This week The Lancet published a friendly reminder from the SAMMPRIS investigators warning us that it is a bad idea to go putting stents in places they do not belong. This unintended favor came in the form of the publication of the long term follow-up from the Stenting versus Aggressive Medical Therapy for Intracranial Arterial Stenosis trial online this week in The Lancet.
The SAMMPRIS trial, originally published in the NEJM in 2011 applied the frequently attempted, but rarely accurate mantra,“If it works on the heart then it should work on the brain.” The authors took high risk TIA patients with radiologically confirmed intracranial stenosis and randomized them to “aggressive” medical management or percutaneous transluminal angioplasty and stenting (PTAS). The trial was stopped early because of the exorbitant amount of periprocedural strokes and death among those in the PTAS group. Specifically there was an 8.9% absolute increase in stroke and 1.8% increase in mortality within the first 30 days of enrollment. The authors’ summary of this dramatic failure was that the true benefits and harms could not be assessed at the time of initial publication, as there was not enough data to determine if the long term benefits outweighed these initial harms.
The recent paper is the 2-year follow up of this cohort and specifically addresses these presumed “long term benefits”. The overall occurrence of stroke was 19% in the medically managed group vs 26% in the PTAS group. It is apparent no clinically significant benefit exists especially when considering the devastating early harms. Yet another example of our limited understanding of the pathophysiology of atherosclerotic disease, and the ramifications of introducing thrombogenic objects into already tight spaces.
“Aggressive Medical Treatment With or Without Stenting in High-Risk Patients with Intracranial Artery Stenosis (SAMMPRIS): the Final Results of a Randomized Trial” http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)62038-3/fulltext
Nihilism, Emergency Medicine, and the art of doing nothing at emnerd.com and @CaptainBasilEM
“Aggressive Medical Treatment With or Without Stenting in High-Risk Patients with Intracranial Artery Stenosis (SAMMPRIS): the Final Results of a Randomized Trial” http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)62038-3/fulltext
Nihilism, Emergency Medicine, and the art of doing nothing at emnerd.com and @CaptainBasilEM