Endovascular Therapy of Anterior Circulation Tandem Occlusions

Abstract

Background and Purpose: Endovascular therapy for tandem occlusion strokes of the anterior circulation is an effective and safe treatment. The best treatment approach for the cervical internal carotid artery (ICA) lesion is still unknown. In this study, we aimed to compare the functional and safety outcomes between different treatment approaches for the cervical ICA lesion during endovascular therapy for acute ischemic strokes due to tandem occlusion in current clinical practice. Methods: Individual patients’ data were pooled from the French prospective multicenter observational ETIS (Endovascular Treatment in Ischemic Stroke) and the international TITAN (Thrombectomy in Tandem Lesions) registries. TITAN enrolled patients from January 2012 to September 2016, and ETIS from January 2013 to July 2019. Patients with acute ischemic stroke due to anterior circulation tandem occlusion who were treated with endovascular therapy were included. Patients were divided based on the cervical ICA lesion treatment into stent and no-stent groups. Outcomes were compared between the two treatment groups using propensity score methods. Results: A total of 603 patients were included, of whom 341 were treated with acute cervical ICA stenting. In unadjusted analysis, the stent group had higher rate of favorable outcome (90-day modified Rankin Scale score, 0–2; 57% versus 45%) and excellent outcome (90-day modified Rankin Scale score, 0–1; 40% versus 27%) compared with the no-stent group. In inverse probability of treatment weighting propensity score–adjusted analyses, stent group had higher odds of favorable outcome (adjusted odds ratio, 1.09 [95% CI, 1.01–1.19]; P =0.036) and successful reperfusion (modified Thrombolysis in Cerebral Ischemia score, 2b-3; adjusted odds ratio, 1.19 [95% CI, 1.11–1.27]; P <0.001). However, stent group had higher odds of any intracerebral hemorrhage (adjusted odds ratio, 1.10 [95%, 1.02–1.19]; P =0.017) but not higher rate of symptomatic intracerebral hemorrhage or parenchymal hemorrhage type 2. Subgroup analysis demonstrated heterogeneity according to the lesion type (atherosclerosis versus dissection; P for heterogeneity, 0.01), and the benefit from acute carotid stenting was only observed for patients with atherosclerosis. Conclusions: Patients treated with acute cervical ICA stenting for tandem occlusion strokes had higher odds of 90-day favorable outcome, despite higher odds of intracerebral hemorrhage; however, most of the intracerebral hemorrhages were asymptomatic.

Emergent carotid stenting versus no stenting for acute ischemic stroke due to tandem occlusion: a meta-analysis

“…Overall, although the need for intracranial revascularization is evident, the optimal approach for the treatment of extracranial occlusion is extreme uncertain. Emergent carotid artery stenting (eCAS) is often performed in the context of MT in cases with TO,9 10 even though its safety is unconfirmed. Additionally, the hemorrhagic risk related to periprocedural antithrombotic agents required for eCAS and the risk of early recurrent ischemic events of eCAS and the carotid artery angioplasty (CAA) or no carotid treatment are extremely variable in observational series 11–18…”

Antithrombotic treatment and outcome after endovascular treatment and acute carotid artery stenting in stroke patients with atrial fibrillation

“…We included acute ischemic stroke patients with AF, who were treated with ET and CAS. While retrospective data suggest a benefit of CAS in patients without AF treated with ET for tandem occlusions [ 23 , 24 ], evading stenting might be feasible especially in patients with AF. In this context, the results of randomized controlled trials (TITAN, EASI-TOC) will hopefully help determine the best approach.…”

What You Always Wanted to Know about Endovascular Therapy in Acute Ischemic Stroke but Never Dared to Ask: A Comprehensive Review

“…Information on emergency extracranial ICA stenting due to dissection is limited to smaller observational studies and case reports. Most of the data have focused on endovascular strategies in tandem occlusions due to ICA dissection [223][224][225]. In a pooled analysis from registry data, emergent stenting in tandem occlusions has been suggested to be effective and safe, with a slight increase in mainly asymptomatic ICH [223,224].…”

“…Most of the data have focused on endovascular strategies in tandem occlusions due to ICA dissection [223][224][225]. In a pooled analysis from registry data, emergent stenting in tandem occlusions has been suggested to be effective and safe, with a slight increase in mainly asymptomatic ICH [223,224]. Although both the anterograde and the retrograde approaches might be feasible, some authors have suggested a more conservative approach with stent placement only in cases of insufficient collateralization [225][226][227].…”