VISSIT Intracranial Stent Study for Ischemic Therapy (VISSIT)

Phase III Study of Pharos Vitesse Neurovascular Stent System Compared to Best Medical Therapy for the Treatment of Ischemic Disease

The main objective of this study is to prospectively evaluate the safety, probable benefit, and effectiveness of the PHAROS Vitesse Neurovascular Stent System in a multicenter, randomized clinical trial.

A secondary objective of this study is to evaluate the impact of stenting in the neurovasculature to treat cerebral ischemia on other outcomes such as hospital length of stay, charges, and costs.

Study Overview

• Status: Terminated
• Conditions: Ischemic Stroke; Transient Ischemic Attack
• Intervention / Treatment: Device: Pharos Vitesse Neurovascular Stent System (Stent implantation) + Medical therapy (Aspirin and Clopidogrel); Drug: Aspirin and Clopidogrel (Medical therapy)

Detailed Description

1.1 Study Hypothesis Treatment of cerebral or retinal ischemia due to plaque in the neurovasculature using the PHAROS Vitesse Stent System plus medical therapy will provide additional clinical benefit over medical therapy alone.

1.2 Primary Effectiveness Endpoint

The primary effectiveness endpoint consists of a composite of the two following outcomes:

• Stroke in the same territory (distal to the target lesion) as the presenting event within 12 months of randomization
• Hard TIA in the same territory (distal to the target lesion) as the presenting event from day 2 through month 12 post-randomization

1.3 Safety Outcomes

Safety outcomes to be collected and reported as part of the overall risk-to-benefit profile for this device are:

• Stroke in any territory within 30 days of randomization
• Death from any cause within 30 days of randomization
• Hard TIA in any territory occurring after a 24 hour post-procedure stabilization period (days 2-30) since the recovery from anesthesia can mask accurate assessment of possible TIA symptoms.
• Intracranial hemorrhage within 30 days of randomization

1.4 Other Outcomes

• Stent Success - PHAROS Vitesse stent deployed across target lesion with residual stenosis 0-20%
• Percentage of Stent Group Subjects with any (symptomatic or asymptomatic) in-stent restenosis ≥ 70% confirmed by angiogram at 12 months
• Percentage of Stent Group Subjects with symptomatic in-stent restenosis ≥ 70% confirmed by angiogram at 12 months
• Percentage of Medical Therapy Group Subjects with interventional procedure (e.g., angioplasty or stent) at 12 months
• Comparison of NIHSS scores between treatment arms
• Comparison of mRS scores between treatment arms

• Study Type: Interventional
• Enrollment (Actual): 125
• Phase: Phase 2; Phase 3

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 14 years to 81 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

1. Subject has at least one neurovascular lesion (70-99%) stenosis [internal carotid, middle cerebral, vertebral artery (C4-BA), and/or basilar artery] symptomatic with a hard TIA or stroke attributable to the territory of the lesion within the past 30 days. An intracranial tandem lesion (50-99%) stenosis may be treated if normal artery segment is sufficient length to avoid overlapping stents.

2. Target vessel diameter / lesion length measurements are within one of the below per angiogram:

   • Vessel diameter is ≥ 2.0 mm and < 2.5 mm / lesion length is ≤ 16 mm, or
   • Vessel diameter is ≥ 2.5 mm and < 3.0 mm / lesion length is ≤ 18 mm, or
   • Vessel diameter is ≥ 3.0 mm and < 4.5 mm / lesion length is ≤ 26 mm, or
   • Vessel diameter is ≥ 4.5 mm and ≤ 5.0 mm / lesion length is ≤ 31 mm
3. Subject has normal artery adjacent to each stenosis; diameter 2.0 mm - 5.0 mm
4. Subject age is 18-85 years
5. Life expectancy is at least 2 years
6. Subject 's mRS score is ≤ 3
7. Subject is available for study follow-up visits (e.g., lives within 3 hours of research center)
8. Subject is willing and cognitively able to provide Informed Consent (consent may be indicated verbally and signed by neutral witness if stroke has impaired hand or visual function)

Exclusion Criteria:

1. Subject has contraindications for balloon expandable stent, e.g.

   • Extreme tortuosity at, or proximal to, target lesion,
   • More than 2 lesions with > 50% stenosis (including vertebral ostia and common carotid disease),
   • Carotid or vertebral dissection

2. CT scan or MRI evidence of any of the following:

   • Intracranial hemorrhage of type PH1 or PH2
   • Subdural or epidural hemorrhage
   • Mass effect, or
   • Intracranial tumor (except small meningioma)
3. Subject has a previous stent in the territory of the target lesion(s)
4. Subject has a previous coil or clip placed in the territory of the target lesion within 6 months
5. Subject has a potential source of cardiac embolism requiring anticoagulation therapy (e.g., atrial fibrillation, intracardiac thrombus or vegetation, significant mitral stenosis, mechanical heart valve, congestive heart failure with EF <30%, or endocarditis)

6. Subject has concurrent intracranial pathology, e.g.

   • Moyamoya
   • Vasculitis documented by biopsy results
   • Ruptured Aneurysm
   • Unruptured aneurysm > 7mm
7. Subject has uncontrolled hypertension (systolic >185 mmHg or diastolic >110 mmHg)
8. Hemoglobin < 10 g/dL; platelet count < 100,000; or INR > 1.5 (e.g., use of warfarin)
9. Subject has an uncorrectable bleeding diathesis
10. Subject's neurological status is unstable and rapidly declining (NIHSS score increased > 4 points within 48 hours prior to randomization)
11. Subject has a contraindication for combination antithrombotic treatment (e.g., clopidogrel and aspirin) such as peptic ulcer disease
12. Subject history indicates high risk of non-compliance (e.g., substance abuse, psychosocial issues, etc.)
13. Subject has a known history contraindicating contrast dye or iodine (vs. sensitivity which can be safely controlled by antihistamine, steroid, etc.)
14. Subject is pregnant or plans to become pregnant in the next 12 months
15. Myocardial infarction within past 3 months
16. Treatment with tPA or other thrombolytic agent within 48 hours prior to randomization
17. Major surgery or trauma within 2 weeks prior to randomization
18. Enrollment in another investigational device or drug study that may confound the results

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Stent Group; Medical therapy + PHAROS Vitesse neurovascular stent ("Stent Group")	Device: Pharos Vitesse Neurovascular Stent System (Stent implantation) + Medical therapy (Aspirin and Clopidogrel); Implantation of one or more balloon-expandable Pharos Vitesse stents to treat neurovascular ischemic lesions + Medical therapy [Treatment with aspirin (81-325 mg daily for the duration of the study) and Clopidogrel (75 mg daily for first 3 months)]; Other Names: Clopidogrel; Pharos Vitesse Neurovascular Stent System; Asprin; Plavix(r)
Active Comparator: Medical Therapy Group; Medical therapy alone ("Medical Therapy Group")	Drug: Aspirin and Clopidogrel (Medical therapy); Medical therapy alone [Treatment with aspirin (81-325 mg daily for the duration of the study) and Clopidogrel (75 mg daily for first 3 months)]; Other Names: Aspirin; Clopidogrel; Plavix(r)

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Successful Outcome: No Stroke or Hard TIA in the Same Territory Within 12 Months	The primary effectiveness endpoint was a composite of the two following outcomes: Stroke in the same territory (distal to the target lesion) as the presenting event within 12 months of randomization; Hard Transient Ischemic Attack (TIA) in the same territory (distal to the target lesion) as the presenting event from day 2 through month 12 post-randomization A subject was deemed to be a primary endpoint success if neither of these outcomes occurred. The Kaplan-Meier success rate at 12-months post-operatively was calculated with Kaplan-Meier time-to-event methodology, where the time variable for patients who were successful (no stroke within 12 months or hard TIA between 2 days and 12 months) was censored at the time of last follow-up, and the time variable for patients who were not successful (had a stroke within 12 months or hard TIA between 2 days and 12 months) was censored at the time of the first event (stroke with 12 months or hard TIA between 2 days and 12 months).	One Year

Collaborators and Investigators

• Sponsor: Codman & Shurtleff

Publications and helpful links

General Publications

• Chimowitz MI, Lynn MJ, Howlett-Smith H, Stern BJ, Hertzberg VS, Frankel MR, Levine SR, Chaturvedi S, Kasner SE, Benesch CG, Sila CA, Jovin TG, Romano JG; Warfarin-Aspirin Symptomatic Intracranial Disease Trial Investigators. Comparison of warfarin and aspirin for symptomatic intracranial arterial stenosis. N Engl J Med. 2005 Mar 31;352(13):1305-16. doi: 10.1056/NEJMoa043033.
• Fiorella D, Woo HH. Emerging endovascular therapies for symptomatic intracranial atherosclerotic disease. Stroke. 2007 Aug;38(8):2391-6. doi: 10.1161/STROKEAHA.107.482752. Epub 2007 Jun 21. No abstract available.
• Berkefeld J, Hamann GF, du Mesnil R, Kurre W, Steinmetz H, Zanella FE, Sitzer M. [Endovascular treatment for intracranial stenoses. A common statement by neurologists and neuroradiologists]. Nervenarzt. 2006 Dec;77(12):1444-55. doi: 10.1007/s00115-006-2182-z. German.
• Cruz-Flores S, Diamond AL. Angioplasty for intracranial artery stenosis. Cochrane Database Syst Rev. 2006 Jul 19;2006(3):CD004133. doi: 10.1002/14651858.CD004133.pub2.
• Derdeyn CP, Chimowitz MI. Angioplasty and stenting for atherosclerotic intracranial stenosis: rationale for a randomized clinical trial. Neuroimaging Clin N Am. 2007 Aug;17(3):355-63, viii-ix. doi: 10.1016/j.nic.2007.05.001.
• Fiorella D, Chow MM, Anderson M, Woo H, Rasmussen PA, Masaryk TJ. A 7-year experience with balloon-mounted coronary stents for the treatment of symptomatic vertebrobasilar intracranial atheromatous disease. Neurosurgery. 2007 Aug;61(2):236-42; discussion 242-3. doi: 10.1227/01.NEU.0000255521.42579.31.
• Zaidat OO, Fitzsimmons BF, Woodward BK, Wang Z, Killer-Oberpfalzer M, Wakhloo A, Gupta R, Kirshner H, Megerian JT, Lesko J, Pitzer P, Ramos J, Castonguay AC, Barnwell S, Smith WS, Gress DR; VISSIT Trial Investigators. Effect of a balloon-expandable intracranial stent vs medical therapy on risk of stroke in patients with symptomatic intracranial stenosis: the VISSIT randomized clinical trial. JAMA. 2015 Mar 24-31;313(12):1240-8. doi: 10.1001/jama.2015.1693.

Study record dates

Study Major Dates

• Study Start: October 1, 2008
• Primary Completion (Actual): April 1, 2013
• Study Completion (Actual): June 1, 2014

Study Registration Dates

• First Submitted: December 29, 2008
• First Submitted That Met QC Criteria: December 30, 2008
• First Posted (Estimate): December 31, 2008

Study Record Updates

• Last Update Posted (Estimate): February 20, 2015
• Last Update Submitted That Met QC Criteria: February 2, 2015
• Last Verified: February 1, 2015

More Information

Terms related to this study

• Keywords: Ischemic stroke; Transient Ischemic Attack; Intracranial Stenting
• Additional Relevant MeSH Terms: Pathologic Processes; Cardiovascular Diseases; Vascular Diseases; Cerebrovascular Disorders; Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Brain Ischemia; Stroke; Ischemic Stroke; Ischemia; Ischemic Attack, Transient; Physiological Effects of Drugs; Neurotransmitter Agents; Molecular Mechanisms of Pharmacological Action; Peripheral Nervous System Agents; Enzyme Inhibitors; Analgesics; Sensory System Agents; Anti-Inflammatory Agents, Non-Steroidal; Analgesics, Non-Narcotic; Anti-Inflammatory Agents; Antirheumatic Agents; Fibrinolytic Agents; Fibrin Modulating Agents; Platelet Aggregation Inhibitors; Cyclooxygenase Inhibitors; Antipyretics; Purinergic P2Y Receptor Antagonists; Purinergic P2 Receptor Antagonists; Purinergic Antagonists; Purinergic Agents; Aspirin; Clopidogrel
• Other Study ID Numbers: VISSIT CA-2007-01; G080051