Rescue Stenting for Failed Mechanical Thrombectomy in Acute Ischemic Stroke

Chang, Yoonkyung; Kim, Byung Moon; Bang, Oh Young; Baek, Jang Hyun; Heo, Ji Hoe; Nam, Hyo Suk; Kim, Young Dae; Yoo, Joonsang; Kim, Dong Joon; Jeon, Pyoung; Baik, Seung Kug; Suh, Sang Hyun; Lee, Ki Young; Kwak, Hyo Sung; Roh, Hong Gee; Lee, Young Jun; Kim, Sang Heum; Ryu, Chang‐Woo; Ihn, Yon Kwon; Kim, Byung Jun; Jeon, Hong Jun; Kim, Jin Woo; Byun, Jun Soo; Suh, Sangil; Park, Jeong Jin; Lee, Woong Jae; Roh, Jee Hoon; Shin, Byoung Soo; Kim, Jeong‐Min

doi:10.1161/strokeaha.117.020072

Cited by 137 publications

(143 citation statements)

References 20 publications

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“…Delgado Acosta et al 28 described preprocedural aspirin use in 3/20 patients and preprocedural clopidogrel use in 6/20 patients. Chang et al 29 employed differing strategies with variable timing of aspirin or clopidogrel administration in the periprocedural period. The details of the antiplatelet regimens included in each study are summarized in table 4.…”

Section: Resultsmentioning

confidence: 99%

A systematic review and meta-analysis of observational evidence for the use of bailout self-expandable stents following failed anterior circulation stroke thrombectomy

Wareham

Flood

Phan³

et al. 2018

J NeuroIntervent Surg

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BackgroundThe crucial role of thrombectomy in the management of emergent large vessel occlusive stroke is not disputed but there is a technical failure rate in a significant minority of patients whose outcomes are often poor. Our objective was to perform a systematic review and meta-analysis to assess the safety and efficacy of permanent self-expandable stent deployment as a bailout procedure in cases of failed anterior circulation thrombectomy.MethodsTwo independent reviewers searched the Pubmed (Medline) database for studies reporting outcomes following failed endovascular thrombectomy with subsequent rescue therapy employing self-expandable stents.ResultsEight studies (one prospective, seven retrospective) originating from Europe, Asia, and America comprising 160 patients met the inclusion criteria. Estimated baseline National Institutes of Health Stroke Scale score was 17.1 (95% CI 15.7 to 18.4). Following failed thrombetcomy and stent deployment, the rate of favorable outcome (modified Rankin Scale score 0–2) was 43% (95% CI 34% to 53%). Pooled mortality was 21% (95% CI 13% to 33%). Successful recanalization (Thrombolysis in Cerebral Infarction (TICI) 2b–3 or Thrombolysis in Myocardial Infarction (TIMI) 2–3) was 71% (95% CI 63% to 77%). Symptomatic intracerebral hemorrhage was seen in 12% (95% CI 7% to 18%). The Solitaire stent (Medtronic) was the most commonly deployed stent following failed thrombectomy attempts (66%; 95% CI 31% to 89%). Pre- or post-stent angioplasty was performed in 39%of patients (95% CI 29% to 48%). Glycoprotein IIb/IIIa inhibitors were used in 89% (95% CI 71% to 97%). 95% of patients received postprocedural antiplatelet therapy.ConclusionA rescue stent procedure seems reasonable as a last resort following failed thrombectomy but currently the level of evidence is limited. Prospective registries may aid in guiding future recommendations.

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Section: Resultsmentioning

confidence: 99%

A systematic review and meta-analysis of observational evidence for the use of bailout self-expandable stents following failed anterior circulation stroke thrombectomy

Wareham

Flood

Phan³

et al. 2018

J NeuroIntervent Surg

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“…For example, recent studies suggest a proximal balloon occlusion during stent retriever withdrawal to protect the distal vessel from thrombus fragments that have sheared off [31]. As a rescue therapy, permanent stenting or intraarterial thrombolysis as well as administration of tirofiban are options worth considering [32][33][34]. In certain cases, creativity on the part of the interventionalist can lead to success: there are case reports of dual-use of stent retrievers for refractory clots involving vessels' bifurcation [35].…”

Section: Discussionmentioning

confidence: 99%

Why we fail: mechanisms and co-factors of unsuccessful thrombectomy in acute ischemic stroke

et al. 2020

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Purpose Mechanical thrombectomy (MT) is an effective treatment for patients suffering from acute ischemic stroke. However, recanalization fails in about 16.5% of interventions. We report our experience with unsuccessful MT and analyze technical reasons plus patient-related parameters for failure. Methods Five hundred ninety-six patients with acute ischemic stroke in the anterior circulation and intention to perform MT with an aspiration catheter and/or stent retriever were analyzed. Failure was defined as 0, 1, or 2a on the mTICI scale. Patients with failing MT were analyzed for interventional progress and compared to patients with successful intervention, whereby parameters included demographics, medical history, stroke presentation, and treatment.Results One hundred of the 596 (16.8%) interventions failed. In 20 cases, thrombus could not be accessed or passed with the device. Peripheral arterial occlusive disease is common in those patients. In 80 patients, true stent retriever failure occurred. In this group, coagulation disorders are associated with poor results, whereas atrial fibrillation is associated with success.The administration of intravenous thrombolysis and intake of nitric oxide donors are associated with recanalization success. Intervention duration was significantly longer in the failing group. Conclusion In 20% of failing MT, thrombus cannot be reached/passed. Direct carotid puncture or surgical arterial access could be considered in these cases.In 80% of failing interventions, thrombus can be passed with the device, but the occluded vessel cannot be recanalized. Rescue techniques can be an option. Development of new devices and techniques is necessary to improve recanalization rates. Assessment of pre-existing illness could sensitize for occurring complications.

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“…Although further studies in other populations are needed to confirm these findings, the results promote permanent stent placement as a feasible rescue technique in cases of stent-retriever failures. 40…”

Section: Delayed Recanalization and Rescue Optionsmentioning

confidence: 99%

Reasons for Reperfusion Failures in Stent-Retriever-Based Thrombectomy: Registry Analysis and Proposal of a Classification System

Kaesmacher

Gralla²,

Mosimann³

et al. 2018

AJNR Am J Neuroradiol

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Rescue Stenting for Failed Mechanical Thrombectomy in Acute Ischemic Stroke

Abstract: RS was independently associated with good outcomes without increasing symptomatic intracranial hemorrhage or mortality. RS seemed considered in MT-failed internal carotid artery or middle cerebral artery M1 occlusion.

Cited by 137 publications

References 20 publications

A systematic review and meta-analysis of observational evidence for the use of bailout self-expandable stents following failed anterior circulation stroke thrombectomy

A systematic review and meta-analysis of observational evidence for the use of bailout self-expandable stents following failed anterior circulation stroke thrombectomy

Why we fail: mechanisms and co-factors of unsuccessful thrombectomy in acute ischemic stroke

Reasons for Reperfusion Failures in Stent-Retriever-Based Thrombectomy: Registry Analysis and Proposal of a Classification System

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