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Fageeh A, Zur G, Diouf A, La Russa D, Drake B, P Dos Santos M, Caron K, Birch N, Karwaski S, Trussler L, Miller E, Fantaneanu T, Varghaei P, Walker G, Lesiuk H, Fahed R. Stent retriever for Tandem Acute Revascularization Technique (START): a novel technique for the endovascular management of tandem occlusions. J Neurointerv Surg 2024; 16:529-530. [PMID: 37903560 DOI: 10.1136/jnis-2023-021011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 10/17/2023] [Indexed: 11/01/2023]
Abstract
Tandem occlusions, characterized by the simultaneous presence of an intracranial large vessel occlusion and extracranial carotid artery stenosis or occlusion,1 pose a unique endovascular challenge.2 3 Typically, the extracranial occlusion is a result of atherosclerotic plaque; however, dissections are also a possible cause. It is currently uncertain whether an intracranial first approach or an extracranial first approach should be employed.4 5 A new technique has been developed which allows for the simultaneous treatment of both the intracranial and the extracranial lesion.6 We describe a variation of this technique: the stent retriever for tandem acute revascularization technique (START), which consists of simultaneously treating the intracranial lesion with stent retriever and contact aspiration, and the extracranial lesion with balloon angioplasty. We present a technical video explaining all the steps of START.(video 1) neurintsurg;16/5/529/V1F1V1Video 1Description and example of the START.
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Affiliation(s)
- Areej Fageeh
- Interventional Neuroradiology, Ottawa Hospital, Ottawa, Ontario, Canada
- Neurosurgery, Ottawa Hospital, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Gil Zur
- Interventional Neuroradiology, Ottawa Hospital, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Ange Diouf
- Interventional Neuroradiology, Ottawa Hospital, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel La Russa
- Interventional Neuroradiology, Ottawa Hospital, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute (OHRI), Ottawa Hospital, Ottawa, Ontario, Canada
| | - Brian Drake
- Interventional Neuroradiology, Ottawa Hospital, Ottawa, Ontario, Canada
- Neurosurgery, Ottawa Hospital, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute (OHRI), Ottawa Hospital, Ottawa, Ontario, Canada
| | - Marlise P Dos Santos
- Interventional Neuroradiology, Ottawa Hospital, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute (OHRI), Ottawa Hospital, Ottawa, Ontario, Canada
| | - Katie Caron
- Interventional Neuroradiology, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Nicole Birch
- Interventional Neuroradiology, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Stephen Karwaski
- Interventional Neuroradiology, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Laurie Trussler
- Interventional Neuroradiology, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Elizabeth Miller
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute (OHRI), Ottawa Hospital, Ottawa, Ontario, Canada
- Department of Anesthesia, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Tadeu Fantaneanu
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute (OHRI), Ottawa Hospital, Ottawa, Ontario, Canada
- Neurology, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Parizad Varghaei
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Neurology, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Gregory Walker
- Interventional Neuroradiology, Ottawa Hospital, Ottawa, Ontario, Canada
- Department of Medicine - Division of Neurology, Royal Columbian Hospital, New Westminster, British Columbia, Canada
| | - Howard Lesiuk
- Interventional Neuroradiology, Ottawa Hospital, Ottawa, Ontario, Canada
- Neurosurgery, Ottawa Hospital, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute (OHRI), Ottawa Hospital, Ottawa, Ontario, Canada
| | - Robert Fahed
- Interventional Neuroradiology, Ottawa Hospital, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute (OHRI), Ottawa Hospital, Ottawa, Ontario, Canada
- Neurology, Ottawa Hospital, Ottawa, Ontario, Canada
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Elder TA, Verhey LH, Schultz H, Smith ES, Adel JG. Cervical carotid occlusion in acute ischemic stroke: Should we give tPA? Surg Neurol Int 2022; 13:177. [PMID: 35509556 PMCID: PMC9063023 DOI: 10.25259/sni_176_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 04/12/2022] [Indexed: 12/03/2022] Open
Abstract
Background: Acute ischemic stroke (AIS) due to cervical internal carotid artery (cICA) occlusion is challenging to treat, with the lower revascularization rates, higher risk for complications, and poor response to thrombolytic therapy compared to isolated intracranial occlusions. While emergent revascularization through mechanical thrombectomy (MT) improves outcomes, the impact of tissue plasminogen activator (tPA) on outcomes in this subgroup of patients remains unclear. The objective of this study is to report our preliminary experience in treating AIS with cICA occlusions secondary to severe atherosclerotic stenosis and to establish the need for further clinical studies to determine the optimal intervention strategy for these lesions. Methods: Data were collected on patients who presented with acute cICA occlusion who underwent MT and either acute or staged carotid angioplasty and stenting. We compare patients who received tPA to those who did not, analyzing revascularization times, outcomes, and complications between the two populations, and discuss how this influenced our preferred treatment approach. Results: Twenty-one patients met inclusion criteria, seven of who received tPA and 14 did not receive tPA before surgical intervention. Procedural and functional outcomes were similar between the two populations. TPA administration correlated with a higher rate of vessel reocclusion in staged procedures and trended toward higher rates of symptomatic ICH and 90-day mortality. Conclusion: Emergent revascularization with acute cICA stenting carries advantages, but its safety is precluded by tPA administration. We suggest a trial which randomizes patients with cICA occlusions to receiving either tPA or dual antiplatelet therapy before surgical intervention, aiming to ultimately improved outcomes in these patients.
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Affiliation(s)
- Theresa A. Elder
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio,
| | - Leonard H. Verhey
- Department of Clinical Neurosciences, Spectrum Health, Michigan State University College of Human Medicine, Grand Rapids,
| | - Haritha Schultz
- Department of Internal Medicine, Central Michigan University College of Medicine,
| | - Eleanor S. Smith
- Department of Neurosurgery, Central Michigan University College of Medicine,
| | - Joseph G. Adel
- Department of Neuroscience, Ascension St Mary’s Hospital, Saginaw, Michigan, United States
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Wang D, Zhang L, Hu X, Zhu J, Tang X, Ding D, Wang H, Kong Y, Cai X, Lin L, Fang Q. Intravenous Thrombolysis Benefits Mild Stroke Patients With Large-Artery Atherosclerosis but No Tandem Steno-Occlusion. Front Neurol 2020; 11:340. [PMID: 32431662 PMCID: PMC7214684 DOI: 10.3389/fneur.2020.00340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 04/07/2020] [Indexed: 01/01/2023] Open
Abstract
At present, there is controversy regarding whether thrombolysis is beneficial for patients suffering from a mild stroke. In this study, we therefore sought to determine whether the therapeutic benefit of thrombolysis is dependent upon stroke subtype for those with mild stroke. We conducted a retrospective analysis of data from consecutive mild stroke patients (National Institutes of Health Stroke Scale ≤5) with and without recombinant tissue plasminogen activator (rt-PA) therapy. The TOAST (Trial of Org 10172 in acute stroke treatment) criteria was used to determine stroke subtypes. Patients suffering from large-artery atherosclerosis (LAA) were subdivided based upon whether or not they exhibited tandem steno-occlusion, as defined by the association of a proximal intracranial occlusion and a cervical internal carotid artery lesion (complete occlusion or severe stenosis ≥ 90%). For this study, favorable outcomes at 90 days of onset (modified Rankin Scale Score [mRS] of 0–1) were the primary measured outcome. Three hundred thirty-nine patients were included in the study. For patients with non-LAA, there were not statistically significant improvements in favorable outcomes for rt-PA treatment (p = 0.889, 0.929, 0.708; respectively). For patients with LAA, compared with non-treated group, rt-PA-treated patients had a significant in the rate of favorable outcomes at 90 days (82.8 vs. 64.9%; OR 2.59; 95%CI, 1.13–5.92; P = 0.024). Among LAA patients exhibiting tandem lesions, favorable outcomes were observed in 66.7% of rt-PA-treated patients, with no significant differences to those observed in untreated patients (OR 1.00; 95%CI, 0.23–4.28; p = 1.000). Among LAA patients without tandem lesions, compared with non-treated group, we found that rt-PA treatment was associated with a significant beneficial impact on favorable outcomes after 90 days (64.4 vs. 88.4%; OR 4.20; 95%CI, 1.43–12.30; p = 0.009). Our findings suggest that intravenous rt-PA is only beneficial in mild stroke patients with LAA-type strokes that do not exhibit tandem steno-occlusion.
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Affiliation(s)
- Dapeng Wang
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Lulu Zhang
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Xiaowei Hu
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Juehua Zhu
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Xiang Tang
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Dongxue Ding
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Hui Wang
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Yan Kong
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Xiuying Cai
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Longting Lin
- Hunter Medical Research Institute, University of Newcastle, New Lambton, NSW, Australia
| | - Qi Fang
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
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Ramsey CN, Newman CB, Jones MR, Archer A, Given CA. Technical note on endovascular treatment of concomitant carotid occlusion in large vessel occlusion stroke: The "single-cross" technique. Interv Neuroradiol 2019; 26:10-18. [PMID: 31311374 DOI: 10.1177/1591019919863435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Emergent large vessel occlusive (ELVO) stroke secondary to underlying carotid occlusive disease is frequently encountered in endovascular ischemic stroke therapy and trials. Up to 29% of all cerebral vascular accidents are attributed to severe carotid occlusive disease, and recent interventional trials have demonstrated this occurrence in 18.6-32.2% of ELVO stroke. We present a novel technique using the stent retriever guide wire to expedite angioplasty and/or stent placement for associated carotid occlusive disease during mechanical thrombectomy of ELVO stroke. This technique utilizes the "waiting time" during stent retriever integration within the thrombus as an opportunity to initiate revascularization of the cervical carotid, using the deployed stent retriever guidewire as an ad hoc rapid exchange wire while the stentriever serves as a potential surrogate distal embolic protection device. We present 23 cases using this novel endovascular approach, which we have called the single-cross technique, as the cervical lesion is only traversed once during therapy. METHODS A case series of 23 consecutive patients who underwent a novel endovascular technique for treating tandem ICA origin and intracranial occlusive lesions is presented. Endpoints measured were time to re-perfusion, rates of intracranial hemorrhage and clinical outcomes (mRS at 30 and 90 days). RESULTS Average procedure time for revascularizing both the carotid and intracranial lesions was 52 min. A symptomatic ICH rate of 9% was observed. Seventy-four percent of patients had an mRS of 0-2 at follow-up. CONCLUSIONS The single-cross technique appears to be a safe and effective option for treating tandem occlusive lesions in the setting of ELVO.
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