Medtech Insight interviews Adnan Siddiqui, MD, PhD, assistant professor of neurosurgery and radiology at the State University of New York, Buffalo, a pioneer in the use of interventional technology for acute ischemic stroke. Siddiqui offers his perspective on the current state of endovascular devices for AIS, the unique challenges faced by physicians in this field, and the factors driving interest in stent-based technologies.
Article preview from Medtech Insight- April, 2010
To gain some clinical perspective on the evolution of endovascular devices for acute ischemic stroke, Medtech Insight spoke recently with Adnan Siddiqui, MD, PhD, assistant professor of neurosurgery and radiology at the State University of New York, Buffalo, who is a pioneer in the use of interventional technology for acute ischemic stroke (AIS). In the following exclusive interview, Siddiqui offers his perspective on the current state of endovascular devices for AIS, the unique challenges faced by physicians in this field, and the factors driving interest in stent-based technologies.
Q: Medtech Insight: What is driving the use of intracranial stents as a primary treatment for acute ischemic stroke?
Adnan Siddiqui: There are two main reasons the use of stents is increasing in acute ischemic stroke. The first is the rapidity of the vessel reopening. You have a patient who had a major blood vessel blocked going to a large part of the brain, the patient's not doing well, he's having an acute stroke. And he comes in within the guidelines where you can potentially do something about it. Based on imaging and other studies, you take the patient to the angio suite and you access the blocked artery. Now what do you do?
What people have been doing for almost 15 years now is trying different things. Nick Hopkins, my chairman, was one of the pioneers of this revolution and has made Buffalo a global leader in neurointervention, particularly stroke intervention. He shows a slide of the progression of technology over the years. They tried injecting clot busting drugs of all kinds directly into the clot, using a balloon catheter to open up the vessel or pulling it back to try and retrieve the clot. Then Merci got approved and people have been using the Merci System to retrieve the clot and, most recently, Penumbra got approved and they use the Penumbra device to try and suck the clot out. All of these procedures take a lot of time. All of them usually take somewhere between, at the quickest, a half hour, sometimes two, sometimes three hours while the brain is not getting the blood supply it needs and the vessel remains plugged.
Some years ago, Nick suggested using a stent to open up an acute ischemic stroke blockage and Elad Levy my partner tried it initially with a cardiology balloon expandable stent—and it worked beautifully! That's how Elad led the charge of trying stenting, although initially only as a salvage option. It quickly became apparent that the salvage option worked much more reliably and quickly than the approved or standard options.
Now for people like me who are used to putting stents in the brain for other reasons, such as brain aneurysms or narrowed vessels, we go up, put in a stent, the vessel opens up, and we leave and we're done. So the advantage there is you can put in a stent in about 15 to 20 minutes; the rapidity of opening the vessel is phenomenal with stents. The second reason this area is taking off is that stents are better at opening up the vessel. With all those other techniques I mentioned, the vessel opens up somewhere between 40% and 60% of the time. With persistence, you can probably bring those figures up a little higher. But persistence takes more time. Stenting, on the other hand, produces much higher recanalization rates much faster. We just completed the SARIS trial for which Elad was PI [principal investigator] and the vessel reopening rate in that study was 100%. And that is not the only trial showing that stenting works—in other reported stenting series, recanalization rates were 90+%.
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