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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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2
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Di Donna A, Muto G, Giordano F, Muto M, Guarnieri G, Servillo G, De Mase A, Spina E, Leone G. Diagnosis and management of tandem occlusion in acute ischemic stroke. Eur J Radiol Open 2023; 11:100513. [PMID: 37609048 PMCID: PMC10440394 DOI: 10.1016/j.ejro.2023.100513] [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: 06/05/2023] [Revised: 07/31/2023] [Accepted: 08/07/2023] [Indexed: 08/24/2023] Open
Abstract
Approximately 20-30% of patients with acute ischemic stroke, caused by large intracranial vessel occlusion, have a tandem lesion, defined as simultaneous presence of high-grade stenosis or occlusion of the cervical internal carotid artery and thromboembolic occlusion of the intracranial terminal internal carotid artery or its branches, usually the middle cerebral artery. Patients with tandem lesions have usually worse outcomes than patients with single intracranial occlusions, and intravenous thrombolysis is less effective in these patients. Although endovascular thrombectomy is currently a cornerstone therapy in the management of acute ischemic stroke due to large vessel occlusion, the optimal management of extracranial carotid lesions in tandem occlusion remains controversial. Acute placement of a stent in the cervical carotid artery lesion is the most used therapeutic strategy compared with stented balloon angioplasty and thrombectomy alone without carotid artery revascularization; however, treatment strategies in these patients are often more complex than with single occlusion, so treatment decisions can change based on clinical and technical considerations. The aim of this review is to analyze the results of different studies and trials, investigating the periprocedural neurointerventional management of patients with tandem lesions and the safety, efficacy of the different technical strategies available as well as their impact on the clinical outcome in these patients, to strengthen current recommendations and thus optimize patient care.
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Affiliation(s)
- Antonio Di Donna
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Gianluca Muto
- Division of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - Flavio Giordano
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Massimo Muto
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Gianluigi Guarnieri
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Giovanna Servillo
- Unit of Neurorology and Stroke Unit, Department of Emergency and Acceptance, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Antonio De Mase
- Unit of Neurorology and Stroke Unit, Department of Emergency and Acceptance, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Emanuele Spina
- Unit of Neurorology and Stroke Unit, Department of Emergency and Acceptance, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Giuseppe Leone
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
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3
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Farooqui M, Divani AA, Galecio-Castillo M, Hassan AE, Jumaa MA, Ribo M, Abraham M, Petersen N, Fifi J, Guerrero WR, Malik AM, Siegler JE, Nguyen TN, Sheth SA, Yoo AJ, Linares G, Janjua N, Quispe-Orozco D, Ikram A, Tekle WG, Zaidi SF, Zevallos CB, Rizzo F, Barkley T, De Leacy R, Khalife J, Abdalkader M, Salazar-Marioni S, Soomro J, Gordon W, Rodriguez-Calienes A, Vivanco-Suarez J, Turabova C, Mokin M, Yavagal DR, Ortega-Gutierrez S. Safety Outcomes of Antiplatelet Therapy During Endovascular Treatment of Tandem Lesions in Acute Ischemic Stroke Patients. Transl Stroke Res 2023:10.1007/s12975-023-01214-9. [PMID: 38017258 PMCID: PMC11271812 DOI: 10.1007/s12975-023-01214-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 10/28/2023] [Accepted: 10/30/2023] [Indexed: 11/30/2023]
Abstract
Risk of hemorrhage remains with antiplatelet medications required with carotid stenting during endovascular therapy (EVT) for tandem lesion (TLs). We evaluated the safety of antiplatelet regimens in EVT of TLs. This multicenter study included anterior circulation TL patients from 2015 to 2020, stratified by periprocedural EVT antiplatelet strategy: (1) no antiplatelets, (2) single oral, (3) dual oral, and (4) intravenous IV (in combination with single or dual oral). Primary outcome was symptomatic intracranial hemorrhage (sICH). Secondary outcomes were any hemorrhage, favorable functional status (mRS 0-2) at 90 days, successful reperfusion (mTICI score ≥ 2b), in-stent thrombosis, and mortality at 90 days. Of the total 691 patients, 595 were included in the final analysis. One hundred and nineteen (20%) received no antiplatelets, 134 (22.5%) received single oral, 152 (25.5%) dual oral, and 196 (31.9%) IV combination. No significant association was found for sICH (ref: no antiplatelet: 5.7%; single:4.2%; aOR 0.64, CI 0.20-2.06, p = 0.45, dual:1.9%; aOR 0.35, CI 0.09-1.43, p = 0.15, IV combination: 6.1%; aOR 1.05, CI 0.39-2.85, p = 0.92). No association was found for parenchymal or petechial hemorrhage. Odds of successful reperfusion were significantly higher with dual oral (aOR 5.85, CI 2.12-16.14, p = 0.001) and IV combination (aOR 2.35, CI 1.07-5.18, p = 0.035) compared with no antiplatelets. Odds of excellent reperfusion (mTICI 2c/3) were significantly higher for cangrelor (aOR 4.41; CI 1.2-16.28; p = 0.026). No differences were noted for mRS 0-2 at 90 days, in-stent thrombosis, and mortality rates. Administration of dual oral and IV (in combination with single or dual oral) antiplatelets during EVT was associated with significantly increased odds of successful reperfusion without an increased rate of symptomatic hemorrhage or mortality in patients with anterior circulation TLs.
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Affiliation(s)
- Mudassir Farooqui
- Department of Neurology, Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Afshin A Divani
- Department of Neurology, University of New Mexico Health Science Center, Albuquerque, NM, USA
| | - Milagros Galecio-Castillo
- Department of Neurology, Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Ameer E Hassan
- Department of Neurology, Valley Baptist Medical Center / University of Texas Rio Grande Valley, Harlingen, TX, USA
| | | | - Marc Ribo
- Department of Neurology, Hospital Vall d'Hebron, Barcelona, Barcelona, Spain
| | - Michael Abraham
- Department of Neurology, University of Kansas Medical Center, Kansas, KS, USA
| | - Nils Petersen
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Johanna Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Waldo R Guerrero
- Department of Neurology and Brain Repair, University of South Florida, Tampa, FL, USA
| | - Amer M Malik
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - James E Siegler
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden, NJ, 08103, USA
| | - Thanh N Nguyen
- Department of Neurology, Boston Medical Center, Boston, USA
| | - Sunil A Sheth
- Department of Neurology, UT Health McGovern Medical School, Houston, TX, USA
| | - Albert J Yoo
- Texas Stroke Institute, Dallas-Fort Worth, Forth Worth, TX, USA
| | | | - Nazli Janjua
- Asia Pacific Comprehensive Stroke Institute, Pomona Valley Hospital Medical Center, Pomona, CA, USA
| | - Darko Quispe-Orozco
- Department of Neurology, Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Asad Ikram
- Department of Neurology, University of New Mexico Health Science Center, Albuquerque, NM, USA
| | - Wondewossen G Tekle
- Department of Neurology, Valley Baptist Medical Center / University of Texas Rio Grande Valley, Harlingen, TX, USA
| | - Syed F Zaidi
- Department of Neurology, ProMedica Toledo Hospital, Toledo, OH, USA
| | - Cynthia B Zevallos
- Department of Neurology, Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Federica Rizzo
- Department of Neurology, Hospital Vall d'Hebron, Barcelona, Barcelona, Spain
| | - Tiffany Barkley
- Department of Neurology, University of Kansas Medical Center, Kansas, KS, USA
| | - Reade De Leacy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jane Khalife
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden, NJ, 08103, USA
| | | | | | - Jazba Soomro
- Texas Stroke Institute, Dallas-Fort Worth, Forth Worth, TX, USA
| | - Weston Gordon
- Department of Neurology, Saint Louis University, St. Louis, MO, USA
| | - Aaron Rodriguez-Calienes
- Department of Neurology, Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Juan Vivanco-Suarez
- Department of Neurology, Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Charoskhon Turabova
- Asia Pacific Comprehensive Stroke Institute, Pomona Valley Hospital Medical Center, Pomona, CA, USA
| | - Maxim Mokin
- Department of Neurology and Brain Repair, University of South Florida, Tampa, FL, USA
| | - Dileep R Yavagal
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Santiago Ortega-Gutierrez
- Department of Neurology, Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, USA.
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4
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Rodriguez-Calienes A, Galecio-Castillo M, Farooqui M, Hassan AE, Jumaa MA, Divani AA, Ribo M, Abraham M, Petersen NH, Fifi J, Guerrero WR, Malik AM, Siegler JE, Nguyen TN, Yoo AJ, Linares G, Janjua N, Quispe-Orozco D, Tekle WG, Alhajala H, Ikram A, Rizzo F, Qureshi A, Begunova L, Matsouka S, Vigilante N, Salazar-Marioni S, Abdalkader M, Gordon W, Soomro J, Turabova C, Vivanco-Suarez J, Mokin M, Yavagal DR, Jovin T, Sheth S, Ortega-Gutierrez S. Safety Outcomes of Mechanical Thrombectomy Versus Combined Thrombectomy and Intravenous Thrombolysis in Tandem Lesions. Stroke 2023; 54:2522-2533. [PMID: 37602387 PMCID: PMC10599264 DOI: 10.1161/strokeaha.123.042966] [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: 02/17/2023] [Accepted: 07/11/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND We aimed to describe the safety and efficacy of mechanical thrombectomy (MT) with or without intravenous thrombolysis (IVT) for patients with tandem lesions and whether using intraprocedural antiplatelet therapy influences MT's safety with IVT treatment. METHODS This is a subanalysis of a pooled, multicenter cohort of patients with acute anterior circulation tandem lesions treated with MT from 16 stroke centers between January 2015 and December 2020. Primary outcomes included symptomatic intracranial hemorrhage (sICH) and parenchymal hematoma type 2. Additional outcomes included hemorrhagic transformation, successful reperfusion (modified Thrombolysis in Cerebral Infarction score 2b-3), complete reperfusion (modified Thrombolysis in Cerebral Infarction score 3), favorable functional outcome (90-day modified Rankin Scale score 0-2), excellent functional outcome (90-day modified Rankin Scale score 0-1), in-hospital mortality, and 90-day mortality. RESULTS Of 691 patients, 512 were included (218 underwent IVT+MT and 294 MT alone). There was no difference in the risk of sICH (adjusted odds ratio [aOR], 1.22 [95% CI, 0.60-2.51]; P=0.583), parenchymal hematoma type 2 (aOR, 0.99 [95% CI, 0.47-2.08]; P=0.985), and hemorrhagic transformation (aOR, 0.95 [95% CI, 0.62-1.46]; P=0.817) between the IVT+MT and MT alone groups after adjusting for confounders. Administration of IVT was associated with an increased risk of sICH in patients who received intravenous antiplatelet therapy (aOR, 3.04 [95% CI, 0.99-9.37]; P=0.05). The IVT+MT group had higher odds of a 90-day modified Rankin Scale score 0 to 2 (aOR, 1.72 [95% CI, 1.01-2.91]; P=0.04). The odds of successful reperfusion, complete reperfusion, 90-day modified Rankin Scale score 0 to 1, in-hospital mortality, or 90-day mortality did not differ between the IVT+MT versus MT alone groups. CONCLUSIONS Our study showed that the combination of IVT with MT for tandem lesions did not increase the overall risk of sICH, parenchymal hematoma type 2, or overall hemorrhagic transformation independently of the cervical revascularization technique used. However, intraprocedural intravenous antiplatelet therapy during acute stent implantation might be associated with an increased risk of sICH in patients who received IVT before MT. Importantly, IVT+MT treatment was associated with a higher rate of favorable functional outcomes at 90 days.
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Affiliation(s)
- Aaron Rodriguez-Calienes
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City
- Department of Neuroscience, Clinical Effectiveness and Public Health Research Group, Universidad Científica del Sur, Lima, Peru
| | | | - Mudassir Farooqui
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City
| | - Ameer E. Hassan
- Department of Neurology, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX
| | | | - Afshin A. Divani
- Department of Neurology, University of New Mexico Health Science Center, Albuquerque
| | - Marc Ribo
- Department of Neurology, Hospital Vall d’Hebron, Barcelona, Spain
| | - Michael Abraham
- Department of Neurology, University of Kansas Medical Center
| | - Nils H. Petersen
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Johanna Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York
| | - Waldo R. Guerrero
- Department of Neurology and Brain Repair, University of South Florida, Tampa
| | - Amer M. Malik
- Department of Neurology, University of Miami Miller School of Medicine, FL
| | - James E. Siegler
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ
- Cooper Medical School of Rowan University, Candem, NJ
| | | | | | | | - Nazli Janjua
- Asia Pacific Comprehensive Stroke Institute, Pomona Valley Hospital Medical Center, CA
| | - Darko Quispe-Orozco
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City
| | - Wondwossen G. Tekle
- Department of Neurology, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX
| | | | - Asad Ikram
- Department of Neurology, University of New Mexico Health Science Center, Albuquerque
| | - Federica Rizzo
- Department of Neurology, Hospital Vall d’Hebron, Barcelona, Spain
| | - Abid Qureshi
- Department of Neurology, University of Kansas Medical Center
| | - Liza Begunova
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Stavros Matsouka
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York
| | | | | | | | - Weston Gordon
- Department of Neurology, Saint Louis University, St. Louis, MO
| | | | - Charoskon Turabova
- Asia Pacific Comprehensive Stroke Institute, Pomona Valley Hospital Medical Center, CA
| | - Juan Vivanco-Suarez
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City
| | - Maxim Mokin
- Department of Neurology and Brain Repair, University of South Florida, Tampa
| | - Dileep R. Yavagal
- Department of Neurology, University of Miami Miller School of Medicine, FL
| | - Tudor Jovin
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ
| | - Sunil Sheth
- Department of Neurology, UT Health McGovern Medical School, Houston, TX
| | - Santiago Ortega-Gutierrez
- Department of Neurology, Neurosurgery & Radiology, University of Iowa Hospitals and Clinics, Iowa City
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5
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Siddiq F, Bhagavan S, Ishfaq MF, Jaura A, Bhatti IA, Gomez CR, Qureshi AI. Balloon-Assisted Catheterization of Occluded Carotid Artery (BOCA) Technique in Acute Stroke. Oper Neurosurg (Hagerstown) 2023; 25:190-198. [PMID: 37133290 DOI: 10.1227/ons.0000000000000723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 02/08/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND Acute ischemic stroke from tandem occlusion of internal carotid artery (ICA) poses a technical challenge to neurointerventionalists. OBJECTIVE To present a novel balloon-assisted catheterization of occluded carotid artery (BOCA) technique used for rapid and effective catheterization of occluded/critically stenosed ICA in tandem occlusion. METHODS A retrospective review of 10 patients with tandem carotid occlusion, treated with BOCA technique for revascularization between July 2020 and June 2021, was performed. Clinical, radiographic, and procedural data; details of BOCA technique; complications; and outcomes were reviewed. RESULTS Of the 10 patients, 8 (80%) had complete occlusion of the cervical ICA and the remaining 2 had high-grade stenosis with poor intracranial flow. The mean age was 63.2 years. The mean presenting NIH Stroke Scale was 13.4. The BOCA technique resulted in recanalization of ICA in all patients and allowed mechanical thrombectomy of middle cerebral artery. Thrombolysis in cerebral infarction grade 2b/3 was achieved in all 10 patients. The mean groin-to-reperfusion time was 41.4 minutes. The mean internal carotid artery stenosis was 99.7% preoperatively and 41.1% postoperatively. Only one patient needed stent at the end of the procedure because of dissection. CONCLUSION The BOCA technique can be used in distal first approach for acute stroke from tandem ICA occlusion. This technique allows direct guide catheterization of occluded ICA by tracking over a partially inflated balloon.
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Affiliation(s)
- Farhan Siddiq
- Department of Neurosurgery, University of Missouri, Columbia, Missouri, USA
| | - Sachin Bhagavan
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - M Fawad Ishfaq
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Attiya Jaura
- Department of Neurosurgery, University of Missouri, Columbia, Missouri, USA
| | | | - Camilo R Gomez
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri, USA
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6
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Farooqui M, Zaidat OO, Hassan AE, Quispe-Orozco D, Petersen N, Divani AA, Ribo M, Abraham M, Fifi J, Guerrero WR, Malik AM, Siegler JE, Nguyen TN, Sheth S, Yoo AJ, Linares G, Janjua N, Galecio-Castillo M, Tekle WG, Ringheanu VM, Oliver M, Dawod G, Kobsa J, Prasad A, Ikram A, Lin E, Below K, Zevallos CB, Gadea MO, Qureshi A, Dajles A, Matsoukas S, Rana A, Abdalkader M, Salazar-Marioni S, Soomro J, Gordon W, Vivanco-Suarez J, Turabova C, Mokin M, Yavagal DR, Jumaa MA, Ortega-Gutierrez S. Functional and Safety Outcomes of Carotid Artery Stenting and Mechanical Thrombectomy for Large Vessel Occlusion Ischemic Stroke With Tandem Lesions. JAMA Netw Open 2023; 6:e230736. [PMID: 36857054 PMCID: PMC9978940 DOI: 10.1001/jamanetworkopen.2023.0736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 01/06/2023] [Indexed: 03/02/2023] Open
Abstract
Importance Approximately 10% to 20% of large vessel occlusion (LVO) strokes involve tandem lesions (TLs), defined as concomitant intracranial LVO and stenosis or occlusion of the cervical internal carotid artery. Mechanical thrombectomy (MT) may benefit patients with TLs; however, optimal management and procedural strategy of the cervical lesion remain unclear. Objective To evaluate the association of carotid artery stenting (CAS) vs no stenting and medical management with functional and safety outcomes among patients with TL-LVOs. Design, Setting, and Participants This cross-sectional study included consecutive patients with acute anterior circulation TLs admitted across 17 stroke centers in the US and Spain between January 1, 2015, and December 31, 2020. Data analysis was performed from August 2021 to February 2022. Inclusion criteria were age of 18 years or older, endovascular therapy for intracranial occlusion, and presence of extracranial internal carotid artery stenosis (>50%) demonstrated on pre-MT computed tomography angiography, magnetic resonance angiography, or digital subtraction angiography. Exposures Patients with TLs were divided into CAS vs nonstenting groups. Main Outcomes and Measures Primary clinical and safety outcomes were 90-day functional independence measured by a modified Rankin Scale (mRS) score of 0 to 2 and symptomatic intracranial hemorrhage (sICH), respectively. Secondary outcomes were successful reperfusion (modified Thrombolysis in Cerebral Infarction score ≥2b), discharge mRS score, ordinal mRS score, and mortality at 90 days. Results Of 685 patients, 623 (mean [SD] age, 67 [12.2] years; 406 [65.2%] male) were included in the analysis, of whom 363 (58.4%) were in the CAS group and 260 (41.6%) were in the nonstenting group. The CAS group had a lower proportion of patients with atrial fibrillation (38 [10.6%] vs 49 [19.2%], P = .002), a higher proportion of preprocedural degree of cervical stenosis on digital subtraction angiography (90%-99%: 107 [32.2%] vs 42 [20.5%], P < .001) and atherosclerotic disease (296 [82.0%] vs 194 [74.6%], P = .003), a lower median (IQR) National Institutes of Health Stroke Scale score (15 [10-19] vs 17 [13-21], P < .001), and similar rates of intravenous thrombolysis and stroke time metrics when compared with the nonstenting group. After adjustment for confounders, the odds of favorable functional outcome (adjusted odds ratio [aOR], 1.67; 95% CI, 1.20-2.40; P = .007), favorable shift in mRS scores (aOR, 1.46; 95% CI, 1.02-2.10; P = .04), and successful reperfusion (aOR, 1.70; 95% CI, 1.02-3.60; P = .002) were significantly higher for the CAS group compared with the nonstenting group. Both groups had similar odds of sICH (aOR, 0.90; 95% CI, 0.46-2.40; P = .87) and 90-day mortality (aOR, 0.78; 95% CI, 0.50-1.20; P = .27). No heterogeneity was noted for 90-day functional outcome and sICH in prespecified subgroups. Conclusions and Relevance In this multicenter, international cross-sectional study, CAS of the cervical lesion during MT was associated with improvement in functional outcomes and reperfusion rates without an increased risk of sICH and mortality in patients with TLs.
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Affiliation(s)
- Mudassir Farooqui
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City
| | - Osama O. Zaidat
- Department of Neurology, Saint Vincent Mercy Hospital, Toledo, Ohio
| | - Ameer E. Hassan
- Department of Neurology, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen
| | - Darko Quispe-Orozco
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City
| | - Nils Petersen
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Afshin A. Divani
- Department of Neurology, University of New Mexico Health Science Center, Albuquerque
| | - Marc Ribo
- Department of Neurology, Hospital Vall d’Hebron, Barcelona, Barcelona, Spain
| | - Michael Abraham
- Department of Neurology, University of Kansas Medical Center, Kansas City
| | - Johanna Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Waldo R. Guerrero
- Department of Neurology and Brain Repair, University of South Florida, Tampa
| | - Amer M. Malik
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida
| | - James E. Siegler
- Cooper Neurological Institute, Cooper University Hospital, Camden, New Jersey
| | - Thanh N. Nguyen
- Department of Neurology, Boston Medical Center, Boston, Massachusetts
| | - Sunil Sheth
- Department of Neurology, UTHealth McGovern Medical School, Houston, Texas
| | | | - Guillermo Linares
- Department of Neurology, Saint Louis University School of Medicine, St Louis, Missouri
| | - Nazli Janjua
- Asia Pacific Comprehensive Stroke Institute, Pomona Valley Hospital Medical Center, Pomona, California
| | | | - Wondewossen G. Tekle
- Department of Neurology, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen
| | - Victor M. Ringheanu
- Department of Clinical Research, Valley Baptist Medical Center, Harlingen, Texas
| | - Marion Oliver
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
| | - Giana Dawod
- Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Jessica Kobsa
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Ayush Prasad
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Asad Ikram
- Department of Neurology, University of New Mexico Health Science Center, Albuquerque
| | - Eugene Lin
- Department of Neurology, Saint Vincent Mercy Hospital, Toledo, Ohio
| | - Kristine Below
- Department of Neurology, Saint Vincent Mercy Hospital, Toledo, Ohio
| | - Cynthia B. Zevallos
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City
| | - Marta Olivé Gadea
- Department of Neurology, Hospital Vall d’Hebron, Barcelona, Barcelona, Spain
| | - Abid Qureshi
- Department of Neurology, University of Kansas Medical Center, Kansas City
| | - Andres Dajles
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City
| | - Stavros Matsoukas
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ameena Rana
- Cooper Neurological Institute, Cooper University Hospital, Camden, New Jersey
| | | | | | | | - Weston Gordon
- Department of Neurology, Saint Louis University School of Medicine, St Louis, Missouri
| | - Juan Vivanco-Suarez
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City
| | - Charoskhon Turabova
- Asia Pacific Comprehensive Stroke Institute, Pomona Valley Hospital Medical Center, Pomona, California
| | - Maxim Mokin
- Department of Neurology and Brain Repair, University of South Florida, Tampa
| | - Dileep R. Yavagal
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida
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7
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Enriquez BAB, Nome T, Nome CG, Tennøe B, Lund CG, Beyer MK, Skjelland M, Aamodt AH. Predictors of outcome after endovascular treatment for tandem occlusions: a single center retrospective analysis. BMC Neurol 2023; 23:82. [PMID: 36849925 PMCID: PMC9969668 DOI: 10.1186/s12883-023-03127-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 02/15/2023] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND The endovascular treatment procedure in tandem occlusions (TO) is complex compared to single occlusion (SO) and optimal management remains uncertain. The aim of this study was to identify clinical and procedural factors that may be associated to efficacy and safety in the management of TO and compare functional outcome in TO and SO stroke patients. METHODS This is a retrospective single center study of medium (MeVO) and large vessel occlusion (LVO) of the anterior circulation. Clinical, imaging, and interventional data were analyzed to identify predictive factors for symptomatic intracranial hemorrhage (sICH) and functional outcome after endovascular treatment (EVT) in TO. Functional outcome in TO and SO patients was compared. RESULTS Of 662 anterior circulation stroke patients with MeVO and LVO stroke, 90 (14%) had TO. Stenting was performed in 73 (81%) of TO patients. Stent thromboses occurred in 8 (11%) patients. Successful reperfusion with modified thrombolysis in cerebral infarction (mTICI) ≥ 2b was achieved in 82 (91%). SICH occurred in seven (8%). The strongest predictors for sICH were diabetes mellitus and number of stent retriever passes. Good functional clinical outcome (mRS ≤ 2) at 90-day follow up was similar in TO and SO patients (58% vs 59% respectively). General anesthesia (GA) was associated with good functional outcome whereas hemorrhage in the infarcted tissue, lower mTICI score and history of smoking were associated with poor outcome. CONCLUSIONS The risk of sICH was increased in patients with diabetes mellitus and those with extra stent-retriever attempts. Functional clinical outcomes in patients with TO were comparable to patients with SO.
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Affiliation(s)
| | - Terje Nome
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway.
| | - Cecilie G. Nome
- grid.55325.340000 0004 0389 8485Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway ,grid.5510.10000 0004 1936 8921Division of Anatomy, Department of Molecular Medicine, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Bjørn Tennøe
- grid.55325.340000 0004 0389 8485Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Christian G. Lund
- grid.55325.340000 0004 0389 8485Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Mona K. Beyer
- grid.55325.340000 0004 0389 8485Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway ,grid.5510.10000 0004 1936 8921Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Mona Skjelland
- grid.55325.340000 0004 0389 8485Department of Neurology, Oslo University Hospital, Oslo, Norway ,grid.5510.10000 0004 1936 8921Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Anne Hege Aamodt
- grid.55325.340000 0004 0389 8485Department of Neurology, Oslo University Hospital, Oslo, Norway
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8
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Yu M, Ma Y, Ren H, Huang Y, Yin L, Ma L, Wang Y, Luo B, Wang Z. Emergent Management of Tandem Occlusions in Anterior Circulation Stroke: A Single-Centre Experience. World Neurosurg 2023; 170:e491-e499. [PMID: 36396050 DOI: 10.1016/j.wneu.2022.11.040] [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: 09/21/2022] [Revised: 11/09/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE For anterior circulation tandem occlusions, the optimal management strategy for extracranial carotid lesions is controversial. We aimed to compare the efficacy and safety of acute stenting (AS) with balloon angioplasty (BA) only. METHODS Clinical data were collected from 98 patients with anterior circulation tandem occlusion who underwent endovascular treatment at our center. Of these patients, 64 and 34 were assigned to the AS and BA groups, respectively. The clinical characteristics and outcome data of the 2 groups were analyzed and compared. RESULTS The proportion of patients with good outcomes was 59.2%. The AS group had a higher rate of successful recanalization (98.4% vs. 82.4%, P = 0.007) and a lower rate of occlusion of the responsible vessel at 90 days (14.1% vs. 32.4%, P = 0.039) than the BA group. The AS group was also significantly better than the BA group in terms of good outcomes (67.2% vs. 44.1%, P = 0.027), but there was no significant difference between the 2 groups in terms of 90-day mortality (6.3% vs. 8.8%, P = 0.691) and asymptomatic intracranial hemorrhage (6.3% vs. 5.9%, P = 1.000). Lower baseline National Institutes of Health Stroke Scale scores were associated with good outcomes (P < 0.001), and the presence of symptomatic intracranial hemorrhage was associated with 90-day mortality (P = 0.003). CONCLUSIONS Acute stent placement in patients with acute ischemic stroke due to anterior circulation tandem occlusion may have a better outcome than BA alone, and the safety of both approaches is comparable.
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Affiliation(s)
- Mingsheng Yu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China; Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Yuxiang Ma
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China; Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Hecheng Ren
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Ying Huang
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Long Yin
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Lin Ma
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Yubo Wang
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Bin Luo
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Zengguang Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.
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9
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Levitt MR, Barros G. The way out is through. J Neurointerv Surg 2022; 14:527. [DOI: 10.1136/neurintsurg-2022-019088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 11/05/2022]
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10
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Zevallos CB, Farooqui M, Quispe-Orozco D, Mendez-Ruiz A, Dajles A, Garg A, Galecio-Castillo M, Patterson M, Zaidat O, Ortega-Gutierrez S. Acute Carotid Artery Stenting Versus Balloon Angioplasty for Tandem Occlusions: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2022; 11:e022335. [PMID: 35023353 PMCID: PMC9238531 DOI: 10.1161/jaha.121.022335] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Despite thrombectomy having become the standard of care for large-vessel occlusion strokes, acute endovascular management in tandem occlusions, especially of the cervical internal carotid artery lesion, remains uncertain. We aimed to compare efficacy and safety of acute carotid artery stenting to balloon angioplasty alone on treating the cervical lesion in tandem occlusions. Similarly, we aimed to explore those outcomes' associations with technique approaches and use of thrombolysis. Methods and Results We performed a systematic review and meta-analysis to compare functional outcomes (modified Rankin Scale), reperfusion, and symptomatic intracranial hemorrhage and 3-month mortality. We explored the association of first approach (anterograde/retrograde) and use of thrombolysis with those outcomes as well. Two independent reviewers performed the screening, data extraction, and quality assessment. A random-effects model was used for analysis. Thirty-four studies were included in our systematic review and 9 in the meta-analysis. Acute carotid artery stenting was associated with higher odds of modified Rankin Scale score ≤2 (odds ratio [OR], 1.95 [95% CI, 1.24-3.05]) and successful reperfusion (OR, 1.89 [95% CI, 1.26-2.83]), with no differences in mortality or symptomatic intracranial hemorrhage rates. Moreover, a retrograde approach was significantly associated with modified Rankin Scale score ≤2 (OR, 1.72 [95% CI, 1.05-2.83]), and no differences were found on thrombolysis status. Conclusions Carotid artery stenting and a retrograde approach had higher odds of successful reperfusion and good functional outcomes at 3 months than balloon angioplasty and an anterograde approach, respectively, in patients with tandem occlusions. A randomized controlled trial comparing these techniques with structured antithrombotic regimens and safety outcomes will offer definitive guidance in the optimal management of this complex disease.
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Affiliation(s)
- Cynthia B Zevallos
- Department of Neurology University of Iowa Hospitals and Clinics Iowa City IA
| | - Mudassir Farooqui
- Department of Neurology University of Iowa Hospitals and Clinics Iowa City IA
| | - Darko Quispe-Orozco
- Department of Neurology University of Iowa Hospitals and Clinics Iowa City IA
| | - Alan Mendez-Ruiz
- Department of Neurology University of Iowa Hospitals and Clinics Iowa City IA
| | - Andres Dajles
- Department of Neurology University of Iowa Hospitals and Clinics Iowa City IA
| | - Aayushi Garg
- Department of Neurology University of Iowa Hospitals and Clinics Iowa City IA
| | | | - Mary Patterson
- Department of Neurology Mercy HealthSt. Vincent Hospital Toledo OH
| | - Osama Zaidat
- Department of Neurology Mercy HealthSt. Vincent Hospital Toledo OH
| | - Santiago Ortega-Gutierrez
- Department of Neurology University of Iowa Hospitals and Clinics Iowa City IA.,Department of Neurosurgery University of Iowa Hospitals and Clinics Iowa City IA.,Department of Radiology University of Iowa Hospitals and Clinics Iowa City IA
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11
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Garg A, Farooqui M, Zevallos CB, Quispe-Orozco D, Mendez-Ruiz A, Zaidat O, Ortega-Gutierrez S. Carotid artery angioplasty versus stenting for management of acute tandem occlusions. J Neurol Sci 2021; 428:117588. [PMID: 34403954 DOI: 10.1016/j.jns.2021.117588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/16/2021] [Accepted: 07/23/2021] [Indexed: 10/20/2022]
Abstract
Background The optimal approach to treat the cervical carotid artery lesion during endovascular thrombectomy (EVT) for acute strokes with tandem occlusions is unclear. While carotid artery stenting (CAS) might be a more definitive recanalization method, the potential risk of intracranial hemorrhage (ICH) limits its routine usage. In this study, we aimed to evaluate the safety outcomes of CAS and carotid artery angioplasty (CAA) in patients with acute tandem occlusions. Methods In this retrospective cohort study, data were obtained from the Nationwide Readmissions Database 2016-2017. The primary safety outcome was a composite of ICH and all-cause in-hospital mortality. Logistic regression analysis was used to compare the in-hospital outcomes. Survival analysis was used to estimate the 30-day readmissions. Results We identified 2042 hospitalizations meeting the study inclusion criteria (median age: 66 years, female 31.3%). Of these, 1391 (68.1%) had undergone CAS and 651 (31.9%) CAA alone. Baseline characteristics between the two groups were similar, except patients with CAS were more likely to be on anti-thrombotic medications and were less likely to have received intravenous thrombolysis. There was no significant difference in the clinical outcomes including ICH, in-hospital mortality, gastrostomy tube placement, prolonged mechanical ventilation, length of stay, hospital charges, and 30-day readmissions between the two groups, however, patients with CAS were more likely to be discharged home after adjusting for the confounding variables [odds ratio (OR) 1.49, 95% confidence interval (CI) 1.05-2.12, P 0.025]. Conclusion The emergent CAS-EVT approach appears to be safe with no adverse outcomes compared to CAA alone.
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Affiliation(s)
- Aayushi Garg
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Mudassir Farooqui
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Cynthia B Zevallos
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Darko Quispe-Orozco
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Alan Mendez-Ruiz
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Osama Zaidat
- Department of Neurology, Mercy Health - St. Vincent Medical Center, Toledo, OH, USA
| | - Santiago Ortega-Gutierrez
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA; Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA; Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
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