Overview of evidence on emergency carotid stenting in patients with acute ischemic stroke due to tandem occlusions: a systematic review and meta-analysis

Coelho, Andreia; Lobo, Miguel; Gouveia, Ricardo; Silveira, Diogo; Campos, J.B.L.M.; Augusto, Rita; Coelho, Nuno; Canedo, Alexandra

doi:10.23736/s0021-9509.18.10312-0

Cited by 21 publications

(10 citation statements)

References 43 publications

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“…11 The existence of community equipoise is also echoed in several studies that were all observational and often only described stented patients. Four main meta-analyses of these smaller case series have been published, 20,25,26,59 most with relatively few patients not having undergone acute stent placement and only 1 59 focusing primarily on whether acute stent placement was associated with different clinical outcomes than no stent placement. The large multicenter retrospective cases-series of 482 patients from the TITAN group was not included in these metaanalyses but suggests that stented patients receiving acute antiplatelet medications have more favorable outcomes than patients treated with angioplasty alone or those with no acute ICA intervention.…”

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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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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“…Meta-analyses of the previous observational studies comparing different treatment strategies reported conflicting results, while one meta-analysis reported better outcome with cervical ICA stenting, 5 one reported no difference in functional outcome, 6 and another reported a higher complication rate and longer procedure time with cervical ICA stenting. 7 Based on the available evidence, the American Heart Association/American Stroke Association considered the treatment of cervical ICA during EVT as reasonable (level IIb evidence). 8 The lack of randomized trials and the conflicting results from the observational studies created a state of uncertainty that was highlighted in a recent international survey regarding acute treatment options of tandem occlusions.…”

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confidence: 99%

Endovascular Therapy of Anterior Circulation Tandem Occlusions

Anadani

Marnat

Consoli

et al. 2021

Stroke

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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.

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“…Recent meta-analyses did not find significant differences in clinical outcomes between patients treated with stenting and patients treated with PTA alone in the acute phase ( 12 , 13 ). Wilson et al concluded that most studies “have entirely or partly treated extracranial occlusion with stenting during initial treatment” and that very few focus on angioplasty-only approaches ( 12 ).…”

Section: Introductionmentioning

confidence: 97%

Mechanical Thrombectomy for Tandem Occlusions of the Internal Carotid Artery—Results of a Conservative Approach for the Extracranial Lesion

et al. 2018

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Background: Mechanical thrombectomy (MT) is of clinical benefit for patients with extracranial-intracranial tandem lesions of anterior circulation. However, the optimal approach to the cervical lesion of the internal carotid artery (ICA) during MT has yet to be established. Data on a conservative approach for the proximal lesion during the acute phase are scarce.Methods: A retrospective study on an institutional, prospective database was conducted. We included patients with anterior circulation stroke presenting with a tandem lesion that was approached conservatively during MT.Results: Thirty-five 35 patients were included, of whom 25 (71.4%) had an atheromatous ICA lesion and 10 (28.6%) a dissection. Despite implementing a conservative strategy, acute percutaneous transluminal angioplasty (PTA) and/or stenting was necessary in 8 (22.9%) and 3 patients (8.6%), respectively. Of 27 surviving patients, 7 (25.9%) underwent delayed treatment of the ICA lesion. No new embolic events occurred between MT and delayed treatment. A favorable clinical outcome (mRS ≤ 2) was achieved in 15/35 patients (45.7%) and was associated with higher baseline ASPECTS (OR 1.62, 95% CI 1.08–2.45, p = 0.002) and successful recanalization (OR 9.39, 95% CI 1.92–45.80, p = 0.0005). Successful recanalization (TICI ≥ 2B) itself was observed in 54.3% of patients and was more likely with acute treatment of the proximal ICA lesion (OR 6.3, 95% CI 11–35.67, p = 0.03) and, more importantly, by the use of distal access catheters (OR 16.25, 95% CI 3.06–86.41, p = 0.0001).Conclusion: A conservative approach for ICA lesions during MT is feasible and offers favorable outcomes and successful recanalization for a significant proportion of patients. However, acute treatment of the cervical lesion is often necessary (31.4%) to make the distal occlusion accessible. Clinical outcome is influenced by the size of the baseline ischemic core and by successful recanalization; the latter is strongly favored by the use of distal access catheters to pass the proximal lesion. The fact that acute treatment of the ICA lesion favored intracranial recanalization but had no effect on clinical outcome is probably due to sample size, emphasizing the need for large scale, randomized studies to determine the optimal treatment strategy for this pathology.

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Overview of evidence on emergency carotid stenting in patients with acute ischemic stroke due to tandem occlusions: a systematic review and meta-analysis

Cited by 21 publications

References 43 publications

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

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

Endovascular Therapy of Anterior Circulation Tandem Occlusions

Mechanical Thrombectomy for Tandem Occlusions of the Internal Carotid Artery—Results of a Conservative Approach for the Extracranial Lesion

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