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  • Impact of qualifying artery on the efficacy of stenting plus medical therapy versus medical therapy alone in patients with symptomatic intracranial stenosis: a post-hoc analysis of the CASSISS trial

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Ischemic stroke
Original research
Impact of qualifying artery on the efficacy of stenting plus medical therapy versus medical therapy alone in patients with symptomatic intracranial stenosis: a post-hoc analysis of the CASSISS trial
  1. Qiaowei Wu1,
  2. Jie Wang2,
  3. Bingjie Zheng1,
  4. Jingtao Qi1,
  5. Shancai Xu1,
  6. Pei Wu1,
  7. Guang Zhang1,
  8. Zhiyong Ji1,
  9. Chunlei Wang1,
  10. Jinbiao Yao1,
  11. Liqun Jiao2,
  12. Peng Gao2,
  13. Tao Wang2,
  14. Daming Wang3,
  15. Tianxiao Li4,
  16. Yingkun He4,
  17. Zhenwei Zhao5,
  18. Yiling Cai6,
  19. Wei Wu7,
  20. Weiwen He8,
  21. Huaizhang Shi1,
  22. Yuchen Li1
  23. for the CASSISS Trial Investigators
    1. 1 Department of Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
    2. 2 Departments of Neurosurgery and Interventional Neuroradiology, Xuanwu Hospital Capital Medical University, Beijing, China
    3. 3 Department of Neurosurgery, Beijing Hospital, Beijing, China
    4. 4 Department of Intervention, Henan Provincial People's Hospital, Zhengzhou, Henan, China
    5. 5 Department of Neurosurgery, Air Force Medical University Tangdu Hospital, Xi'an, Shanxi, China
    6. 6 Department of Neurology, Chinese People's Liberation Army Rocket Force Characteristic Medical Center, Beijing, China
    7. 7 Department of Neurology, Qilu Hospital of Shandong University, Jinan, Shandong, China
    8. 8 Department of Neurosurgery, Guangzhou Medical University Second Affiliated Hospital, Guangzhou, Guangdong, China
    1. Correspondence to Dr Huaizhang Shi, Department of Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China; huaizhangshi{at}126.com; Dr Yuchen Li, Department of Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China; liyuchen8999{at}163.com

    Abstract

    Background A recent trial failed to show any benefit of stenting plus medical therapy over medical therapy alone in patients with symptomatic intracranial stenosis. We aimed to examine whether the symptomatic qualifying artery modifies the effect of stenting plus medical therapy.

    Methods This is a post-hoc analysis of the CASSISS trial that included patients with symptomatic intracranial stenosis, randomly assigned to undergo stenting plus medical therapy or medical therapy alone; 358/380 patients were included. Multivariable logistic regression analysis was used with an interaction term to estimate the altered treatment effect by the qualifying artery. The primary outcome was a composite of stroke or death within 30 days or stroke in the qualifying artery territory beyond 30 days through 1 year. The five secondary outcomes included stroke or death related to the qualifying artery territory at 2 and 3 years.

    Results No significant treatment allocation-by-stenosis site interaction was observed (Pinteraction=0.435). Compared with medical therapy alone, the adjusted ORs for stenting plus medical therapy were 2.73 (95% CI 0.42 to 17.65) for internal carotid artery stenosis, 1.20 (95% CI 0.29 to 4.99) for M1 stenosis, 0.23 (95% CI 0.02 to 2.31) for vertebral artery stenosis, and 1.33 (95% CI 0.34 to 5.28) for basilar artery stenosis. Of the five secondary outcomes, none showed a significant treatment allocation-by-stenosis site interaction including stroke in the qualifying artery territory at 2 years (Pinteraction=0.659) and 3 years (Pinteraction=0.493).

    Conclusions Among patients with transient ischemic attacks or ischemic stroke due to severe intracranial atherosclerotic stenosis, there was no evidence that the symptomatic qualifying artery could determine the addition of stenting to medical therapy.

    • Artery
    • Stenosis
    • Atherosclerosis
    • Angioplasty
    • Stent

    Data availability statement

    Data are available upon reasonable request. Requests to access an anonymized dataset supporting the conclusions may be obtained following review.

    https://doi.org/10.1136/jnis-2023-020456

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      Data availability statement

      Data are available upon reasonable request. Requests to access an anonymized dataset supporting the conclusions may be obtained following review.

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      Footnotes

      • QW, JW and BZ contributed equally.

      • Contributors QW, BZ, JQ, SX, PW, GZ, ZJ, CW, JY, HS, and YL designed the study. BZ, LJ, PG, TW, DW, TL, YH, ZZ, YC, WW, WH, HS, and YL conducted the trial and collected information. QW drafted the manuscript. JW independently contributed to the statistical analysis. HS is the guarantor for this work and accepts responsibility for the data presented. All authors critically reviewed the manuscript and approved the final version.

      • Funding This study was supported by grants from the National Natural Science Foundation of China (82101383), the China Postdoctoral Science Foundation project (2021MD703829), and the Key research and development projects in Heilongjiang Province (2022ZX06C03).

      • Competing interests None declared.

      • Provenance and peer review Not commissioned; externally peer reviewed.

      • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.