Drug-coated Balloon for Endovascular Treatment Versus Aggressive Medical Management in High-Risk Symptomatic Intracranial Atherosclerotic Stenosis
| Registry | NCT07830277, acronym DRBEYOND2 |
|---|---|
| Status | Not yet recruiting |
| Phase | Not applicable |
| Study type | Interventional; randomized, parallel, masking: none, treatment |
| Enrollment | 570 (Estimated) |
| Sponsor | Beijing Tiantan Hospital (Other); collaborators: Baotou Central Hospital |
| Conditions | Symptomatic Intracranial Atherosclerotic Stenosis |
| Interventions | Drug-Coated Balloon Angioplasty, Aggressive Medical Management (Procedure, other) |
| Dates | start 2026-10-01 (estimated), primary completion 2028-12-31 (estimated), completion 2031-06-01 (estimated), first posted 2026-09-21, last updated 2026-09-23 |
| Locations | 2 sites in China |
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All trials for Symptomatic Intracranial Atherosclerotic Stenosis All trials of Drug-Coated Balloon Angioplasty All trials of Aggressive Medical Management
DR.BEYOND-2 is an investigator-initiated, prospective, multicenter, randomized, open-label, blinded-endpoint, parallel-group clinical trial designed to evaluate the efficacy and safety of drug-coated balloon (DCB) angioplasty plus aggressive medical management compared with aggressive medical management alone in patients with high-risk symptomatic intracranial atherosclerotic stenosis (sICAS).
A total of 570 eligible patients will be randomized in a 1:1 ratio to the DCB group or the medical management group. Patients assigned to the DCB group will undergo DCB angioplasty in addition to aggressive medical management, with rescue stenting permitted when clinically necessary according to the study protocol. Patients assigned to the control group will receive aggressive medical management alone.
The primary endpoint is the composite of any stroke or death within 30 days after enrollment and ischemic stroke in the territory of the qualifying artery from day 31 through 1 year. Participants will be followed for up to 3 years to further evaluate recurrent ischemic events, vascular outcomes, functional outcomes, and long-term safety.
Symptomatic intracranial atherosclerotic stenosis (sICAS) is an important cause of ischemic stroke and recurrent cerebrovascular events. Although aggressive medical management is the standard treatment, patients with severe stenosis and high-risk clinical or hemodynamic features may remain at substantial risk of recurrent ischemic events. Previous randomized trials of intracranial stenting have raised concerns regarding periprocedural safety, whereas balloon angioplasty has shown potential benefit but may be limited by arterial dissection, elastic recoil, and restenosis. Drug-coated balloon angioplasty may provide an alternative endovascular strategy by combining luminal enlargement with local delivery of an antiproliferative agent while minimizing permanent intracranial implants.
DR.BEYOND-2 is an investigator-initiated, prospective, multicenter, randomized, open-label trial with blinded endpoint assessment. The study will enroll 570 patients with high-risk symptomatic intracranial atherosclerotic stenosis involving a major intracranial artery. Eligible patients must have had a recent ischemic stroke or transient ischemic attack attributable to the qualifying artery, severe intracranial stenosis, and prior treatment with at least one antithrombotic agent and/or guideline-based vascular risk-factor management. For anterior-circulation lesions, evidence of hemodynamic compromise is additionally required according to the protocol.
Participants will be randomly assigned in a 1:1 ratio to DCB angioplasty plus aggressive medical management or aggressive medical management alone. In the intervention group, DCB angioplasty will be performed using a submaximal angioplasty strategy. Rescue stenting may be used in cases of severe dissection, significant residual stenosis, or marked elastic recoil according to predefined procedural criteria.
Both treatment groups will receive standardized aggressive medical management, including antiplatelet therapy, lipid-lowering therapy, blood-pressure control, diabetes management, and management of other vascular risk factors. The medical regimen and risk-factor targets will be applied consistently across both treatment groups.
The primary endpoint is the composite of any stroke or death within 30 days after enrollment and ischemic stroke in the territory of the qualifying artery from day 31 through 1 year. Secondary outcomes include recurrent ischemic stroke or transient ischemic attack, target-vessel revascularization, hemorrhagic events, mortality, functional outcome, quality of life, and target-vessel restenosis. Exploratory outcomes include high-resolution magnetic resonance imaging changes of the target vessel and clinical and vascular outcomes through 3 years.
Participants will undergo scheduled follow-up at 7 days, 30 days, 3 months, 6 months, and 12 months, followed by assessments every 6 months through 3 years. The trial is designed to determine whether DCB-based endovascular treatment in addition to aggressive medical management can reduce recurrent cerebrovascular events while maintaining acceptable procedural safety in patients with high-risk sICAS.
| Arm | Type | Interventions | Description |
|---|---|---|---|
| Drug-Coated Balloon Angioplasty Plus Aggressive Medical Management | Experimental | Procedure: Drug-Coated Balloon Angioplasty | Participants assigned to this group will undergo drug-coated balloon angioplasty in addition to aggressive medical management. Rescue stenting is permitted when clinically necessary according to predefined procedural criteria, including severe dissection, significant residual stenosis, or marked elastic recoil. |
| Aggressive Medical Management Alone | Active comparator | Other: Aggressive Medical Management | Participants assigned to this group will receive aggressive medical management alone, including standardized antiplatelet therapy and intensive management of vascular risk factors. |
Sex: All, ages: 18 Years to 80 Years
Inclusion Criteria: 1. Age 18-80 years old, regardless of gender 2. Patients with symptomatic ICAS caused by stenosis of a major intracranial artery (the degree of ischemic stroke with target vessel stenosis within 90 days before enrollment is required to be 70-99%, or the degree of transient ischemic attack with target vessel stenosis is required to be 80-99%), standardized drug management of at least one antithrombotic drug and/or vascular risk factors 3. DSA or CTA confirmed that the stenosis degree of one main intracranial artery (internal carotid artery C4-C7 segment, middle cerebral artery M1 segment, vertebral artery V4 segment and basilar artery) was between 70% and 99% (measured by WASID method), and was corresponding to the clinical symptoms. The normal diameter of the proximal end of the target lesion was ≥ 2mm, and the length of the target lesion was ≤ 15mm 4. If the target lesion is located in the anterior circulation system (C4-C7 of the internal carotid artery or M1 of the middle cerebral artery), it is required that there is hypoperfusion in the blood supply area of the target vessel (at least one of the following conditions is met): ①head CTP or PWI showed that CBF in the target vessel area decreased significantly (the lesion side decreased by more than 30% compared with the opposite side); ②Cerebral infarction with hemodynamic abnormalities confirmed by head CT or MRI (such as watershed infarction); ③ASITN/SIR collateral circulation score based on DSA<3 points) 5. Those who voluntarily participated in the study and signed the informed consent Exclusion Criteria: 1. Serious calcification of target vessels, or serious distortion of target vessels or anatomical factors make it difficult for interventional instruments to be in place 2. Severe stenosis or occlusion of extracranial or intracranial vessels in series at the proximal or distal end of the target vessel 3. Major surgical operations have been performed in recent 3 weeks 4. Cerebral hemorrhage, massive cerebral infarction (the infarct area is greater than 50% of the middle cerebral artery supply area; cerebellar infarction: the infarct diameter is greater than 3cm) and myocardial infarction have occurred in the past three months 5. The target lesion has undergone stent implantation before 6. Intracranial artery stenosis caused by non atherosclerotic lesions, including but not limited to: arterial dissection, moyamoya disease, vasculitis, radiation vascular disease or fibromuscular dysplasia 7. mRS score ≥ 3 8. Patients with coagulation dysfunction 9. Those who cannot tolerate anesthesia and anticoagulant drugs, are contraindicated or allergic to surgical drugs (paclitaxel, heparin, contrast agent, aspirin, clopidogrel, etc.), and are allergic to surgical instruments or operating devices 10. Platelet (PLT<90×109/L),hematocrit (<30%), international normalized ratio (INR)>1.5, uncontrollable severe hypertension (systolic blood pressure>180mmHg or diastolic blood pressure>110mmHg),severe liver injury (ALT or AST more than 3 times the normal value), severe renal function injury (creatinine>3mg/dl,>265μmol/L),and severe insufficiency of other important organs such as heart and lung 11. The subjects participated in other clinical trials and have not completed the follow-up or the researchers judged that the patients' compliance was poor and they were unable to complete the follow-up as required 12. Pregnant or lactating women, or those who plan to become pregnant within one year 13. The disease will cause difficulties in treatment and follow-up evaluation (such as dementia or mental disorders, cancer, infection, severe metabolic diseases), and it is speculated that the life expectancy of the participants is less than 3 years 14. Other cases that clinicians think should be excluded
| Facility | City | Country | Status |
|---|---|---|---|
| Beijing Tiantan Hospital | Beijing, Beijing Municipality | China | |
| Baotou Central Hospital | Baotou, Inner Mongolia | China |