Transluminal angioplasty and stenting versus conservative treatment in patients with symptomatic basilar artery stenosis : Perspective for future clinical trials.

PURPOSE: Two recent randomized controlled trials (RCT) consistently showed superiority of aggressive medical treatment versus percutaneous transluminal angioplasty and stenting (PTAS) in patients with intracranial artery stenosis. Patients with symptomatic basilar stenosis have a higher long-term risk of recurrent stroke compared to patients with anterior circulation stenosis but no study has specifically focused on the role of PTAS in this subgroup. The aim of our study was to investigate the subgroup of patients with symptomatic basilar artery stenosis to find evidence for the feasibility of a future clinical trial. METHODS: Patients with ischemic stroke caused by a symptomatic basilar stenosis and admitted to five German tertiary care hospitals were included in this multicenter effectiveness study. Primary outcome was a composite endpoint of stroke recurrence, clinically relevant restenosis, progression and death. Shared frailty Cox regression models were used to compare outcome rates between groups. RESULTS: Of the 139 patients included in the study 79 (57 %) underwent PTAS and 60 (43 %) conservative treatment alone. The median follow-up period was 300 (IQR 18-738) days. Risks of the primary composite outcome (hazard ratio HR 0.49, 95 % confidence interval CI 0.25-0.97, p = 0.039) and of the key secondary outcomes recurrent stroke (HR 0.42, 95 % CI 0.19-0.95, p = 0.037) and clinically relevant restenosis/progression (HR 0.12, 95 % CI 0.03-0.59, p = 0.009) were lower in patients with PTAS compared to conservative treatment. There was no difference in all-cause mortality between groups (HR 0.98, 95 % CI 0.19-5.09, p = 0.979). CONCLUSION: In this retrospective study we could not reproduce the findings from large RCTs on intracranial stenting. Our data could be considered as a basis for a prospective study on patient selection for PTAS in the basilar artery.

The eNOS 894G/T gene polymorphism and its influence on early and long-term mortality after on-pump cardiac surgery.

BACKGROUND: The eNOS 894G/T polymorphism (GG, GT, and TT) is associated with cardiovascular mortality and may influence cardiovascular diseases as a genetic risk factor. Moreover, this polymorphism has an impact on intraoperative hemodynamics during cardiac surgery with cardiopulmonary bypass (CPB). In this study, we analyzed the influence of this gene polymorphism on early clinical outcome in patients who underwent cardiac surgery with CPB. Also, we performed a 5-year follow-up, assessing the impact of this polymorphism on long-term mortality. METHOD: 500 patients who underwent cardiac surgery with CPB between 2006 and 2007 were included in this prospective single centre study. Genotyping for the eNOS gene polymorphism was performed by polymerase chain reaction amplification. RESULTS: Genotype distribution of 894G/T was: GG 50.2%; GT 42.2%; TT 7.8%. Cardiovascular risk factors were equally distributed between the different genotypes of the eNOS 894G/T polymorphism. No significant difference among the groups was shown regarding Euroscore, SAPS II and APACHE II. Perioperative characteristics were also not affected by the genotypes, except for the consumption of norepinephrine (p = 0.03) and amiodarone (p = 0.01) which was higher in the GT allele carrier. The early postoperative course was quite uniform across the genotypes, except for mean intensive care unit length of stay which was significantly prolonged in GT carriers (p = 0.001). The five-year follow-up was 100% complete and showed no significant differences regarding mortality between the groups. CONCLUSION: Our results show that the eNOS 894G /T polymorphism is not associated with early and late clinical outcome after cardiac surgery. Thus, this polymorphism can actually not help to identify high risk groups in the heterogeneous population of individuals who undergo cardiac surgery with CPB.