Primary angioplasty and stenting may be superior to thrombectomy for acute atherosclerotic large-artery occlusion

Abstract

<jats:sec><jats:title>Objective</jats:title><jats:p> The objective of this article is to compare the effectiveness of primary angioplasty and/or stenting with stent retriever thrombectomy in acute anterior large-vessel occlusion due to atherosclerotic disease. </jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p> Patients were retrospectively reviewed from the endovascular treatment for acute anterior circulation ischemic stroke registry. Patients with large-vessel occlusions due to atherosclerosis were selected. We evaluated modified Rankin Scale (mRS) score at 90 days, modified thrombolysis in cerebral infarction (mTICI) score immediately post-procedure, and symptomatic and asymptomatic intracranial hemorrhage within 72 hours. </jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p> Of 302 patients with acute anterior circulation occlusion due to atherosclerotic disease, 269 were treated with stent retriever thrombectomy as first-line therapy and 33 with angioplasty and/or stenting. Patients who received primary angioplasty treatment showed favorable independent outcome at 90 days (69.7% (23/33) vs 47.6% (128/269), p = 0.02) and lower rate of asymptomatic intracranial hemorrhage (9.1% (3/23) vs 30.5% (82/269), p = 0.01). Recanalization immediately post procedure did not differ (78.8%% (26/33) vs 86.2% (232/269), p = 0.29). Primary angioplasty therapy (OR, 0.27; 95% confidence interval (CI): 0.08–0.90; p = 0.03) and small baseline infarct (OR 0.36: 0.16–0.82; p = 0.02) were protective factors against poor functional outcome, while old age (OR 1.04:1.01–1.07; p = 0.006), severe neurological deficits (OR 3.76: 2.00–7.07; p &lt; 0.001), and high glucose (OR 1.11: 1.01–1.23; p = 0.03) were associated with poor prognosis. </jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p> Patients with acute anterior circulation large-vessel occlusion due to atherosclerosis may benefit from urgent angioplasty and/or stenting as first-line therapy. Randomized controlled trials are warranted. </jats:p></jats:sec>

Current endovascular strategies for posterior circulation large vessel occlusion stroke: report of the Society of NeuroInterventional Surgery Standards and Guidelines Committee

“…92 In the anterior circulation, for patients with acute atherosclerotic occlusion, it has even been suggested that primary angioplasty and stenting may be superior to thrombectomy. 93 Both intracranial angioplasty/ stenting and intra-arterial infusion of a glycoprotein IIb/IIIa inhibitor were found to be safe and effective in treating underlying severe atherosclerotic stenosis in acute stroke patients with ELVO in a series of 140 patients in Korea, although only 1 in 5 patients in this study had basilar occlusions. 94 Also, a higher stroke complication rate has been noted in angioplasty and stenting of perforator bearing arteries in the posterior circulation versus the anterior circulation.…”

Angiographical Identification of Intracranial, Atherosclerosis-Related, Large Vessel Occlusion in Endovascular Treatment

“…With modern endovascular modalities (e.g., stent retriever, contact aspiration thrombectomy), successful recanalization was possible in <30% of cases of ICAS-LVO (17, 23). Thus, the feasibility and safety of rescue endovascular modalities appropriate to ICAS-LVO (e.g., balloon angioplasty, stenting, intra-arterial glycoprotein IIb/IIIa inhibitor infusion) are constant points of discussion (17, 20, 23, 26, 28, 30–36). Although there is a lack of prospective studies regarding treatment of ICAS-LVO, most reports have indicated that ICAS-specific endovascular modalities are feasible in an acute setting.…”

Direct angioplasty for acute ischemic stroke due to intracranial atherosclerotic stenosis-related large vessel occlusion

“…In our study, the procedure duration was under 60 min in most cases, similar to findings reported in a previous study. 23 Several studies have highlighted the safety and efficacy of angioplasty as rescue treatment following thrombectomy in patients with ICAS-related LVO. 24,25 Use of a balloon catheter for angioplasty can increase the diameter of the lumen lesion and reduce the risk of intra-procedure re-occlusion.…”

“…Occlusions involved the first segment of the middle cerebral artery (M1) in four patients (80%) and the intracranial internal carotid artery in one patient (20%). The mean baseline NIHSS score was 17.6 (range: [11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26]. Two patients received intravenous thrombolytic agents prior to endovascular treatment.…”