A randomized pilot study of patients with tandem carotid lesions undergoing thrombectomy

Poppe, Alexandre Y; Jacquin, Grégory; Stapf, Christian; Daneault, Nicole; Deschaintre, Yan; Gioia, Laura; Odier, Céline; Labrie, Marilyn; Nehme, Ahmad; Nico, Lorena; Roy, Daniel; Weill, Alain; Raymond, Jean

doi:10.1016/j.neurad.2019.08.003

Cited by 9 publications

(11 citation statements)

References 17 publications

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“…Thirty‐three studies were retrospective cohort studies (22 single‐center and 11 multicenter), and 1 was a single‐center pilot randomized controlled trial study. 17 Of the 33 cohort studies, 17 were from prospectively collected databases. Fifteen studies evaluated outcomes of CAS±BA, 7 , 10 , 11 , 12 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 and 1 evaluated BA‐alone outcomes without comparison groups.…”

Section: Resultsmentioning

confidence: 99%

Acute Carotid Artery Stenting Versus Balloon Angioplasty for Tandem Occlusions: A Systematic Review and Meta‐Analysis

Zevallos

Farooqui

Quispe‐Orozco

et al. 2022

JAHA

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Background Despite thrombectomy having become the standard of care for large‐vessel occlusion strokes, acute endovascular management in tandem occlusions, especially of the cervical internal carotid artery lesion, remains uncertain. We aimed to compare efficacy and safety of acute carotid artery stenting to balloon angioplasty alone on treating the cervical lesion in tandem occlusions. Similarly, we aimed to explore those outcomes’ associations with technique approaches and use of thrombolysis. Methods and Results We performed a systematic review and meta‐analysis to compare functional outcomes (modified Rankin Scale), reperfusion, and symptomatic intracranial hemorrhage and 3‐month mortality. We explored the association of first approach (anterograde/retrograde) and use of thrombolysis with those outcomes as well. Two independent reviewers performed the screening, data extraction, and quality assessment. A random‐effects model was used for analysis. Thirty‐four studies were included in our systematic review and 9 in the meta‐analysis. Acute carotid artery stenting was associated with higher odds of modified Rankin Scale score ≤2 (odds ratio [OR], 1.95 [95% CI, 1.24–3.05]) and successful reperfusion (OR, 1.89 [95% CI, 1.26–2.83]), with no differences in mortality or symptomatic intracranial hemorrhage rates. Moreover, a retrograde approach was significantly associated with modified Rankin Scale score ≤2 (OR, 1.72 [95% CI, 1.05–2.83]), and no differences were found on thrombolysis status. Conclusions Carotid artery stenting and a retrograde approach had higher odds of successful reperfusion and good functional outcomes at 3 months than balloon angioplasty and an anterograde approach, respectively, in patients with tandem occlusions. A randomized controlled trial comparing these techniques with structured antithrombotic regimens and safety outcomes will offer definitive guidance in the optimal management of this complex disease.

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Section: Resultsmentioning

confidence: 99%

Acute Carotid Artery Stenting Versus Balloon Angioplasty for Tandem Occlusions: A Systematic Review and Meta‐Analysis

Zevallos

Farooqui

Quispe‐Orozco

et al. 2022

JAHA

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“…Nonetheless, the data have served as a proof-of-concept for the forthcoming Endovascular Acute Stroke Intervention-Tandem Occlusion (EASI-TOC) trial (NCT04261478). 61 In the absence of high-level data to guide management decisions and if randomization in a clinical trial is not possible, observational data do suggest that some clinical and radiologic factors may favor acute stent placement, while others may argue against it ( F2 Fig 2).…”

Section: Aq: Fmentioning

confidence: 99%

Tandem Carotid Lesions in Acute Ischemic Stroke: Mechanisms, Therapeutic Challenges, and Future Directions

Poppe

Jacquin

Roy

et al. 2020

AJNR Am J Neuroradiol

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Approximately 15% of patients undergoing endovascular thrombectomy for anterior circulation acute ischemic stroke have a tandem lesion, defined as a severe stenosis or occlusion of the cervical internal carotid artery ipsilateral to its intracranial occlusion. Patients with tandem lesions have worse outcomes than patients with isolated intracranial occlusions, but the optimal management of their carotid lesions during endovascular thrombectomy remains controversial. The main options commonly used in current practice include acute stent placement in the carotid lesion versus thrombectomy alone without definitive revascularization of the carotid artery. While treatment decisions for these patients are often complex and strategies vary according to clinical, anatomic, and technical considerations, only results from randomized trials comparing these approaches are likely to strengthen current recommendations and optimize patient care.

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“…A randomised pilot study has already shown the feasibility of this next step. 10 Unlike previous reported studies, we focused on the patients who underwent EVT without immediate CAS. Only 19% of the patients within this group received a deferred treatment by means of a carotid endarterectomy or CAS.…”

Section: Discussionmentioning

confidence: 99%

“…3 Although EVT has become standard of care in patients with an acute ischaemic stroke due to large vessel occlusion, the optimal treatment approach of a concomitant ipsilateral ICA stenosis remains unclear. [4][5][6][7][8][9][10][11][12] Some interventionists prefer to perform EVT with carotid artery stenting (CAS), while others advocate a more conservative approach without CAS, but with percutaneous transluminal angioplasty (PTA) to gain intracranial access, if necessary. In the latter case, carotid endarterectomy or CAS are usually considered as a deferred treatment if a patient shows adequate neurological improvement and residual high-grade ICA stenosis is still present.…”

Section: Introductionmentioning

confidence: 99%

Management of extracranial carotid artery stenosis during endovascular treatment for acute ischaemic stroke: results from the MR CLEAN Registry

et al. 2022

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BackgroundThe optimal management of ipsilateral extracranial internal carotid artery (ICA) stenosis during endovascular treatment (EVT) is unclear. We compared the outcomes of two different strategies: EVT with vs without carotid artery stenting (CAS).MethodsIn this observational study, we included patients who had an acute ischaemic stroke undergoing EVT and a concomitant ipsilateral extracranial ICA stenosis of ≥50% or occlusion of presumed atherosclerotic origin, from the Dutch Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry (2014–2017). The primary endpoint was a good functional outcome at 90 days, defined as a modified Rankin Scale score ≤2. Secondary endpoints were successful intracranial reperfusion, new clot in a different vascular territory, symptomatic intracranial haemorrhage, recurrent ischaemic stroke and any serious adverse event.ResultsOf the 433 included patients, 169 (39%) underwent EVT with CAS. In 123/168 (73%) patients, CAS was performed before intracranial thrombectomy. In 42/224 (19%) patients who underwent EVT without CAS, a deferred carotid endarterectomy or CAS was performed. EVT with and without CAS were associated with similar proportions of good functional outcome (47% vs 42%, respectively; adjusted OR (aOR), 0.90; 95% CI, 0.50 to 1.62). There were no major differences between the groups in any of the secondary endpoints, except for the increased odds of a new clot in a different vascular territory in the EVT with CAS group (aOR, 2.96; 95% CI, 1.07 to 8.21).ConclusionsFunctional outcomes were comparable after EVT with and without CAS. CAS during EVT might be a feasible option to treat the extracranial ICA stenosis but randomised studies are warranted to prove non-inferiority or superiority.

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A randomized pilot study of patients with tandem carotid lesions undergoing thrombectomy

Cited by 9 publications

References 17 publications

Acute Carotid Artery Stenting Versus Balloon Angioplasty for Tandem Occlusions: A Systematic Review and Meta‐Analysis

Acute Carotid Artery Stenting Versus Balloon Angioplasty for Tandem Occlusions: A Systematic Review and Meta‐Analysis

Tandem Carotid Lesions in Acute Ischemic Stroke: Mechanisms, Therapeutic Challenges, and Future Directions

Management of extracranial carotid artery stenosis during endovascular treatment for acute ischaemic stroke: results from the MR CLEAN Registry

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