forward will be in patient selection. "We've been so focused on the technology that we've failed to put sufficient emphasis on patient selection and identifying the right time interval for the procedures."
SAMMPRIS Trial
Definitive answers are expected from the SAMMPRIS trial, the eagerly awaited Stenting vs Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis. Results from the National Institutes of Health study out of the Medical University of South Carolina are expected in 2013.
Asked by Medscape Medical News to comment, Jeffrey Saver, MD, director of the University of California at Los Angeles Stroke Unit, said the evidence is incomplete. "We'll have a clearer idea of who will benefit after SAMMPRIS is reported."
Dr. Saver agrees with Dr. Quereshi that endovascular treatment will likely be appropriate in carefully selected patients. Who might those patients be? Dr. Saver says SAMMPRIS will provide more on this as well, but if he had to wager a guess, he'd choose patients with incomplete collateral flow, those with progressive narrowing or multiple events.
This study is funded by the Agency for Healthcare Research and Quality. The researchers have disclosed no relevant financial relationships.
International Stroke Conference (ISC) 2011: Abstract LB12. Presented February 11, 2011.
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Cite this: Intracranial Angioplasty and Stenting Triple Hospital Costs - Medscape - Feb 18, 2011.
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