Rescue stenting for acute ischemic stroke with refractory emergent large vessel occlusion in the modern thrombectomy era

Sweid, Ahmad; Sajja, Kalyan; Mouchtouris, Nikolaos; Weinberg, Joshua; Shivashankar, Kavya; Saad, Hassan; Abbas, Rawad; Naamani, Kareem El; Ramesh, Sunidhi; Schaefer, Joseph; Saiegh, Fadi Al; Jabbour, Pascal; Herial, Nabeel; Zarzour, Hekmat; Tjoumakaris, Stavropoula; Romo, Victor; Rosenwasser, Robert H.; Gooch, M. Reid

doi:10.1016/j.clineuro.2022.107183

Cited by 8 publications

(7 citation statements)

References 30 publications

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“…We report good outcomes and low rates of clinically significant bleeding despite utilization of aggressive platelet inhibition post procedure. Overall, our population seems to be younger than other reported cohorts from China (24), USA(25), Spain(26) and, South Korea(13).…”

Section: Discussioncontrasting

confidence: 55%

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Rescue Stenting in Mechanical Thrombectomy Refractory Occlusions: A Single Center Multiethnic Cohort

Imam

Akhtar

Kamran

et al. 2022

Preprint

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Introduction: Refractory large vessel occlusion in acute ischemic stroke carries high morbidity and mortality. Rescue stenting is an emerging modality that is increasingly utilized especially in East Asia. We aim to investigate the safety and efficacy of performing rescue stenting in acute stroke patients who had failed mechanical thrombectomy. Methods: This is a retrospective, all-inclusive, observational, descriptive review of the prospectively collected stroke database. Post stenting, an aggressive antiplatelet protocol was followed with glycoprotein IIb/IIIa infusion. Incidence of intracerebral hemorrhage (ICH), recanalization score and favorable prognosis (modified Rankin Score ≤3) at 90 days was used to determine primary outcome. Additionally, comparison was made between patients from the Middle East and North Africa (MENA) region and others. Results: In total, 55 patients were included with 87.3% being male. Mean age was 51.3+11.8 years. This included 32 patients (58.3%) from South Asia, 12 (21.8%) from the MENA region, 9 (16.4%) from Southeast Asia and 2 (3.6%) from other parts of the world. Optimal recanalization (Thrombolysis in cerebral infarction (TICI) scale=2b-3) was achieved in 43 (78.2%); the incidence of symptomatic ICH was 2 (3.6%) and favorable outcome at 90 days was seen in 23 (41.8%). Apart from significantly older age, mean 62.8+13 years (median 69) vs. 48.1+9.3 (mean 49) and coronary artery disease burden 4 (33.3%) vs.1 (2.3%) (p<0.05). Patients from the MENA cohort had similar risk factor profiles, stroke severity, recanalization rates, ICH rates and 90-day outcomes compared to patients from South and Southeast Asia. Conclusion: Rescue stenting showed comparably good outcomes and low risk of clinically significant bleeding in a multiethnic cohort of patients from MENA and South and Southeast Asia.

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Section: Discussioncontrasting

confidence: 55%

“…Overall, our population seems to be younger than other reported cohorts from China (24), USA (25), Spain (26) and , South Korea (13).…”

Section: Discussioncontrasting

confidence: 54%

Rescue Stenting in Mechanical Thrombectomy Refractory Occlusions: A Single Center Multiethnic Cohort

Imam

Akhtar

Kamran

et al. 2022

Preprint

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“…Despite initially successful recanalization, patients with underlying atherosclerosis may develop immediate reocclusion of the target vessel by up to 40%, which is associated with poorer clinical outcomes [4][5][6][7]. In these cases, rescue stent angioplasty might be a treatment option to achieve permanent recanalization [8][9][10][11][12][13]. Retrospective data suggest that acute intracranial stenting is a safe and effective rescue strategy in patients with large-vessel occlusion (LVO) who fail mechanical thrombectomy (MT), potentially leading to better functional outcomes and lower mortality rates than those in patients with failed MT without rescue stenting [14].…”

Section: Introductionmentioning

confidence: 99%

Comparison of Safety and Efficacy after Emergency Stenting in Patients Exhibiting Intracranial Atherosclerotic Stenosis Associated with Large-vessel Occlusion with and without Intravenous Infusion of Tirofiban

Garayzade

Berlis

Schiele

et al. 2023

Cardiovasc Intervent Radiol

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Purpose Intracranial rescue stent angioplasty is a bailout strategy for acute stroke patients in cases of unsuccessful endovascular thrombectomy due to underlying atherosclerotic stenosis. However, there is no consensus on a preprocedural and intraprocedural antiplatelet regimen. The aim of this single-centre study was to compare the safety and efficacy of emergency stenting in patients exhibiting intracranial atherosclerotic stenosis-related acute large-vessel occlusion with or without peri-interventional intravenous infusion of tirofiban. Materials and Methods We performed a retrospective analysis of 78 patients who were treated with rescuestent angioplasty between 2010 and 2019 due to acute ischaemic stroke. The patients were divided into 2 groups: those who received peri-interventional intravenous tirofiban and those who did not receive tirofiban. We compared clinical safety and functional outcomes in both treatment groups with symptomatic haemorrhage as the primary endpoint. Bivariate and multivariable logistic regression was performed to investigate the association between tirofiban and outcome measures. Results Thirty-seven patients were treated with intravenous tirofiban (47.4%), and 41 patients did not receive intravenous tirofiban (52.6%). Statistical analysis revealed no significant difference between the two groups in the rate of symptomatic haemorrhage (16.2% in the tirofiban group versus 14.6% in the control group, p = 0.847). The 3-month mortality (21.6% in the tirofiban group versus 17.1% in the control group, p = 0.611) and good functional outcomes according to the modified Rankin scale (45.9% versus 34.1%, p = 0.289) were comparable. Conclusion The results of our study suggest that the application of tirofiban for rescue stenting after failed mechanical thrombectomy is safe.

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“…Yet, the main difference between previous publications and the present analysis was that we aimed to match our large group of patients with RIS with the most relevant group of patients that were treated with MT, and with a true refractory occlusion (that is, not the failure to reach the clot). For this purpose, we chose a minimum of three clot retrieving maneuvers in the control group, using the definition of refractory thrombectomy already employed14 15; in practice, rescue maneuvers are rarely performed before two or three attempts to remove the clot. l 16–18.…”

Section: Discussionmentioning

confidence: 99%

Rescue intracranial permanent stenting for refractory occlusion following thrombectomy: a propensity matched analysis

Ifergan

Dargazanli

Hassen

et al. 2023

J NeuroIntervent Surg

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BackgroundRescue intracranial stenting (RIS) can be used in refractory large vessel occlusion (LVO) after mechanical thrombectomy (MT). We aimed to assess the safety and efficacy of RIS versus a propensity matched sample of patients with persistent LVO.MethodsWe retrospectively analysed a multicenter retrospective pooled cohort of patients with anterior LVO (2015−2021) treated with MT, and identified patients with at least three passes and a modified Thrombolysis In Cerebral Infarction (mTICI) score of 0 to 2a. Propensity score matching was used to account for determinants of outcome in patients with or without RIS. The study outcomes included 3 months modified Rankin Scale (mRS) and symptomatic hemorrhagic transformation (HT).Results420 patients with a refractory anterior occlusion were included, of which 101 were treated with RIS (mean age 69 years). Favorable outcome (mRS 0–2) was more frequent in patients with a patent stent at day 1 (53% vs 6%, P<0.001), which was independently associated with an early dual antiplatelet regimen (P<0.05). In the propensity matched sample, patients treated with RIS versus without RIS had similar rates of favorable outcomes (36.8% vs 30.3%, P=0.606). Patients with RIS showed a favorable shift in the overall mRS distributions (common adjusted OR 0.74, 95% CI 0.60 to 0.91, P=0.006). Symptomatic HT was marginally more frequent in the RIS group (9% vs 3%, P=0.07), and there was no difference in 3-month mortality.ConclusionIn selected patients with a refractory intracranial occlusion despite at least three thrombectomy passes, RIS may be associated with an overall shift towards more favorable clinical outcome, and no significant increase in the odds of symptomatic HT or death.

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Rescue stenting for acute ischemic stroke with refractory emergent large vessel occlusion in the modern thrombectomy era

Cited by 8 publications

References 30 publications

Rescue Stenting in Mechanical Thrombectomy Refractory Occlusions: A Single Center Multiethnic Cohort

Rescue Stenting in Mechanical Thrombectomy Refractory Occlusions: A Single Center Multiethnic Cohort

Comparison of Safety and Efficacy after Emergency Stenting in Patients Exhibiting Intracranial Atherosclerotic Stenosis Associated with Large-vessel Occlusion with and without Intravenous Infusion of Tirofiban

Rescue intracranial permanent stenting for refractory occlusion following thrombectomy: a propensity matched analysis

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