Journal article
Extracranial-Intracranial Bypass and Risk of Stroke and Death in Patients With Symptomatic Artery Occlusion: The CMOSS Randomized Clinical Trial
JAMA : the journal of the American Medical Association, Vol.330(8), pp.704-714
08/22/2023
DOI: 10.1001/jama.2023.13390
PMCID: PMC10445185
PMID: 37606672
Abstract
ImportancePrior trials of extracranial-intracranial (EC-IC) bypass surgery showed no benefit for stroke prevention in patients with atherosclerotic occlusion of the internal carotid artery (ICA) or middle cerebral artery (MCA), but there have been subsequent improvements in surgical techniques and patient selection. ObjectiveTo evaluate EC-IC bypass surgery in symptomatic patients with atherosclerotic occlusion of the ICA or MCA, using refined patient and operator selection. Design, Setting, and ParticipantsThis was a randomized, open-label, outcome assessor-blinded trial conducted at 13 centers in China. A total of 324 patients with ICA or MCA occlusion with transient ischemic attack or nondisabling ischemic stroke attributed to hemodynamic insufficiency based on computed tomography perfusion imaging were recruited between June 2013 and March 2018 (final follow-up: March 18, 2020). InterventionsEC-IC bypass surgery plus medical therapy (surgical group; n = 161) or medical therapy alone (medical group; n = 163). Medical therapy included antiplatelet therapy and stroke risk factor control. Main Outcomes and MeasuresThe primary outcome was a composite of stroke or death within 30 days or ipsilateral ischemic stroke beyond 30 days through 2 years after randomization. There were 9 secondary outcomes, including any stroke or death within 2 years and fatal stroke within 2 years. ResultsAmong 330 patients who were enrolled, 324 patients were confirmed eligible (median age, 52.7 years; 257 men [79.3%]) and 309 (95.4%) completed the trial. For the surgical group vs medical group, no significant difference was found for the composite primary outcome (8.6% [13/151] vs 12.3% [19/155]; incidence difference, -3.6% [95% CI, -10.1% to 2.9%]; hazard ratio [HR], 0.71 [95% CI, 0.33-1.54]; P = .39). The 30-day risk of stroke or death was 6.2% (10/161) in the surgical group and 1.8% (3/163) in the medical group, and the risk of ipsilateral ischemic stroke beyond 30 days through 2 years was 2.0% (3/151) and 10.3% (16/155), respectively. Of the 9 prespecified secondary end points, none showed a significant difference including any stroke or death within 2 years (9.9% [15/152] vs 15.3% [24/157]; incidence difference, -5.4% [95% CI, -12.5% to 1.7%]; HR, 0.69 [95% CI, 0.34-1.39]; P = .30) and fatal stroke within 2 years (2.0% [3/150] vs 0% [0/153]; incidence difference, 1.9% [95% CI, -0.2% to 4.0%]; P = .08). Conclusions and RelevanceAmong patients with symptomatic ICA or MCA occlusion and hemodynamic insufficiency, the addition of bypass surgery to medical therapy did not significantly change the risk of the composite outcome of stroke or death within 30 days or ipsilateral ischemic stroke beyond 30 days through 2 years. Trial RegistrationClinicalTrials.gov Identifier: NCT01758614.
Details
- Title: Subtitle
- Extracranial-Intracranial Bypass and Risk of Stroke and Death in Patients With Symptomatic Artery Occlusion: The CMOSS Randomized Clinical Trial
- Creators
- Yan MaTao Wang - Capital Medical UniversityHaibo Wang - Peking University First HospitalSepideh Amin-Hanjani - University Hospitals of ClevelandXiaoguang Tong - Tianjin Huanhu HospitalJiyue Wang - Shandong First Medical UniversityZhiyong Tong - First Hospital of China Medical UniversityDong Kuai - Shanxi Cardiovascular HospitalYiling CaiJun Ren - Lanzhou University Second HospitalDonghai Wang - Qilu Hospital of Shandong UniversityLian Duan - Hainan Branch of People's Liberation Army General HospitalAisha Maimaitili - First Affiliated Hospital of Xinjiang Medical UniversityChunhua Hang - Nanjing Drum Tower HospitalJiasheng YuXuesong Bai - Capital Medical UniversityWilliam J Powers - Duke UniversityColin P Derdeyn - University of IowaYangfeng Wu - Peking University First HospitalFeng LingYuxiang Gu - Huashan HospitalLiqun Jiao - Capital Medical University
- Resource Type
- Journal article
- Publication Details
- JAMA : the journal of the American Medical Association, Vol.330(8), pp.704-714
- DOI
- 10.1001/jama.2023.13390
- PMID
- 37606672
- PMCID
- PMC10445185
- ISSN
- 0098-7484
- eISSN
- 1538-3598
- Language
- English
- Date published
- 08/22/2023
- Academic Unit
- Neurology; Radiology; Iowa Neuroscience Institute; Neurosurgery
- Record Identifier
- 9984457958902771
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