Carotid artery stenting in the context of endovascular treatment of acute ischemic stroke

Abstract

Intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator (r-tPA) is the standard treatment for acute ischemic stroke (AIS) within the first four and a half hours of symptom onset 1 , and five recent clinical trials demonstrated better clinical outcomes when mechanical thrombectomy with stentrievers were performed as an adjunctive treatment to IVT for patients presenting large vessel occlusions within the first six hours of symptom onset 2,3,4,5 . However, those trials lacked sufficient power to evaluate the clinical outcomes of patients presenting carotid tandem occlusions. Carotid tandem occlusions are defined as both extra-cranial occlusion or stenosis of the internal carotid artery (ICA) and downstream intracranial vessel occlusion, which comprises a subgroup of patients that usually present poor recanalization rates under IVT and poor clinical outcomes 6 . Despite of the lack of clinical data from randomized trials on the best management course of acute carotid tandem occlusions, a combined recanalization strategy by means of carotid artery stenting and mechanical thrombectomy has recently shown promising results 7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25 . We aimed to assess the clinical and radiological data of patients who underwent carotid artery stenting (CAS) and ABSTRACTMechanical thrombectomy as an adjunctive to intravenous thrombolysis is now the standard treatment for acute ischemic stroke (AIS) due to large vessel occlusions. However, the best management of acute carotid tandem occlusions (CTO) remains controversial. Method: Twenty patients underwent endovascular treatment of acute CTO. The primary endpoint was the composite rate of complete or partial recanalization without a symptomatic intracranial hemorrhage (sICH). Secondary endpoints were recanalization times, procedure times, and clinical outcomes at three months. Results: The primary endpoint was reached in 17 (85%) patients. Recanalization rate was reached in 90% of patients (19/20) and sICH rate was 5% (1/20). At the 3-month follow-up we obtained a mRS ≤ 2 rate of 35% (7/20) and a mortality rate of 20% (4/20). Conclusion: Carotid angioplasty stenting and endovascular treatment of AIS due to CTO appears effective with an acceptable rate of sICH.Keywords: acute ischemic stroke, symptomatic carotid artery stenosis, carotid angioplasty stenting. ReSumoTrombectomia mecânica com stentrievers associada a trombólise endovenosa com rTPA é o tratamento padrão-ouro do acidente vascular cerebral isquêmico agudo (AVCi) devido à oclusões de grandes vasos. No entanto, a melhor estratégia terapêutica para oclusões carotídeas combinadas ainda permanece controversa. Método: Vinte paciente receberam tratamento endovascular. O desfecho primário foi a taxa de recanalização completa sem sangramento intracraniano sintomático. Os desfechos secundários foram os tempos de recanalização, duração dos procedimentos e desfechos clínicos em 3 meses. Resultados: O desfecho primário foi alcançado em 17 (85%) pacientes. A taxa de recanaliz...

Thrombectomy outcomes for acute stroke patients with anterior circulation tandem lesions: a clinical registry and an update of a systematic review with meta‐analysis

“…This updated meta-analysis, including our registry data, reports a positive association between emergent carotid stenting after MT and successful reperfusion Overall (I 2 = 71.11%, P = 0.00) Lockau et al [13] Marnat et al [14] Lescher et al [12] de Lucena et al [9] Fahed et al [10] Steglich-Arnholm [20] Rangel-Castilla et al [17] Heck and Brown [11] Cohen et al [8] Sallustio et al [18] Mpotsaris et al [16] Author Stampfl et al [19] Our series Maurer el al. [15] Rangel-Castilla et al [17] Fahed et al [10] Stampfl et al [19] de Lucena et al [9] Heck and Brown [11] Lockau et al [13] Mpotsaris et al [16] Our series Lescher et al [12] Sallustio et al [18] Marnat et al [14] Steglich-Arnholm [20] Author…”

“…Fifty-seven articles were reviewed at full-text level, of which 13 studies were selected for final analysis, including four studies included in our previous review and matching our inclusion criteria ( Fig. 1) [8][9][10][11][12][13][14][15][16][17][18][19][20]. A total of 590 proximal anterior circulation stroke patients [mean age 66.4 years; 65% (n = 382) men] presenting with ECD were included.…”

“…Mpotsaris et al [16] Lockau et al [13] Steglich-Arnholm [20] Marnat et al [14] Author Stampfl et al [19] Lescher et al [12] Fahed et al [10] de Lucena et al [9] Heck and Brown [11] Sallustio et al [18] rate in acute ischaemic stroke patients with tandem lesion. The risk of intracranial bleeding following MT and emergent carotid stenting appears comparable to that of isolated intracranial occlusion patients treated with MT alone reported in large prospective registries.…”

“…Stampfl et al [19] Cohen et al [8] Steglich-Arnholm [20] Mpotsaris et al [16] Heck and Brown [11] Lockau et al [13] Fahed et al [10] de Lucena et al [9] Author…”

Rescue therapy with stent retrievers for thromboembolism during endovascular treatment of intracranial aneurysms

“…Furthermore, modern devices permit faster access and easier navigation due to a more flexible profile 20 . Recent prospective trials have shown the clinical benefit of endovascular therapy, providing high-level evidence that has changed the guidelines of acute stroke therapy to recommend endovascular therapy with a stent retriever over intra-arterial fibrinolysis alone as first-line therapy 10,19,20,21 . However, its use during transprocedural thromboembolic events is still not validated, as the passage of the device over the coil mass could displace it and occlude the parent vessel.…”