Carotid stent occlusion after emergent stenting in acute ischemic stroke: Incidence, predictors and clinical relevance

Renú, Arturo; Blasco, Jordi; Laredo, Carlos; Llull, Laura; Urra, Xabier; Obach, Vı́ctor; López-Rueda, Antonio; Rudilosso, Salvatore; Zarco, Federico; González, Elisabet; Guio, José David; Amaro, Sergio

doi:10.1016/j.atherosclerosis.2020.09.002

Cited by 19 publications

(46 citation statements)

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“…Few published studies have reported stent patency rates for a large proportion of patients in their cohort. 8,[12][13][14]17 The time point of stent thrombosis (early versus subacute/late) is not listed in most of these studies. Malik et al 16 reported 24-hour imaging follow-up of stent patency for all 77 patients in their cohort, with only 1 (1.2%) thrombosed stent.…”

Section: Discussionmentioning

confidence: 99%

“…Stent thrombosis was recently identified as a predictor of unfavorable clinical outcome. 7,8 To date, available data regarding stent patency rates remain scarce. Most case series of endovascular management for tandem lesions 5,[9][10][11] do not report postprocedural stent patency, while some publications [12][13][14][15] offer partial data for a subgroup of patients for whom carotid imaging controls were available.…”

mentioning

confidence: 99%

“…Reported rates of stent thrombosis ranged between 1.2% and 22.0%. [6][7][8][12][13][14]16,17 To date, no study has attempted to differentiate between early (first 24 hours) and subacute/late postprocedural stent thrombosis. During the first 24 hours, protection against stent thrombosis is conferred by antiplatelet agents administered during the procedure (periprocedural antiplatelets).…”

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confidence: 99%

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Postprocedural Antiplatelet Treatment after Emergent Carotid Stenting in Tandem Lesions Stroke: Impact on Stent Patency beyond Day 1

Pop

Hasiu

Mangin

et al. 2021

AJNR Am J Neuroradiol

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BACKGROUND AND PURPOSE: Postprocedural dual-antiplatelet therapy is frequently withheld after emergent carotid stent placement during stroke thrombectomy. We aimed to assess whether antiplatelet regimen variations increase the risk of stent thrombosis beyond postprocedural day 1. MATERIALS AND METHODS:Retrospective review was undertaken of all consecutive thrombectomies for acute stroke with tandem lesions in the anterior circulation performed in a single comprehensive stroke center between January 9, 2011 and March 30, 2020. Patients were included if carotid stent patency was confirmed at day 1 postprocedure. The group of patients with continuous dual-antiplatelet therapy from day 1 was compared with the group of patients with absent/discontinued dual-antiplatelet therapy.RESULTS: Of a total of 109 tandem lesion thrombectomies, 96 patients had patent carotid stents at the end of the procedure. The early postprocedural stent thrombosis rate during the first 24 hours was 14/96 (14.5%). Of 82 patients with patent stents at day 1, in 28 (34.1%), dual-antiplatelet therapy was either not initiated at day 1 or was discontinued thereafter. After exclusion of cases without further controls of stent patency, there was no significant difference in the rate of subacute/late stent thrombosis between the 2 groups: 1/50 (2%) in patients with continuous dual-antiplatelet therapy versus 0/22 (0%) in patients with absent/discontinued dual-antiplatelet therapy (P = 1.000). In total, we observed 88 patient days without any antiplatelet treatment and 471 patient days with single antiplatelet treatment.CONCLUSIONS: Discontinuation of dual-antiplatelet therapy was not associated with an increased risk of stent thrombosis beyond postprocedural day 1. Further studies are warranted to better assess the additional benefit and optimal duration of dual-antiplatelet therapy after tandem lesion stroke thrombectomy.ABBREVIATIONS: DAPT ¼ dual-antiplatelet therapy; ST ¼ stent thrombosis I n around 15% of endovascular procedures for anterior circulation stroke, 1 there is a tight stenosis or occlusion of the cervical carotid artery in addition to the intracranial artery occlusion. The optimal endovascular management of tandem lesions has yet to be defined; however, there is mounting evidence 2,3 that emergent stent

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

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Postprocedural Antiplatelet Treatment after Emergent Carotid Stenting in Tandem Lesions Stroke: Impact on Stent Patency beyond Day 1

Pop

Hasiu

Mangin

et al. 2021

AJNR Am J Neuroradiol

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“…Moreover, day 1 carotid stent artery patency seems to be associated with a better clinical outcome and may constitute a therapeutic target, especially in atherosclerotic tandem occlusions 4. However, the rate of stent thrombosis in the first 24 hours is not negligible (around 20%) and is associated with an unfavorable clinical outcome 5–7. In this context, ‘aggressive’ antiplatelet medication such as oral or intravenous glycoprotein (GP) IIb/IIIa or P2Y12 inhibitors may increase the likelihood of carotid stent patency on day 1 8–12.…”

Section: Introductionmentioning

confidence: 99%

Aspirin versus aggressive antiplatelet therapy for acute carotid stenting plus thrombectomy in tandem occlusions: ETIS Registry results

Marnat

Finistis

Moreno

et al. 2022

J NeuroIntervent Surg

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BackgroundPatients treated with acute carotid stenting (CAS) may have higher odds of a favorable outcome than those treated without CAS during thrombectomy in tandem occlusions. Antiplatelet therapy is associated with CAS to avoid stent thrombosis, which occurs in around 20% of patients and negatively impacts outcomes. In this study we compared two antiplatelet strategies in tandem occlusion strokes treated with CAS and intracranial thrombectomy in clinical practice.MethodsThe Endovascular Treatment in Ischemic Stroke Registry is an ongoing prospective observational study involving 21 comprehensive stroke centers performing thrombectomy in France. We analyzed patients with atherosclerotic tandem occlusions treated with acute CAS and intracranial thrombectomy who received at least one antiplatelet agent. Aggressive antiplatelet therapy included oral or intravenous glycoprotein (GP) IIb/IIIa or P2Y12 inhibitors. The primary outcome was cervical carotid artery patency at day 1 imaging follow-up.ResultsAmong the 187 included patients, 124 (66.3%) received aspirin alone and 63 (33.7%) received aggressive antiplatelet therapy. There was no significant difference regarding safety outcomes, especially in symptomatic intracerebral hemorrhage, parenchymal hematoma, and procedural complications. There was a significantly higher rate of carotid stent patency at day 1 in the aggressive antiplatelet therapy group (81.7% vs 97.1%, aOR 17.49, 95% CI 1.10 to 277.2, p=0.042). Odds of favorable functional outcome (90-day modified Rankin Scale score 0–2) were similar between the groups (OR 3.04, 95% CI 0.64 to 14.25, p=0.158).ConclusionsIn tandem occlusions treated with CAS plus thrombectomy, an aggressive antiplatelet regimen was associated with an increased rate of carotid stent patency at day 1 without safety concerns. Randomized trials are warranted to confirm these findings.

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“…Patients received dual antiplatelet therapy, but the role of individualized testing and rescue therapies was not assessed. 7…”

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confidence: 99%

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

Masoud

Nguyen

Broderick

2023

Stroke

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xtracranial internal carotid artery (ICA) steno-occlusive disease with tandem intracranial occlusion is a major cause of acute ischemic stroke and associated with poor clinical outcome with medical management alone. 1 In 2005, a treatment strategy of acute carotid artery stenting (CAS) was suggested in patients with acute ICA occlusions (most presenting within 6 hours of symptom onset). They reported successful revascularization in 92% (23/25) of patients. 2 As revascularization of acute carotid occlusion gained acceptance as a treatment option, other groups reported their results. 3 A 2022 meta-analysis comparing acute CAS in patients with a tandem lesion, reported higher functional outcome with acute CAS (90-day modified Rankin Scale score ≤2, odds ratio, 1.52 [95% CI, 1.19-1.95]) but increased risk of symptomatic intracranial hemorrhage (odds ratio, 1.97 [95% CI, 1.23-3.15]). 4 However, this meta-analysis did not differentiate the pathophysiology of the tandem lesion by atherosclerotic versus dissection etiologies.

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Carotid stent occlusion after emergent stenting in acute ischemic stroke: Incidence, predictors and clinical relevance

Cited by 19 publications

References 30 publications

Postprocedural Antiplatelet Treatment after Emergent Carotid Stenting in Tandem Lesions Stroke: Impact on Stent Patency beyond Day 1

Postprocedural Antiplatelet Treatment after Emergent Carotid Stenting in Tandem Lesions Stroke: Impact on Stent Patency beyond Day 1

Aspirin versus aggressive antiplatelet therapy for acute carotid stenting plus thrombectomy in tandem occlusions: ETIS Registry results

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

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