24-Hour Carotid Stent Patency and Outcomes After Endovascular Therapy: A Multicenter Study

Abstract

Background: Management of extracranial internal carotid artery steno-occlusive lesion during endovascular therapy remains debated. Stent occlusion within 24 hours of endovascular therapy is a frequent event after acute carotid artery stenting, and we currently lack large population results. We investigated the incidence, predictors, and clinical impact of stent occlusion after acute carotid artery stenting in current clinical practice. Methods: Patients treated by endovascular therapy with acute carotid artery stenting between 2015 and 2019 in 5 large-volume endovascular-capable centers were retrospectively analyzed. Patients were separated in 2 groups according to the stent patency at 24 hours after carotid artery stenting. We compared baseline characteristics, treatment modalities, and clinical outcome depending on 24-hour stent patency. Primary end point was favorable outcome, defined as a modified Rankin Scale score 0–2 at 3 months. Results: A stent occlusion was observed in 47/225 patients (20.9%). Patients with stent patency had a lower baseline National Institutes of Health Stroke Scale (median [interquartile range]: 13 [7–17] versus 18 [12–21]) and had more often stroke of atherothrombotic origin (77.0% versus 53.2%). A higher stent patency rate was found for patients treated with P2Y 12 antagonists at the acute phase (odds ratio [OR]‚ 2.95 [95% CI‚ 1.10–7.91]; P =0.026) and treated with angioplasty (OR‚ 2.42 [95% CI‚ 1.24–4.67]; P =0.008). A better intracranial angiographic reperfusion was observed in patients with 24-hour stent patency compared with patients without stent patency (OR‚ 8.38 [95% CI‚ 3.07–22.78]; P <0.001). Patients with a stent patency at 24 hours had a higher chance of favorable outcome (OR‚ 3.29 [95% CI, 1.66–6.52]; P <0.001) and a lower risk of death (OR‚ 0.32 [95% CI, 0.13–0.76]; P =0.009). Conclusions: One out of 5 patients treated with carotid artery stenting during endovascular therapy presented a stent occlusion within 24 hours. This event was associated with worse functional outcome. Stroke etiology, P2Y 12 antagonist administration, quality of intracranial reperfusion, and angioplasty were associated with 24-hour stent patency.

Early Stent Patency After Endovascular Therapy for Tandem or Isolated Carotid Steno-Occlusive Disease

“…In their study, delayed stent thrombosis was an independent predictor of unfavorable clinical outcome (odds ratio, 19.8 [95% CI, 2.8-296.8]). 9 However, patients who had unsuccessful reperfusion or stents that occluded during procedure would be more likely to be placed on aspirin alone rather than dual antiplatelet therapy and those with large ischemic strokes may have been more likely to be placed on aspirin alone due to increased hemorrhagic risk as suggested by Allard et al 6 Other than procedural medication, technical factors are important to consider to maintain carotid stent patency acutely. In elective or subacute settings of CAS, post-stent balloon angioplasty for residual post-stent carotid artery stenosis has been associated with microemboli, which was associated with neurological deficit after CAS.…”

“…The carotid occlusive/severe stenosis disease was due to atheroma (72%) and dissection (28%). 6 Allard and colleagues found that the rate of stent patency was related to reperfusion status, use of P2Y 12 inhibitors, and balloon angioplasty after CAS, whereas factors related to stent occlusion were use of multiple stents, dual layer stent, and dissection as the cause of occlusive disease. In fact, several factors-multiple stents, type of stent, reperfusion status and use of P2Y 12 inhibitors are related to carotid dissection where the occlusive lesion is longer and aggressive means are often needed to open the artery and maintain patency.…”

“…In summary, Allard et al's study confirms the rate of early stent occlusion and its negative impact on clinical outcomes. 6 The use of stenting in the setting of carotid dissection versus atherothrombotic disease should be considered separately since the pathophysiology and treatment approaches are different. Current antiplatelet regimens vary and ongoing trials investigating the role of P2Y 12 inhibitors and platelet inhibition testing may inform management strategies to mitigate the risk of early stent thrombosis as well as whether a carotid stent deployed acutely confers benefit to the patient with a tandem occlusion or tandem carotid severe stenosis.…”

“…In this issue of Stroke, Allard et al 6 report a 20% rate of stent-occlusion in the ETIS (Endovascular Treatment in Ischemic Stroke Follow-up Evaluation) registry of patients with stroke treated with acute CAS that was associated with poor clinical outcome. There were less peri-procedural complications in patients with stent patency (6.8% versus 23.4%; P =0.002).…”

“…In fact, several factors—multiple stents, type of stent, reperfusion status and use of P2Y 12 inhibitors are related to carotid dissection where the occlusive lesion is longer and aggressive means are often needed to open the artery and maintain patency. 6 One interpretation of their data is that stenting of ICA occlusion in the setting of dissection, has a high rate of stent closure and poor outcome, despite a younger age of patients, and the indication for stenting in this setting may not be as strong as for atherosclerotic disease. In the TITAN (Thrombectomy in Tandem Lesions) and ETIS registries, of patients with tandem occlusion related to carotid dissection, there was no difference in the functional outcomes between patients who had a carotid stent versus no carotid stent.…”