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Zidan M, Voss YL, Wolf M, Keil F, Brockmann C, Gronemann C, Lehnen NC, Paech D, Nordmeyer H, Dorn F. The Dual-layer CGuard Stent Is Safe and Effective in Emergent Carotid Artery Stenting and in Tandem Occlusions: a Multi-centric Study. Clin Neuroradiol 2024:10.1007/s00062-024-01455-7. [PMID: 39225802 DOI: 10.1007/s00062-024-01455-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 08/11/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Dual-layer stents have fallen into disrepute after several studies reported high rates of in-stent occlusions in acute stroke treatments. The CGuard stent is a new-generation hybrid dual-layer stent that has been designed to provide less thrombogenicity and to prevent peri- and postinterventional emboli. The aim of the study is to evaluate the safety and efficacy of the CGuard stent for the acute treatment of occlusion or high-grade stenosis of the extracranial internal carotid artery (ICA) in patients with acute ischemic stroke (AIS) with and without concomitant intracranial large vessel occlusion (LVO). METHODS All patients who underwent emergent carotid artery stenting (CAS) with the CGuard stent were identified and analyzed from the stroke registries from four tertiary German stroke centers. Clinical, procedural, and imaging data were evaluated. Stent patency within 72 h, intracranial hemorrhage, and modified Rankin score (mRS) at discharge were the safety and efficacy end points. RESULTS Overall, ninety-six patients were included (mean age 70.2 ± 11.8, 66 males (68.8%), median NIHSS score at admission 11 (7-17), IV lysis: n = 44 (45.8%)). Stent placement was successful in all patients. Eighty-three (86.4%) patients had tandem occlusions. In-stent occlusion occurred in 5 patients (5.2%) and 3 patients developed early in-stent stenosis (3.1%). Median mRS at discharge was 2 (1-4). CONCLUSION In this multicenter study, the use of the dual-layer CGuard stent for emergent CAS, particularly in tandem occlusions, was safe and resulted in low rates of in-stent occlusions.
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Affiliation(s)
- Mousa Zidan
- Department of Neuroradiology, Bonn University Hospital, Venusberg-Campus1, Gebäude 81, 53127, Bonn, Germany.
| | - Yves Leonard Voss
- Radprax MVZ Nordrhein GmbH, Department of Interventional Neuroradiology, St. Lukas-Klinik, Solingen, Germany
| | - Marcel Wolf
- Department of Neuroradiology, Mainz University Hospital, Mainz, Germany
| | - Fee Keil
- Department of Neuroradiology, Frankfurt University Hospital, Frankfurt, Germany
| | - Carolin Brockmann
- Department of Neuroradiology, Mainz University Hospital, Mainz, Germany
| | - Christian Gronemann
- Department of Neuroradiology, Bonn University Hospital, Venusberg-Campus1, Gebäude 81, 53127, Bonn, Germany
| | - Nils Christian Lehnen
- Department of Neuroradiology, Bonn University Hospital, Venusberg-Campus1, Gebäude 81, 53127, Bonn, Germany
| | - Daniel Paech
- Department of Neuroradiology, Bonn University Hospital, Venusberg-Campus1, Gebäude 81, 53127, Bonn, Germany
- Department of Radiology, German Cancer Research Centre, Heidelberg, Germany
| | - Hannes Nordmeyer
- Radprax MVZ Nordrhein GmbH, Department of Interventional Neuroradiology, St. Lukas-Klinik, Solingen, Germany
- School of Medicine, Department of Health, Witten/Herdecke University, Witten, Germany
| | - Franziska Dorn
- Department of Neuroradiology, Bonn University Hospital, Venusberg-Campus1, Gebäude 81, 53127, Bonn, Germany
- Department of Neuroradiology, Medizinische Klinik und Poliklinik IV, LMU-Klinikum, Universität München, Munich, Bayern, Germany
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Zidan M, Gronemann C, Lehnen NC, Bode F, Weller J, Petzold G, Radbruch A, Paech D, Dorn F. Stenting with dual-layer CGuard stent in acute sub-occlusive carotid artery stenosis and in tandem occlusions: a monocentric study. Neuroradiology 2024; 66:1635-1644. [PMID: 38844697 PMCID: PMC11322317 DOI: 10.1007/s00234-024-03397-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 06/01/2024] [Indexed: 08/16/2024]
Abstract
PURPOSE Double-layer design carotid stents have been cast in a negative light since several investigations reported high rates of in-stent occlusions, at least in the acute setting of tandem occlusions. CGuard is a new generation double-layered stent that was designed to prevent periinterventional embolic events. The aim of this study was to analyze the safety and efficacy of the CGuard in emergent CAS and for the acute treatment of tandem occlusions in comparison with the single-layer Carotid Wallstent (CWS) system. METHODS All patients who underwent CAS with CGuard or CWS after intracranial mechanical thrombectomy (MT) between 11/2018 and 12/2022 were identified from our local thrombectomy registry. Clinical, interventional and neuroimaging data were analyzed. Patency of the stent was assessed within 72 h. Intracranial hemorrhage and modified Rankin score (mRS) at discharge were the main endpoints. RESULTS In total, 86 stent procedures in 86 patients were included (CWS: 44, CGuard: 42). CGuard had a lower, but not statistically significant rate (p = 0.431) of in-stent occlusions (n = 2, 4.8%) when compared to the CWS (n = 4, 9.1%). Significant in-stent stenosis was found in one case in each group. There was no statistically significant difference in functional outcome at discharge between the two groups with a median mRS for CGuard of 2 (IQR:1-5) vs. CWS 3 (IQR:2-4). CONCLUSION In our series, the rate of in-stent occlusions after emergent CAS was lower with the dual-layer CGuard when compared to the monolayer CWS. Further data are needed to evaluate the potential benefit of the design in more detail.
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Affiliation(s)
- Mousa Zidan
- Department of Neuroradiology, Bonn University Hospital, Venusberg-Campus1, Gebäude 81, 53127, Bonn, Germany.
| | - Christian Gronemann
- Department of Neuroradiology, Bonn University Hospital, Venusberg-Campus1, Gebäude 81, 53127, Bonn, Germany
| | - Nils Christian Lehnen
- Department of Neuroradiology, Bonn University Hospital, Venusberg-Campus1, Gebäude 81, 53127, Bonn, Germany
| | - Felix Bode
- Department of Neurology, Bonn University Hospital, Bonn, Germany
| | - Johannes Weller
- Department of Neurology, Bonn University Hospital, Bonn, Germany
| | - Gabor Petzold
- Department of Neurology, Bonn University Hospital, Bonn, Germany
| | - Alexander Radbruch
- Department of Neuroradiology, Bonn University Hospital, Venusberg-Campus1, Gebäude 81, 53127, Bonn, Germany
| | - Daniel Paech
- Department of Neuroradiology, Bonn University Hospital, Venusberg-Campus1, Gebäude 81, 53127, Bonn, Germany
- Department of Radiology, German Cancer Research Centre, Heidelberg, Germany
| | - Franziska Dorn
- Department of Neuroradiology, Bonn University Hospital, Venusberg-Campus1, Gebäude 81, 53127, Bonn, Germany
- Department of Neuroradiology, LMU-Klinikum der Universität München Medizinische Klinik und Poliklinik IV, Munich, Bayern, Germany
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Diana F, Abdalkader M, Behme D, Li W, Maurer CJ, Pop R, Hwang YH, Bartolini B, Da Ros V, Bracco S, Cirillo L, Marnat G, Katsanos AH, Kaesmacher J, Fischer U, Aguiar de Sousa D, Peschillo S, Zini A, Tomasello A, Ribo M, Nguyen TN, Romoli M. Antithrombotic regimen in emergent carotid stenting for acute ischemic stroke due to tandem occlusion: a meta-analysis of aggregate data. J Neurointerv Surg 2024; 16:243-247. [PMID: 37185107 DOI: 10.1136/jnis-2023-020204] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 04/14/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND The periprocedural antithrombotic regimen might affect the risk-benefit profile of emergent carotid artery stenting (eCAS) in patients with acute ischemic stroke (AIS) due to tandem lesions, especially after intravenous thrombolysis. We conducted a systematic review and meta-analysis to evaluate the safety and efficacy of antithrombotics following eCAS. METHODS We followed PRISMA guidelines and searched MEDLINE, Embase, and Scopus from January 1, 2004 to November 30, 2022 for studies evaluating eCAS in tandem occlusion. The primary endpoint was 90-day good functional outcome. Secondary outcomes were symptomatic intracerebral hemorrhage, in-stent thrombosis, delayed stent thrombosis, and successful recanalization. Meta-analysis of proportions and meta-analysis of odds ratios were implemented. RESULTS 34 studies with 1658 patients were included. We found that the use of no antiplatelets (noAPT), single antiplatelet (SAPT), dual antiplatelets (DAPT), or glycoprotein IIb/IIIa inhibitors (GPI) yielded similar rates of good functional outcomes, with a marginal benefit of GPI over SAPT (OR 1.88, 95% CI 1.05 to 3.35, Pheterogeneity=0.31). Sensitivity analysis and meta-regression excluded a significant impact of intravenous thrombolysis and Alberta Stroke Program Early CT Score (ASPECTS). We observed no increase in symptomatic intracerebral hemorrhage (sICH) with DAPT or GPI compared with noAPT or SAPT. We also found similar rates of delayed stent thrombosis across groups, with acute in-stent thrombosis showing marginal, non-significant benefits from GPI and DAPT over SAPT and noAPT. CONCLUSIONS In AIS due to tandem occlusion, the periprocedural antithrombotic regimen of eCAS seems to have a marginal effect on good functional outcome. Overall, high intensity antithrombotic therapy may provide a marginal benefit on good functional outcome and carotid stent patency without a significant increase in risk of sICH.
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Affiliation(s)
- Francesco Diana
- Interventional Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Catalunya, Spain
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Catalunya, Spain
| | | | - Daniel Behme
- Neuroradiology, University Hospital Magdeburg, Magdeburg, Sachsen-Anhalt, Germany
| | - Wei Li
- Neurology, Hainan Medical University, Haikou, Hainan, China
| | - Christoph Johannes Maurer
- Diagnostic and Interventional Neuroradiology, University Hospital Augsburg, Augsburg, Bayern, Germany
| | - Raoul Pop
- Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, France
| | - Yang-Ha Hwang
- Neurology and Radiology, Kyungpook National University Hospital, Daegu, Korea (the Republic of)
| | - Bruno Bartolini
- Diagnostic and Interventional Radiology, Interventional Neuroradiology Unit, CHUV - Lausanne University Hospital, Lausanne, Switzerland
| | - Valerio Da Ros
- Biomedicine and Prevention, Diagnostic Imaging Unit, Fondazione PTV Policlinico Tor Vergata, Roma, Italy
| | - Sandra Bracco
- Neurology and Human Movement Sciences, Interventional Neuroradiology Unit, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Luigi Cirillo
- Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Gaultier Marnat
- Interventional and Diagnostic Neuroradiology, Bordeaux University Hospital, Bordeaux, France
| | - Aristeidis H Katsanos
- Neurology Division, McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada
| | - Johannes Kaesmacher
- Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Urs Fischer
- Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Diana Aguiar de Sousa
- Neurosciences and Mental Health, Neurology Service, Hospital de Santa Maria/ CHULN, University of Lisbon, Lisboa, Portugal
| | - Simone Peschillo
- Endovascular Neurosurgery, Pia Fondazione Cardinale G Panico Hospital, Tricase, Italy
- UniCamillus International Medical University, Rome, Italy
| | - Andrea Zini
- Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy, IRCCS Istituto Delle Scienze Neurologiche di Bologna, Bologna, Emilia-Romagna, Italy
| | - Alejandro Tomasello
- Interventional Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Catalunya, Spain
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Catalunya, Spain
| | - Marc Ribo
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Catalunya, Spain
- Stroke Unit, Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Thanh N Nguyen
- Radiology, Boston Medical Center, Boston, Massachusetts, USA
- Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Michele Romoli
- Neurology and Stroke Unit, Maurizio Bufalini Hospital, Cesena, Emilia-Romagna, Italy
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Kojima T, Aihara M, Naito I, Shimizu T, Miyamoto N, Yamaguchi R, Aishima K, Sato K, Shimauchi-Ohtaki H, Shintoku R, Wakabayashi K, Yoshimoto Y. Management of Cervical Internal Carotid Artery Stenosis or Occlusion in Tandem Lesion with Acute Ischemic Stroke: Which Is More Appropriate Percutaneous Transluminal Angioplasty or Stent? World Neurosurg 2023; 175:e208-e217. [PMID: 36924889 DOI: 10.1016/j.wneu.2023.03.054] [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: 01/19/2023] [Revised: 03/11/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023]
Abstract
OBJECTIVE Carotid artery stenting (CAS) is the established treatment strategy of the cervical internal carotid artery (cICA) stenosis, but its use for acute tandem lesions remains controversial. We investigated the clinical and procedural outcomes of management of cICA lesions and evaluated the risk factors for complications. METHODS Fifty patients who underwent acute mechanical thrombectomy for tandem lesion between January 2014 and June 2022 were included. Treatment of the cICA lesion was classified into the CAS group or the non-CAS group. The risk factors for postoperative ischemic events or symptomatic intracranial hemorrhage (sICH) were analyzed. RESULTS The CAS group included 36 patients (72%) and the non-CAS group 14 (28%). Postoperative complications were observed in 9 patients (18%). Thromboembolic complications occurred in 4 patients (29%) of the non-CAS group but in 1 patient (3%) of the CAS group. Severe calcification of the cICA (P = 0.04), non-CAS (P = 0.018), and more than 60% residual stenosis (P = 0.016) were significant risk factors associated with thromboembolic complications. sICH occurred in 4 patients (11%) of the CAS group but in none of the non-CAS group. More than 80% stenosis improvement was significantly associated with sICH (P = 0.049). Twenty-nine patients (58%) had a good clinical outcome at 90 days after onset. CONCLUSIONS Acute CAS is effective for the management for cICA tandem lesions during mechanical thrombectomy, but care not to overextend may be important to reduce the risk of sICH. Severe calcification of the cICA may increase the risk of postoperative thromboembolic complications using non-CAS treatment.
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Affiliation(s)
- Takeo Kojima
- Department of Neurosurgery, Saku Central Hospital Nagano Prefectural Federation of Agricultural Cooperation for Health and Welfare, Saku, Nagano, Japan
| | - Masanori Aihara
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan.
| | - Isao Naito
- Department of Neurosurgery, Geriatrics Research Institute and Hospital, Maebashi, Gunma, Japan
| | - Tatsuya Shimizu
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Naoko Miyamoto
- Department of Neurosurgery, Geriatrics Research Institute and Hospital, Maebashi, Gunma, Japan
| | - Rei Yamaguchi
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Kaoru Aishima
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Koji Sato
- Department of Neurosurgery, National Hospital Organization Takasaki General Medical Center, Takasaki, Gunma, Japan
| | - Hiroya Shimauchi-Ohtaki
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Ryosuke Shintoku
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Kazuki Wakabayashi
- Department of Neurosurgery, General Fujioka Hospital, Fujioka, Gunma, Japan
| | - Yuhei Yoshimoto
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
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Diana F, Romoli M, Toccaceli G, Rouchaud A, Mounayer C, Romano DG, Di Salle F, Missori P, Zini A, Aguiar de Sousa D, Peschillo S. Emergent carotid stenting versus no stenting for acute ischemic stroke due to tandem occlusion: a meta-analysis. J Neurointerv Surg 2023; 15:428-432. [PMID: 35428740 DOI: 10.1136/neurintsurg-2022-018683] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/24/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Emergent carotid artery stenting (eCAS) is performed during mechanical thrombectomy for acute ischemic stroke due to tandem occlusion. However, the optimal management strategy in this setting is still unclear. OBJECTIVE To carry out a systematic review and meta-analysis to investigate the safety and efficacy of eCAS in patients with tandem occlusion. METHODS Systematic review followed the PRISMA guidelines. Medline, EMBASE, and Scopus were searched from January 1, 2004 to March 7, 2022 for studies evaluating eCAS and no-stenting approach in patients with stroke with tandem occlusion. Primary endpoint was the 90-day modified Rankin Scale score 0-2; secondary outcomes were (1) symptomatic intracerebral hemorrhage (sICH), (2) recurrent stroke, (3) successful recanalization (Thrombolysis in Cerebral Infarction score 2b-3), (4) embolization in new territories, and (5) restenosis rate. Meta-analysis was performed using the Mantel-Haenszel method and random-effects modeling. RESULTS Forty-six studies reached synthesis. eCAS was associated with higher good functional outcome compared with the no-stenting approach (OR=1.52, 95% CI 1.19 to 1.95), despite a significantly increased risk of sICH (OR=1.97, 95% CI 1.23 to 3.15), and higher successful recanalization rate (OR=1.91, 95% CI 1.29 to 2.85). Restenosis rate was lower in the eCAS group than in the no-stenting group (2% vs 9%, p=0.001). Recanalization rate was higher in retrograde than antegrade eCAS (OR=0.51, 95% CI 0.28 to 0.93). Intraprocedural antiplatelets during eCAS were associated with higher rate of good functional outcome (60% vs 46%, p=0.016) and lower rate of sICH (7% vs 11%; p=0.08) compared with glycoprotein IIb/IIIa inhibitors. CONCLUSIONS In observational studies, eCAS seems to be associated with higher good functional outcome than no-stenting in patients with acute ischemic stroke due to tandem occlusion, despite the higher risk of sICH. Dedicated trials are needed to confirm these results.
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Affiliation(s)
- Francesco Diana
- Neuroradiology, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy
| | - Michele Romoli
- Neurology and Stroke Unit, Maurizio Bufalini Hospital, Cesena, Italy
| | - Giada Toccaceli
- Emergency Neurosurgery, Ospedale Civile 'Santo Spirito', Pescara, Italy
| | - Aymeric Rouchaud
- Interventional Neuroradiology, University Hospital Centre of Limoges, Limoges, France
- BioEMXLim, University of Limoges Medical Faculty, Limoges, France
| | - Charbel Mounayer
- Interventional Neuroradiology, University Hospital Centre of Limoges, Limoges, France
- BioEMXLim, University of Limoges Medical Faculty, Limoges, France
| | | | - Francesco Di Salle
- Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Fisciano, Italy
| | - Paolo Missori
- Human Neurosciences, Neurosurgery, University of Rome La Sapienza, Rome, Italy
| | - Andrea Zini
- Neurology and Stroke Center, IRCCS Istituto Delle Scienze Neurologiche di Bologna, Maggiore Hospital, Bologna, Italy
| | - Diana Aguiar de Sousa
- Neurosciences and Mental Health, Neurology Service, Hospital de Santa Maria/CHULN, University of Lisbon, Santa Maria, Portugal
| | - Simone Peschillo
- Surgical Medical Sciences and Advanced Technologies "G.F. Ingrassia" - Endovascular Neurosurgery, University of Catania, Catania, Italy
- Neurosurgery, Pia Fondazione Cardinale G Panico Hospital, Tricase, Italy
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Safety and Efficacy of Carotid Artery Stenting with the CGuard Double-layer Stent in Acute Ischemic Stroke. Clin Neuroradiol 2023; 33:237-244. [PMID: 36070140 PMCID: PMC9449946 DOI: 10.1007/s00062-022-01209-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 07/30/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Double-layer stents show promising results in preventing periinterventional and postinterventional embolic events in elective settings of carotid artery stenting (CAS). We report a single-center experience with the CGuard stent in the treatment of acute ischemic stroke (AIS) due to symptomatic internal carotid artery (ICA) stenosis or occlusion with or without intracranial occlusion. METHODS We retrospectively analyzed all patients who received a CGuard stent in the setting of AIS at our institution. Neuroimaging and clinical data were analyzed with the following primary endpoints: technical feasibility, acute and delayed stent occlusion or thrombosis, distal embolism, symptomatic intracranial hemorrhage (sICH) and functional outcome at 3 months. RESULTS In 33 patients, stenting with the CGuard was performed. Stent deployment was successful in all patients (28 with tandem occlusions, 5 with isolated ICA occlusion). Transient acute in-stent thrombus formation occurred in three patients (9%) without early stent occlusion. Delayed, asymptomatic stent occlusion was seen in 1 patient (3%) after 49 days. Asymptomatic periinterventional distal emboli occurred in 2 patients (6%), 1 patient experienced a transient ischemic attack 79 days after the procedure and 1 patient (3%) developed sICH. Favorable clinical outcome (mRS 0-2) at 3 months was achieved in 12 patients (36%) and the mortality rate was 24%. CONCLUSION The CGuard use in emergencies was technically feasible, the safety has to be confirmed by further multicentric studies.
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Sýkora J, Zeleňák K, Vorčák M, Števík M, Sýkorová M, Sivák J, Rovňák M, Zapletalová J, Mužík J, Šinák I, Kurča E, Meyer L, Fiehler J. Comparison of Restenosis Risk in Single-Layer versus Dual-Layer Carotid Stents: A Duplex Ultrasound Evaluation. Cardiovasc Intervent Radiol 2022; 45:1257-1266. [PMID: 35798859 DOI: 10.1007/s00270-022-03200-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 06/04/2022] [Indexed: 01/22/2023]
Abstract
PURPOSE The aim of this study was to report intermediate-term results of duplex ultrasound follow-up of carotid artery stenting performed with the dual-layer stent as compared to concurrent patients treated with other commercially available single-layer carotid stents. MATERIALS AND METHODS A single centre, retrospective, nonrandomized study including 162 non-consecutive patients with 199 implanted carotid stents treated over a 7-year period was conducted. Patients with at least one ultrasound examination after treatment were included. Procedural and follow-up data for patients treated with the dual-layer stent implantation (83 stents) vs first-generation carotid stents implantations (116 stents) were compared. RESULTS The median follow-up time was 24.0 months (IQR 10-32 months) for dual-layer stents and 27.5 months (IQR 10.3-59 months) for single-layer stents. The rate of severe restenosis was significantly higher in the dual-layer stent group than in the single-layer group (13.3% [11/83] vs 3.4% [4/116], p = 0.01). Seven reinterventions were performed in 5 patients with dual-layer stents. The rate of reintervention was significantly higher compared to no reinterventions in single-layer stents (6% [5/83] vs 0% [0/116], p = 0.012). Patients with restenosis had significantly higher presence of dyslipidaemia (100% [12/12] vs 63.3% [95/150], p = 0.009). CONCLUSIONS In this real-world cohort of patients undergoing carotid artery stenting, the patients treated with low-profile dual-layer micromesh stent showed higher rates of restenosis and reinterventions compared to first-generation single-layer stents.
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Affiliation(s)
- Ján Sýkora
- Clinic of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Kollárova 2, 036 59, Martin, Slovakia.,Department of Radiology, Faculty of Medicine and Dentistry, Palacky University Olomouc, I. P. Pavlova 185/6, 77520, Olomouc, Czech Republic
| | - Kamil Zeleňák
- Clinic of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Kollárova 2, 036 59, Martin, Slovakia.
| | - Martin Vorčák
- Clinic of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Kollárova 2, 036 59, Martin, Slovakia
| | - Martin Števík
- Clinic of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Kollárova 2, 036 59, Martin, Slovakia
| | - Martina Sýkorová
- Vaša Ambulancia, s. r. o., Prieložtek 1, 036 01, Martin, Slovakia
| | - Jozef Sivák
- Department of Radiology, Faculty of Medicine and Dentistry, Palacky University Olomouc, I. P. Pavlova 185/6, 77520, Olomouc, Czech Republic.,Middle-Slovak Institute of Cardiovascular Diseases, Cesta k nemocnici 1, 974 01, Banská Bystrica, Slovakia
| | - Marek Rovňák
- Orthopedic Clinic, Comenius University's Jessenius Faculty of Medicine and University Hospital, Kollárova 2, 036 59, Martin, Slovakia
| | - Jana Zapletalová
- Department of Medical Biophysics, Faculty of Medicine and Dentistry, Palacký University Olomouc, Hněvotínská 976/3, 775 15, Olomouc, Czech Republic
| | - Juraj Mužík
- Department of Geotechnics, Faculty of Civil Engineering, University of Žilina, Univerzitná, 8215/1, 010 26, Žilina, Slovakia
| | - Igor Šinák
- Department of Vascular Surgery, University Hospital, Kollárova 2, 036 59, Martin, Slovakia
| | - Egon Kurča
- Clinic of Neurology, University Hospital, Kollárova 2, 036 59, Martin, Slovakia
| | - Lukas Meyer
- Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251, Hamburg, Germany
| | - Jens Fiehler
- Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251, Hamburg, Germany
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Carvalho P, Coelho A, Mansilha A. Effectiveness and safety of dual-layer stents in carotid artery disease: a systematic review. INT ANGIOL 2020; 40:97-104. [PMID: 33337115 DOI: 10.23736/s0392-9590.20.04553-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Carotid artery stenting (CAS) has emerged as a minimally invasive alternative to carotid endarterectomy (CEA) in atherosclerotic carotid artery disease, even though the risk for procedural stroke after CAS remains significantly higher. Recently, in order to reduce embolic cerebral events after CAS, a new generation of dual-layer stents (DLS) has been developed. This review aimed to perform a detailed analysis of the available evidence on safety and efficacy of DLS in both symptomatic and asymptomatic atherosclerotic carotid artery stenosis. EVIDENCE ACQUISITION A systematic review was conducted according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The primary endpoint was the 30-day rate of myocardial infarction (MI), stroke and death. Secondary outcomes included rate and timing of stent occlusion/restenosis. EVIDENCE SYNTHESIS A total of 20 articles with 1193 patients were included. Thirty-day MI ranged from 0-5%, 30-day stroke ranged from 0-10.5% and 30-day mortality ranged from 0-10%. Stent occlusion rate ranged from 0-52.4%, the majority of which occurred intraprocedurally (N.=50; 61.7%), in emergency treated patients. The incidence of new ipsilateral cerebral ischemic lesions after CAS with DLS was reported in five studies, ranging from 5.5-37%. CONCLUSIONS Despite the theoretic advantage of reducing the risk for procedural embolic events when compared to conventional stents, high quality evidence is scarce. Also, safety issues regarding DLS in the emergency setting have been raised, particularly for thrombotic complications. Additional data from well-designed Randomized Controlled Trials are needed to assert the true value of DLS.
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Affiliation(s)
| | - Andreia Coelho
- Faculty of Medicine, University of Porto, Porto, Portugal.,Department of Angiology and Vascular Surgery, Hospital Center of Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Armando Mansilha
- Faculty of Medicine, University of Porto, Porto, Portugal.,Department of Angiology and Vascular Surgery, University Hospital Center of São João, Porto, Portugal
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9
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Zevallos CB, Farooqui M, Quispe-Orozco D, Mendez-Ruiz A, Patterson M, Below K, Martins SO, Mansour OY, Mont'Alverne F, Nguyen TN, Lemme L, Siddiqui AH, Fraser JF, Jadhav AP, Zaidat OO, Ortega-Gutierrez S. Proximal Internal Carotid artery Acute Stroke Secondary to tandem Occlusions (PICASSO) international survey. J Neurointerv Surg 2020; 13:1106-1110. [PMID: 33323501 DOI: 10.1136/neurintsurg-2020-017025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 11/19/2020] [Accepted: 11/24/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND While mechanical thrombectomy (MT) is the standard of care for large vessel occlusion strokes, the optimal management of tandem occlusions (TO) remains uncertain. We aimed to determine the current practice patterns among stroke physicians involved in the treatment of TO during MT. METHODS We distributed an online survey to neurovascular practitioners (stroke neurologists, neurointerventionalists, neurosurgeons, and radiologists), members of professional societies. After 2 months the site was closed and data were extracted and analyzed. We divided respondents into acute stenting and delayed treatment groups and responses were compared between the two groups. RESULTS We received 220 responses from North America (48%), Latin America (28%), Asia (15%), Europe (5%), and Africa (4%). Preferred timing for cervical revascularization varied among respondents; 51% preferred treatment in a subsequent procedure during the same hospitalization whereas 39% preferred to treat during MT. Angioplasty and stenting (41%) was the preferred technique, followed by balloon angioplasty and local aspiration (38%). The risk of intracerebral hemorrhage was the most compelling reason for not stenting acutely (68%). There were no significant differences among practice characteristics and timing groups. Most practitioners (70%) agreed that there is equipoise regarding the optimal endovascular treatment of cervical lesions in TO; hence, 77% would participate in a randomized controlled trial. CONCLUSIONS The PICASSO survey demonstrates multiple areas of uncertainty regarding the medical and endovascular management of TOs. Experts acknowledged the need for further evidence and their willingness to participate in a randomized controlled trial to evaluate the best treatment for the cervical TO lesion.
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Affiliation(s)
- Cynthia B Zevallos
- Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Mudassir Farooqui
- Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | | | - Alan Mendez-Ruiz
- Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Mary Patterson
- Neurology, Mercy Health St Vincent Hospital, Toledo, Ohio, USA
| | - Kristine Below
- Neurology, Mercy Health St Vincent Hospital, Toledo, Ohio, USA
| | - Sheila O Martins
- Neurology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Ossama Y Mansour
- Neurology, Stroke and NeuroInterventional Unit, Alexandria University Faculty of Medicine, Alexandria, Egypt
| | | | - Thanh N Nguyen
- Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Luis Lemme
- Interventional Neuroradiology, Centro Endovascular Neurologico Buenos Aires, Buenos Aires, Argentina
| | - Adnan H Siddiqui
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Justin F Fraser
- Neurological Surgery, University of Kentucky, Lexington, Kentucky, USA
| | | | - Osama O Zaidat
- Neuroscience, St Vincent Mercy Hospital, Toledo, Indiana, USA
| | - Santiago Ortega-Gutierrez
- Division of Neurointerventional Surgery-Interventional Neuroradiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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10
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Poppe AY, Jacquin G, Roy D, Stapf C, Derex L. Tandem Carotid Lesions in Acute Ischemic Stroke: Mechanisms, Therapeutic Challenges, and Future Directions. AJNR Am J Neuroradiol 2020; 41:1142-1148. [PMID: 32499251 DOI: 10.3174/ajnr.a6582] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 03/17/2020] [Indexed: 11/07/2022]
Abstract
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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Affiliation(s)
- A Y Poppe
- From the Departments of Medicine (Neurology) (A.Y.P., G.J., C.S.) .,Neurovascular Group (A.Y.P., G.J., C.S.), Axe Neurosciences, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - G Jacquin
- From the Departments of Medicine (Neurology) (A.Y.P., G.J., C.S.).,Neurovascular Group (A.Y.P., G.J., C.S.), Axe Neurosciences, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - D Roy
- Radiology (Neuroradiology) (D.R.), Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - C Stapf
- From the Departments of Medicine (Neurology) (A.Y.P., G.J., C.S.).,Neurovascular Group (A.Y.P., G.J., C.S.), Axe Neurosciences, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - L Derex
- Stroke Center (L.D.), Department of Neurology, Neurological Hospital, Hospices Civils de Lyon, Lyon, France.,EA 7425 HESPER (L.D.), Health Services and Performance Research, Claude Bernard Lyon 1 University, Lyon, France
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11
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Ozpeynirci Y, Capatana C, Rosskopf J, Schmitz BL, Hamann GF, Braun M. Emergency carotid artery revascularization using Casper-RX stent: A single-center experience. Interv Neuroradiol 2020; 26:433-438. [PMID: 32046548 DOI: 10.1177/1591019919900879] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Casper-RX (MicroVention, Aliso Viejo, California, USA) is a dual-layer closed cell stent recently introduced as a carotid artery revascularization device. Although its effectiveness and safety has been proved in elective cases, there are contradictive results regarding its patency in emergency settings. The purpose of the study is to present our single-center experience with the Casper-RX stent in the emergency interventions. PATIENTS AND METHODS Consecutive patients who underwent emergency carotid artery stenting using Casper-RX system with or without additional intracranial thrombectomy between August 2016 and June 2019 at our institution were included. Primary end point was the short-term patency of the carotid stents evaluated before hospital discharge by use of Doppler ultrasonography. RESULTS Twenty-nine procedures performed on 28 patients were included in the study. All stents were patent on final angiograms. Acute stent occlusion was observed only in one case (3.4%) with a spontaneous cervical internal carotid artery dissection the day after the procedure. In 26 (89.6%) cases, an additional intracranial thrombectomy was performed with a successful recanalization rate of 96.1%. Seven adverse events occurred peri-/post-procedural: two cases (6.9%) with iatrogenic dissection of distal cervical internal carotid artery during intracranial thrombectomy, two parenchymal hematoma type 2 (6.8%), and three patients (10.3%) developed massive infarction. CONCLUSION This study supports the safety and efficacy of the Casper-RX stent in emergency endovascular carotid artery revascularization procedures.
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Affiliation(s)
- Yigit Ozpeynirci
- Department of Neuroradiology, Ludwig Maximilian University, Munich, Germany
| | - Cristian Capatana
- Department of Neuroradiology, Bezirkskrankenhaus Gunzburg, Gunzburg, Germany
| | | | - Bernd L Schmitz
- Department of Neuroradiology, Bezirkskrankenhaus Gunzburg, Gunzburg, Germany.,Department of Neuroradiology, Ulm University, Ulm, Germany
| | - Gerhard F Hamann
- Clinic for Neurology and Neurologic Rehabilitation, Bezirkskrankenhaus Gunzburg, Gunzburg, Germany
| | - Michael Braun
- Department of Neuroradiology, Bezirkskrankenhaus Gunzburg, Gunzburg, Germany
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12
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de Vries EE, Vonken EJ, de Borst GJ. Response by de Vries et al to Letter Regarding Article, "Short-Term Double Layer Mesh Stent Patency for Emergent or Elective Carotid Artery Stenting: A Single Center Experience". Stroke 2019; 50:e435. [PMID: 31679503 DOI: 10.1161/strokeaha.119.027656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Evelien E de Vries
- Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands
| | - Evert J Vonken
- Department of Radiology, University Medical Center Utrecht, the Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands
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13
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Pfaff JAR, Maurer C, Broussalis E, Janssen H, Blanc R, Dargazanli C, Costalat V, Piotin M, Runck F, Berlis A, Killer-Oberpfalzer M, Hensler JT, Bendszus M, Wodarg F, Möhlenbruch MA. Acute thromboses and occlusions of dual layer carotid stents in endovascular treatment of tandem occlusions. J Neurointerv Surg 2019; 12:33-37. [PMID: 31308199 DOI: 10.1136/neurintsurg-2019-015032] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 05/15/2019] [Accepted: 05/15/2019] [Indexed: 11/03/2022]
Abstract
PURPOSE To evaluate the occurrence and risk factors of acute in-stent thrombosis or stent occlusion in patients with tandem occlusions receiving intracranial mechanical thrombectomy and emergent extracranial internal carotid artery stenting with a dual layer carotid stent. METHODS Multicenter retrospective data collection and analysis of stroke databases of seven comprehensive stroke centers from three European countries. RESULTS Overall, 160 patients (mean (SD) age 66 (12) years; 104 men (65%); median (IQR) baseline NIHSS 14 (9-18); IV lysis, n=97 (60.6%)) were treated for a cervical carotid artery occlusion or stenosis using a CASPER stent (MicroVention), and received mechanical thrombectomy for an intracranial occlusion between April 2014 and November 2018. During the procedure or within 72 hours, formation of thrombus and complete occlusion of the CASPER stent was observed in 33/160 (20.8%) and in 12/160 patients (7.5%), respectively. In 25/33 (75.8%) and in 9/12 patients (75%), respectively, this occurred during the procedure. No statistically significant difference was observed between patients with and without thrombus formation with regard to pre-existing long term medication with anticoagulants or intraprocedural administration of heparin, acetylsalicylic acid (ASA), or heparin and ASA. Favorable early neurological outcome was similar in patients with (n=15; 45.5%) and without (n=63; 49.6%) thrombus formation at the CASPER stent. CONCLUSION Acute thrombosis or occlusion of CASPER stents in thrombectomy patients receiving emergent extracranial internal carotid artery stenting for tandem occlusions were observed more often during the procedure than within 72 hours of follow-up, were less frequent then previously reported, and showed no impact on early neurological outcome.
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Affiliation(s)
- Johannes A R Pfaff
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Christoph Maurer
- Department of Diagnostic and Interventionell Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Bayern, Germany
| | - Erasmia Broussalis
- Institute of Neurointervention, Paracelsus Medical University Salzburg, Salzburg, Salzburg, Austria.,Department of Neurology, Paracelsus Medical University Salzburg, Salzburg, Salzburg, Austria
| | - Hendrik Janssen
- Department of Neuroradiology, Paracelsus Medical University, Nuremberg, Germany.,Department of Neuroradiology, Klinikum Ingolstadt, Ingolstadt, Germany
| | - Raphael Blanc
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - Cyril Dargazanli
- Department of Neuroradiology, Hospital Güi-de-Chauliac, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Vincent Costalat
- Department of Neuroradiology, Hospital Güi-de-Chauliac, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Michel Piotin
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - Frank Runck
- Department of Diagnostic and Interventionell Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Bayern, Germany
| | - Ansgar Berlis
- Department of Diagnostic and Interventionell Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Bayern, Germany
| | - Monika Killer-Oberpfalzer
- Institute of Neurointervention, Paracelsus Medical University Salzburg, Salzburg, Salzburg, Austria.,Department of Neurology, Paracelsus Medical University Salzburg, Salzburg, Salzburg, Austria
| | - Johannes Tobias Hensler
- Department of Radiology and Neuroradiology, UniversityHospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Fritz Wodarg
- Department of Radiology and Neuroradiology, UniversityHospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
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