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Medina-Rodriguez M, Villagran D, Luque-Ambrosiani AC, Cabezas-Rodríguez JA, Ainz-Gómez L, Baena Palomino P, Pardo-Galiana B, Zamora A, de Albóniga-Chindurza A, Aguilar-Perez M, González A, Moniche F, Zapata-Arriaza E. Tirofiban versus aspirin to prevent in-stent thrombosis after emergent carotid artery stenting in acute ischemic stroke. J Neurointerv Surg 2024:jnis-2024-021845. [PMID: 38906690 DOI: 10.1136/jnis-2024-021845] [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: 04/12/2024] [Accepted: 05/31/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND Several antithrombotic treatments during emergent carotid artery stenting (eCAS) have been proposed, but an appropriate protocol to balance risk-benefit is not well known. OBJECTIVE To investigate the efficacy and safety of tirofiban compared with aspirin in patients with acute ischemic stroke undergoing eCAS. METHODS We conducted a retrospective single-center study of the prospective ARTISTA Registry, including patients with atherosclerotic internal carotid artery occlusion treated with eCAS. Two groups, according to antiplatelet drug, were studied: aspirin (250-500 mg single-dose) versus tirofiban (500 μg bolus+200 μg/h). Primary outcomes were the rate of in-stent thrombosis and symptomatic intracranial hemorrhage (sICH) within the first 24 hours. RESULTS During the period 2019-2023, 181 patients were included, 103 received aspirin, 78 tirofiban; 149 (82.3%) had tandem lesions. The primary efficacy outcome occurred in 9 (9.4%) in the aspirin group, as compared with 1 (1.3%) in the tirofiban group (adjusted odds ratio (aOR)=0.11, 95% CI 0.01 to 0.98; P=0.048). The primary safety outcome was detected in 12 (11.7%) in the aspirin group, as compared with 2 (2.6%) in the tirofiban group (aOR=0.16, 95% CI 0.03 to 0.87; P=0.034). The tirofiban group presented a lower risk of parenchymal hemorrhage (18 (17.4%) vs 4 (5.2%), aOR=0.27, 95% CI 0.09 to 0.88; P=0.029) and an increased rate of excellent recanalization (expanded Treatment in Cerebral Infarction (eTICI) 2c-3) (50 (48.5%) vs 54 (69.2%); aOR=2.15, 95% CI 1.12 to 4.13; P=0.02). There were no differences in functional outcomes or mortality at 3 months. CONCLUSIONS Periprocedural antithrombotic therapy with tirofiban was associated with a lower risk of in-stent thrombosis and sICH at 24 hours from eCAS compared with aspirin. Prospective randomized clinical trials are needed to confirm our results.
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Affiliation(s)
- Manuel Medina-Rodriguez
- Stroke Unit, Department of Neurology, Virgen del Rocio University Hospital, Sevilla, Spain
- Neurovascular Laboratory, Instituto de Biomedicina de Sevilla IBiS/University Hospital Virgen del Rocio/CSIC/University of Seville, Sevilla, Spain
| | - Diego Villagran
- Stroke Unit, Department of Neurology, Virgen del Rocio University Hospital, Sevilla, Spain
| | | | - Juan Antonio Cabezas-Rodríguez
- Stroke Unit, Department of Neurology, Virgen del Rocio University Hospital, Sevilla, Spain
- Neurovascular Laboratory, Instituto de Biomedicina de Sevilla IBiS/University Hospital Virgen del Rocio/CSIC/University of Seville, Sevilla, Spain
| | - Leire Ainz-Gómez
- Stroke Unit, Department of Neurology, Virgen del Rocio University Hospital, Sevilla, Spain
- Neurovascular Laboratory, Instituto de Biomedicina de Sevilla IBiS/University Hospital Virgen del Rocio/CSIC/University of Seville, Sevilla, Spain
| | - Pablo Baena Palomino
- Stroke Unit, Department of Neurology, Virgen del Rocio University Hospital, Sevilla, Spain
- Neurovascular Laboratory, Instituto de Biomedicina de Sevilla IBiS/University Hospital Virgen del Rocio/CSIC/University of Seville, Sevilla, Spain
| | - Blanca Pardo-Galiana
- Stroke Unit, Department of Neurology, Virgen del Rocio University Hospital, Sevilla, Spain
- Neurovascular Laboratory, Instituto de Biomedicina de Sevilla IBiS/University Hospital Virgen del Rocio/CSIC/University of Seville, Sevilla, Spain
| | - Aynara Zamora
- Neurovascular Laboratory, Instituto de Biomedicina de Sevilla IBiS/University Hospital Virgen del Rocio/CSIC/University of Seville, Sevilla, Spain
| | - Asier de Albóniga-Chindurza
- Neurovascular Laboratory, Instituto de Biomedicina de Sevilla IBiS/University Hospital Virgen del Rocio/CSIC/University of Seville, Sevilla, Spain
- Department of Radiology, Interventional Neuroradiology, Virgen del Rocío University Hospital, Seville, Spain
| | - Marta Aguilar-Perez
- Neurovascular Laboratory, Instituto de Biomedicina de Sevilla IBiS/University Hospital Virgen del Rocio/CSIC/University of Seville, Sevilla, Spain
- Department of Radiology, Interventional Neuroradiology, Virgen del Rocío University Hospital, Seville, Spain
| | - Alejandro González
- Neurovascular Laboratory, Instituto de Biomedicina de Sevilla IBiS/University Hospital Virgen del Rocio/CSIC/University of Seville, Sevilla, Spain
- Department of Radiology, Interventional Neuroradiology, Virgen del Rocío University Hospital, Seville, Spain
| | - Francisco Moniche
- Stroke Unit, Department of Neurology, Virgen del Rocio University Hospital, Sevilla, Spain
- Neurovascular Laboratory, Instituto de Biomedicina de Sevilla IBiS/University Hospital Virgen del Rocio/CSIC/University of Seville, Sevilla, Spain
| | - Elena Zapata-Arriaza
- Neurovascular Laboratory, Instituto de Biomedicina de Sevilla IBiS/University Hospital Virgen del Rocio/CSIC/University of Seville, Sevilla, Spain
- Department of Radiology, Interventional Neuroradiology, Virgen del Rocío University Hospital, Seville, Spain
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2
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Khanafer A, Henkes H, Bücke P, Hennersdorf F, Bäzner H, Forsting M, von Gottberg P. Triple platelet inhibition in intracranial thrombectomy with additional acute cervical stent angioplasty due to tandem lesion: a retrospective single-center analysis. BMC Neurol 2024; 24:99. [PMID: 38500074 PMCID: PMC10946095 DOI: 10.1186/s12883-024-03597-0] [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: 01/09/2024] [Accepted: 03/11/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Acute stroke treatment with intracranial thrombectomy and treatment of ipsilateral carotid artery stenosis/occlusion ("tandem lesion", TL) in one session is considered safe. However, the risk of stent restenosis after TL treatment is high, and antiplatelet therapy (APT) preventing restenosis must be well balanced to avoid intracranial hemorrhage. We investigated the safety and 90-day outcome of patients receiving TL treatment under triple-APT, focused on stent-patency and possible disadvantageous comorbidities. METHODS Patients receiving TL treatment in the setting of acute stroke between 2013 and 2022 were analyzed regarding peri-/postprocedural safety and stent patency after 90 days. All patients received intravenous eptifibatide and acetylsalicylic acid and one of the three drugs prasugrel, clopidogrel, or ticagrelor. Duplex imaging was performed 24 h after treatment, at discharge and 90 days, and digital subtraction angiography was performed if restenosis was suspected. RESULTS 176 patients were included. Periprocedural complications occurred in 2.3% of the patients at no periprocedural death, and in-hospital death in 13.6%. Discharge mRS score was maintained or improved at the 90-day follow-up in 86%, 4.54% had an in-stent restenosis requiring treatment at 90 days. No recorded comorbidity considered disadvantageous for stent patency showed statistical significance, the duration of the endovascular procedure had no significant effect on outcome. CONCLUSION In our data, TL treatment with triple APT resulted in a low restenosis rate, low rates of sICH and a comparably high number of patients with favorable outcome. Aggressive APT in the initial phase may therefore have the potential to prevent recurrent stroke better than restrained platelet inhibition. Comorbidities did not influence stent patency.
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Affiliation(s)
- Ali Khanafer
- Neuroradiological Clinic, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiological Clinic, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Philipp Bücke
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Florian Hennersdorf
- Department of Diagnostic and Interventional Neuroradiology, University of Tübingen, Tübingen, Germany
| | - Hansjörg Bäzner
- Neurological Clinic, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Michael Forsting
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Philipp von Gottberg
- Neuroradiological Clinic, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany.
- Klinik für Neuroradiologie, Klinikum Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Germany.
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3
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Kern AY, Kreinin Y, Charle L, Epshrein M, Korin N, Mangin PH. A macrofluidic model to investigate the intrinsic thrombogenicity of clinically used stents and develop less thrombogenic stents. Heliyon 2024; 10:e26550. [PMID: 38463800 PMCID: PMC10920166 DOI: 10.1016/j.heliyon.2024.e26550] [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: 08/09/2023] [Revised: 02/08/2024] [Accepted: 02/15/2024] [Indexed: 03/12/2024] Open
Abstract
Microfluidic blood flow models have been instrumental to study the functions of blood platelets in hemostasis and arterial thrombosis. However, they are not suited to investigate the interactions of platelets with the foreign surfaces of medical devices such as stents, mainly because of the dimensions and geometry of the microfluidic channels. Indeed, the channels of microfluidic chips are usually rectangular and rarely exceed 50 to 100 μm in height, impairing the insertion of clinically used stents. To fill this gap, we have developed an original macrofluidic flow system, which precisely reproduces the size and geometry of human vessels and therefore represents a biomimetic perfectly suited to insert a clinical stent and study its interplay with blood cells. The system is a circular closed loop incorporating a macrofluidic flow chamber made of silicone elastomer, which can mimic the exact dimensions of any human vessel, including the coronary, carotid or femoral artery. These flow chambers allow the perfect insertion of stents as they are implanted in patients. Perfusion of whole blood anticoagulated with hirudin through the device at relevant flow rates allows one to observe the specific accumulation of fluorescently labeled platelets on the stent surface using video-microscopy. Scanning electron microscopy revealed the formation of very large thrombi composed of tightly packed activated platelets on the stents.
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Affiliation(s)
- Axelle Y. Kern
- University of Strasbourg, INSERM, EFS Grand-Est, BPPS UMR_S1255, FMTS, F-67065 Strasbourg, France
| | - Yevgeniy Kreinin
- Department of Biomedical Engineering Technion, Israel Institute of Technology, Haifa, Israel
| | - Lise Charle
- University of Strasbourg, INSERM, EFS Grand-Est, BPPS UMR_S1255, FMTS, F-67065 Strasbourg, France
| | - Mark Epshrein
- Department of Biomedical Engineering Technion, Israel Institute of Technology, Haifa, Israel
| | - Netanel Korin
- Department of Biomedical Engineering Technion, Israel Institute of Technology, Haifa, Israel
| | - Pierre H. Mangin
- University of Strasbourg, INSERM, EFS Grand-Est, BPPS UMR_S1255, FMTS, F-67065 Strasbourg, France
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4
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Perrin G, Molinier E, Gory B, Kyheng M, Labreuche J, Pasi M, Janot K, Bourcier R, Sibon I, Consoli A, Desilles JP, Olivot JM, Papagiannaki C, Soize S, Gentric JC, Dargazanli C, Caroff J, Pop R, Naggara O, Moulin S, Eker O, Alias Q, Clarençon F, Lapergue B, Marnat G. Impact of Day 1 carotid patency on outcome in dissection-related tandem occlusions treated with mechanical thrombectomy. J Neuroradiol 2024; 51:196-203. [PMID: 38309578 DOI: 10.1016/j.neurad.2024.01.076] [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: 11/29/2023] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 02/05/2024]
Abstract
BACKGROUND The clinical benefit of mechanical thrombectomy(MT) for stroke patients with tandem occlusion is similar to that of isolated intracranial occlusions. However, the management of cervical internal carotid artery(ICA) occlusion during the MT, particularly in the setting of carotid dissection, remains controversial. We aimed to investigate the clinical impact of cervical ICA patency at day 1 on 3-month functional outcome. METHODS We collected data from the Endovascular Treatment in Ischemic Stroke, a prospective national registry in 30 French centers performing MT between January 2015 and January 2022. Inclusion criteria were consecutive tandem occlusions related to cervical ICA dissection treated with MT. Tandem occlusions of other etiology, isolated cervical ICA occlusions without intracranial thrombus and patients without day-1 ICA imaging were excluded. Primary endpoint was the 3-month functional outcome. Secondary endpoints included intracranial hemorrhage(ICH), excellent outcome, mortality and early neurological improvement. A sensitivity analysis was performed in patients with intracranial favorable recanalization after MT. RESULTS During the study period, 137 patients were included of which 89(65%) presented ICA patency at day 1. The odds of favorable outcome did not significantly differ between patients with patent and occluded ICA at day 1(68.7 vs 59.1%;aOR=1.30;95%CI 0.56-3.00,p=0.54). Excellent outcome, early neurological improvement, mortality and ICH were also comparable between groups. Sensitivity analysis showed similar results. CONCLUSION ICA patency at day 1 in patients with tandem occlusions related to dissection did not seem to influence functional outcome. Endovascular recanalization of the cervical ICA including stenting might not be systematically required in this setting.
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Affiliation(s)
| | | | - Benjamin Gory
- Neuroradiology Department, Nancy University Hospital, INSERM 1254, IADI, Université de Loraine, Nancy, France
| | - Maeva Kyheng
- Biostatistic Department - Lille University Hospital, Lille, France
| | - Julien Labreuche
- Biostatistic Department - Lille University Hospital, Lille, France
| | - Marco Pasi
- Neurology department, Tours University Hospital, Tours, France
| | - Kevin Janot
- Neuroradiology department, Tours University Hospital, Tours, France
| | - Romain Bourcier
- Neuroradiology Department, Nantes University Hospital, Nantes, France
| | - Igor Sibon
- Neurology Department, Bordeaux University Hospital, Bordeaux, France
| | - Arturo Consoli
- Neuroradiology Department, Foch Hospital, Suresnes, France
| | | | - Jean-Marc Olivot
- Neurology Department, Toulouse University Hospital, Toulouse, France
| | | | - Sebastien Soize
- Neuroradiology Department, Reims University Hospital, Reims, France
| | | | - Cyril Dargazanli
- Neuroradiology Department, Montpellier University Hospital, Montpellier, France
| | - Jildaz Caroff
- Neuroradiology Department, Kremlin-Bicêtre University Hospital, Kremlin-Bicêtre, France
| | - Raoul Pop
- Neuroradiology Department, Strabsourg University Hospital, Strasbourg, France
| | - Olivier Naggara
- Neuroradiology Department, Sainte-Anne University Hospital, Paris, France
| | - Solene Moulin
- Neurology Department, Reims University Hospital, Reims, France
| | - Omer Eker
- Neuroradiology Department, Lyon University Hospital, Lyon, France
| | - Quentin Alias
- Neuroradiology Department, Rennes University Hospital, Rennes, France
| | - Frederic Clarençon
- Neuroradiology Department, Pitié-Salpêtriere University Hospital, Paris, France
| | | | - Gaultier Marnat
- Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France.
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5
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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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6
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Pop R, Burel J, Finitsis SN, Papagiannaki C, Severac F, Mangin PH, Mihoc D, Leonard-Lorant I, Gheoca R, Wolff V, Chibbaro S, Sibon I, Richard S, Beaujeux R, Marnat G, Gory B. Comparison of three antithrombotic strategies for emergent carotid stenting during stroke thrombectomy: a multicenter study. J Neurointerv Surg 2023; 15:e388-e395. [PMID: 36759180 DOI: 10.1136/jnis-2022-019875] [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: 11/11/2022] [Accepted: 01/30/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Periprocedural antithrombotic treatment is a key determinant for the risk-benefit balance of emergent carotid artery stenting (eCAS) during stroke thrombectomy. We aimed to assess the safety and efficacy of three types of antithrombotic treatment. METHODS Retrospective review of prospectively collected endovascular databases in four comprehensive stroke centers, including consecutive cases of eCAS for tandem lesion strokes between January 2019 and July 2021. During this period, each center prospectively applied one of three periprocedural protocols: (a) two centers administered aspirin (250 mg IV); (b) one center administered aspirin and heparin (bolus+24 hours infusion); and (c) one center applied an aggressive antiplatelet strategy consisting of aspirin and clopidogrel (loading doses), with added intravenous tirofiban if in-stent thrombosis was observed during thrombectomy. Dichotomized comparisons of outcomes were performed between aggressive versus non-aggressive strategy (aspirin±heparin) and aspirin+heparin versus aspirin-alone groups. RESULTS Among 161 included patients, 62 received aspirin monotherapy, 38 aspirin+heparin, and 61 an aggressive treatment. Aggressive antiplatelet treatment was associated with an increased rate of excellent (modified Thrombolysis in Cerebral Infarction (mTICI) 2c-3) recanalization and reduced carotid stent thrombosis at day 1 (3.5% vs 16.3%), compared with non-aggressive strategy. There were no significant differences in hemorrhagic transformation or 90-day mortality. There was a tendency towards better clinical outcome with aggressive treatment, without reaching statistical significance. Addition of heparin to aspirin was not associated with an increased rate of carotid stent patency. CONCLUSIONS Aggressive antiplatelet treatment was associated with improved intracranial recanalization and carotid stent patency, without safety concerns. These findings have implications for randomized trials and may be of utility for clinicians when making antithrombotic treatment choices.
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Affiliation(s)
- Raoul Pop
- Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, France
- Interventional Radiology, Institut de Chirurgie Guidée par l'Image, Strasbourg, France
- INSERM, EFS Grand-Est, BPPS UMR-S1255, FMTS, F-67065, University of Strasbourg, Strasbourg, France
| | - Julien Burel
- Radiology, University Hospital Centre Rouen, Rouen, France
| | | | | | - Francois Severac
- Public Healthcare Department, University Hospitals Strasbourg, Strasbourg, France
| | - Pierre H Mangin
- INSERM, EFS Grand-Est, BPPS UMR-S1255, FMTS, F-67065, University of Strasbourg, Strasbourg, France
| | - Dan Mihoc
- Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, France
| | - Ian Leonard-Lorant
- Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, France
| | - Roxana Gheoca
- Neurology, University Hospitals Strasbourg, Strasbourg, France
| | - Valerie Wolff
- Neurology, University Hospitals Strasbourg, Strasbourg, France
| | | | - Igor Sibon
- Neurology, University Hospital Center Bordeaux, Bordeaux, France
| | - Sébastien Richard
- Neurology Stroke Unit, University Hospital Centre Nancy, Nancy, France
| | - Remy Beaujeux
- Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, France
| | - Gaultier Marnat
- Interventional and Diagnostic Neuroradiology, University Hospital Centre Bordeaux, Bordeaux, France
| | - Benjamin Gory
- Department of Diagnostic and Interventional Neuroradiology, Centre hospitalier regional universitaire de Nancy, Nancy, France
- Université de Lorraine, Nancy, France
- IADI, INSERM U1254, Nancy, France
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7
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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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8
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Marnat G, Finistis S, Moreno R, Sibon I, Pop R, Mazighi M, Clarençon F, Rosso C, Dargazanli C, Darcourt J, Olivot JM, Boulouis G, Janot K, Moulin S, Bourcier R, Consoli A, Richard S, Arquizan C, Vannier S, Richter S, Gentric JC, Papagiannaki C, Naggara O, Eker OF, Lapergue B, Caroff J, Gory B. Aspirin versus aggressive antiplatelet therapy for acute carotid stenting plus thrombectomy in tandem occlusions: ETIS Registry results. J Neurointerv Surg 2023; 15:e248-e254. [PMID: 36357169 DOI: 10.1136/jnis-2022-019527] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 10/24/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Patients treated with acute carotid stenting (CAS) may have higher odds of a favorable outcome than those treated without CAS during thrombectomy in tandem occlusions. Antiplatelet therapy is associated with CAS to avoid stent thrombosis, which occurs in around 20% of patients and negatively impacts outcomes. In this study we compared two antiplatelet strategies in tandem occlusion strokes treated with CAS and intracranial thrombectomy in clinical practice. METHODS The Endovascular Treatment in Ischemic Stroke Registry is an ongoing prospective observational study involving 21 comprehensive stroke centers performing thrombectomy in France. We analyzed patients with atherosclerotic tandem occlusions treated with acute CAS and intracranial thrombectomy who received at least one antiplatelet agent. Aggressive antiplatelet therapy included oral or intravenous glycoprotein (GP) IIb/IIIa or P2Y12 inhibitors. The primary outcome was cervical carotid artery patency at day 1 imaging follow-up. RESULTS Among the 187 included patients, 124 (66.3%) received aspirin alone and 63 (33.7%) received aggressive antiplatelet therapy. There was no significant difference regarding safety outcomes, especially in symptomatic intracerebral hemorrhage, parenchymal hematoma, and procedural complications. There was a significantly higher rate of carotid stent patency at day 1 in the aggressive antiplatelet therapy group (81.7% vs 97.1%, aOR 17.49, 95% CI 1.10 to 277.2, p=0.042). Odds of favorable functional outcome (90-day modified Rankin Scale score 0-2) were similar between the groups (OR 3.04, 95% CI 0.64 to 14.25, p=0.158). CONCLUSIONS In tandem occlusions treated with CAS plus thrombectomy, an aggressive antiplatelet regimen was associated with an increased rate of carotid stent patency at day 1 without safety concerns. Randomized trials are warranted to confirm these findings.
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Affiliation(s)
- Gaultier Marnat
- Interventional and Diagnostic Neuroradiology, CHU Bordeaux GH Pellegrin, Bordeaux, France
| | - Stefanos Finistis
- Neurosurgery, Aristotle University of Thessaloniki, Thessaloniki, Central Macedonia, Greece
| | - Ricardo Moreno
- Neuroradiology, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Igor Sibon
- Neurology, CHU de Bordeaux, Bordeaux, France
| | - Raoul Pop
- Neuroradiolology, CHU Strasbourg, Strasbourg, France
| | - Mikaël Mazighi
- Interventional Neuroradiology, Fondation Rothschild, Paris, France
- Neurology, GH Lariboisiere Fernand-Widal, Paris, France
| | - Frédéric Clarençon
- Neuroradiology, Hopital Universitaire Pitie Salpetriere, Paris, France
- Sorbonne University, Paris, France
| | - Charlotte Rosso
- Neurology, Hopital Universitaire Pitie Salpetriere, Paris, France
| | - Cyril Dargazanli
- Neuroradiology, University Hospital Centre Montpellier, Montpellier, France
| | | | | | | | | | - Solène Moulin
- Neurology, University Hospital Centre Reims, Reims, France
| | | | | | - Sébastien Richard
- Neurology Stroke Unit, University Hospital Centre Nancy, Nancy, France
| | | | | | | | | | | | | | - Omer F Eker
- Neuroradiology, Hospices Civils de Lyon, Bron, France
| | | | - Jildaz Caroff
- Interventional Neuroradiology, NEURI Brain Vascular Center, Bicêtre Hospital, APHP, Le Kremlin Bicêtre, France
| | - Benjamin Gory
- Diagnostic and Interventional Neuroradiology, Centre Hospitalier Universitaire de Nancy, Nancy, France
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9
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Pop R, Severac F, Hasiu A, Mihoc D, Mangin PH, Chibbaro S, Simu M, Tudor R, Gheoca R, Quenardelle V, Wolff V, Beaujeux R. Conservative versus aggressive antiplatelet strategy for emergent carotid stenting during stroke thrombectomy. Interv Neuroradiol 2023; 29:268-276. [PMID: 35253529 PMCID: PMC10369108 DOI: 10.1177/15910199221083112] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/07/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND There is no consensus regarding optimal antiplatelet regimen for emergent carotid stenting during stroke thrombectomy. We aimed to assess the safety and efficacy of an aggressive periprocedural antiplatelet strategy focused on preserving stent patency, in comparison with conservative antiplatelet strategy consisting of aspirin monotherapy. MATERIALS AND METHODS Retrospective review of a prospectively collected database in a comprehensive stroke center, including all cases of emergent carotid stenting for tandem lesions stroke between 01.03.2012-01.06.2021. Aggressive antiplatelet strategy consisted of dual antiplatelet therapy (DAPT) with aspirin and clopidogrel loading doses, with added intravenous (IV) tirofiban if in-stent thrombosis was observed during thrombectomy. Clinical and radiological outcomes were compared between conservative and aggressive antiplatelet treatment groups using inverse probability of treatment weighting (IPTW) analysis based on propensity scores. RESULTS We included 132 cases (76.5% atheroma, 22.7% dissection, 0.7% carotid web). Forty-five patients (34%) cases received conservative antiplatelet therapy. The remaining 87 (65.9%) received aggressive antiplatelet therapy: 66 (75.8%) treated with DAPT, 21 (24.1%) with DAPT and tirofiban. Periprocedural heparin was avoided in all cases. In adjusted analysis of the weighted samples, aggressive antiplatelet strategy was associated with improved carotid stent patency (aOR 0.23, 95% CI 0.07-0.80, p = 0.021), higher proportion of moderate clinical outcome (mRS ≤ 3, aOR 2.72, 95% CI 1.01-7.30, p = 0.04), with no significant differences in mortality and hemorrhagic transformation (HT) rates. CONCLUSIONS In this retrospective study, aggressive periprocedural antiplatelet strategy led to improved stent patency and clinical outcomes, without increased HT. Further prospective randomized research is warranted to identify the optimal combination of antiplatelet agents for emergent carotid stenting in the setting of acute stroke.
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Affiliation(s)
- Raoul Pop
- Interventional Neuroradiology Department, Strasbourg University Hospitals, Strasbourg, France
- Institut de Chirurgie Minime Invasive Guidée par l’Image, Strasbourg, France
- University of Strasbourg, INSERM, EFS Grand-Est, BPPS UMR-S1255, FMTS, Strasbourg, France
| | - François Severac
- Public Healthcare Department, Strasbourg University Hospitals, Strasbourg, France
| | - Anca Hasiu
- Interventional Neuroradiology Department, Strasbourg University Hospitals, Strasbourg, France
| | - Dan Mihoc
- Interventional Neuroradiology Department, Strasbourg University Hospitals, Strasbourg, France
| | - Pierre H Mangin
- University of Strasbourg, INSERM, EFS Grand-Est, BPPS UMR-S1255, FMTS, Strasbourg, France
| | - Salvatore Chibbaro
- Neurosurgery Department, Strasbourg University Hospitals, Strasbourg, France
| | - Mihaela Simu
- Neurology Department, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania
| | - Raluca Tudor
- Neurology Department, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania
| | - Roxana Gheoca
- Stroke Unit, Strasbourg University Hospitals, Strasbourg, France
| | | | - Valérie Wolff
- Stroke Unit, Strasbourg University Hospitals, Strasbourg, France
| | - Rémy Beaujeux
- Interventional Neuroradiology Department, Strasbourg University Hospitals, Strasbourg, France
- Institut de Chirurgie Minime Invasive Guidée par l’Image, Strasbourg, France
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10
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Yamashita S, Imahori T, Koyama J, Tanaka K, Okamura Y, Arai A, Iwahashi H, Mori T, Onobuchi K, Sasayama T. Endovascular Treatment of Tandem Atherosclerotic Cervical Internal Carotid Artery Occlusion in the Setting of Acute Ischemic Stroke. Vasc Endovascular Surg 2023; 57:137-148. [PMID: 36189731 DOI: 10.1177/15385744221130865] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Among tandem occlusions, atherosclerotic cervical internal carotid artery occlusion (ACICAO) can be technically challenging and associated with its unique complications. We evaluated our experience with endovascular treatment (EVT) of ACICAO in the setting of acute ischemic stroke. METHODS In total, 154 consecutive patients who underwent EVT for acute anterior circulation stroke at our institute were retrospectively reviewed. Patients with tandem ACICAO were analyzed in this study. Procedures, recanalization rates, complications, and prognoses were evaluated. RESULTS Ten patients (6%) of all 154 patients had ACICAO. In nine (90%) of the 10 patients, cervical lesions were successfully crossed and intervened upon. Four patients underwent stenting and five underwent angioplasty alone, followed by intracranial procedure. Eight patients (80%) achieved successful recanalization following mechanical thrombectomy for intracranial occlusion. However, one patient had massive subarachnoid hemorrhage during the procedure and another patient developed massive intracranial hemorrhage after EVT, both after stenting. Four of the five patients who initially underwent angioplasty alone subsequently underwent staged endarterectomy or stenting for residual stenosis on or after the next day. The single patient in whom the cervical lesion could not be crossed and another with reocclusion after EVT underwent a rescue bypass procedure due to persistent ischemic symptoms. After 90 days, four patients (40%) were functionally independent (modified Rankin scale score 0-2). CONCLUSIONS Our experience suggests that EVT for ACICAO is technically feasible; however, it involves the potential risk of several significant complications. To avoid serious hemorrhagic complications, cervical lesions may be better treated with angioplasty alone first.
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Affiliation(s)
- Shunsuke Yamashita
- Department of Neurosurgery, 38303Kobe University Graduate School of Medicine, Hyogo, Japan.,Department of Neurosurgery, 157128Toyooka Hospital, Hyogo, Japan
| | - Taichiro Imahori
- Department of Neurosurgery, 38303Kobe University Graduate School of Medicine, Hyogo, Japan.,Department of Neurosurgery, 157128Toyooka Hospital, Hyogo, Japan
| | - Junji Koyama
- Department of Neurosurgery, 157128Toyooka Hospital, Hyogo, Japan
| | - Kazuhiro Tanaka
- Department of Neurosurgery, 38303Kobe University Graduate School of Medicine, Hyogo, Japan.,Department of Neurosurgery, 157128Toyooka Hospital, Hyogo, Japan
| | - Yusuke Okamura
- Department of Neurosurgery, 157128Toyooka Hospital, Hyogo, Japan
| | - Atsushi Arai
- Department of Neurosurgery, 157128Toyooka Hospital, Hyogo, Japan
| | | | - Tatsuya Mori
- Department of Neurosurgery, 157128Toyooka Hospital, Hyogo, Japan
| | - Kana Onobuchi
- Department of Neurosurgery, 157128Toyooka Hospital, Hyogo, Japan
| | - Takashi Sasayama
- Department of Neurosurgery, 38303Kobe University Graduate School of Medicine, Hyogo, Japan
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11
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Allard J, Delvoye F, Pop R, Labreuche J, Maier B, Marnat G, Sibon I, Zhu F, Lapergue B, Consoli A, Spelle L, Denier C, Richard S, Piotin M, Gory B, Mazighi M, Redjem H, Escalard S, Dessilles JP, Delvoye F, Smajda S, Maier B, Solène H, Mazighi M, Obadia M, Sabben C, Pierre S, Igor R, Corabianu O, de Broucker T, Manchon E, Taylor G, Maacha MB, Thion LA, Augustin L, Julien S, Wang A, Evrard S, Tchikviladze M, Ajili N, WeisenburgerLile D, Gorza L, Buard G, Coskun O, Di Maria F, Rodesh G, Zimatore S, Leguen M, Gratieux J, Pico F, Rakotoharinandrasana H, Tassan P, Poll R, Marinier S, Barreau X, Berge J, Menegon P, Lucas L, Olindo S, Renou P, Sagnier S, Poli M, Debruxelles S, Rouanet F, Tourdias T, Liegey JS, Briau P, Pangon N, Coussy A, Papillon L, Papaxanthos J, Detraz L, Daumas-Duport B, Alexandre PL, Roy M, Lenoble C, Desal H, Guillon B, de Gaalon S, Preterre C, Bracard S, Anxionnat R, Braun M, Derelle AL, Tonnelet R, Liao L, Zhu F, Schmitt E, Planel S, Humbertjean L, Lacour JC, Riou-Comte N, Voicu M, Alb L, Reitter M, Brezeanu M, Masson A, Tabarna A, Podar I, Macian-Montoro F, Saleme S, Mounayer C, Rouchaud A, Costalat V, Arquizan C, Dargazanli C, Gascou G, Lefèvre PH, Derraz I, Riquelme C, Gaillard N, Mourand I, Corti L, Cagnazzo F, Ter Schiphorst A, Ferre JC, Raoult H, Ronziere T, Lassale M, Paya C, Gauvrit JY, Tracol C, Langnier-Lemercier S. 24-Hour Carotid Stent Patency and Outcomes After Endovascular Therapy: A Multicenter Study. Stroke 2023; 54:124-131. [PMID: 36542074 DOI: 10.1161/strokeaha.122.039797] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Management of extracranial internal carotid artery steno-occlusive lesion during endovascular therapy remains debated. Stent occlusion within 24 hours of endovascular therapy is a frequent event after acute carotid artery stenting, and we currently lack large population results. We investigated the incidence, predictors, and clinical impact of stent occlusion after acute carotid artery stenting in current clinical practice. METHODS Patients treated by endovascular therapy with acute carotid artery stenting between 2015 and 2019 in 5 large-volume endovascular-capable centers were retrospectively analyzed. Patients were separated in 2 groups according to the stent patency at 24 hours after carotid artery stenting. We compared baseline characteristics, treatment modalities, and clinical outcome depending on 24-hour stent patency. Primary end point was favorable outcome, defined as a modified Rankin Scale score 0-2 at 3 months. RESULTS A stent occlusion was observed in 47/225 patients (20.9%). Patients with stent patency had a lower baseline National Institutes of Health Stroke Scale (median [interquartile range]: 13 [7-17] versus 18 [12-21]) and had more often stroke of atherothrombotic origin (77.0% versus 53.2%). A higher stent patency rate was found for patients treated with P2Y12 antagonists at the acute phase (odds ratio [OR]' 2.95 [95% CI' 1.10-7.91]; P=0.026) and treated with angioplasty (OR' 2.42 [95% CI' 1.24-4.67]; P=0.008). A better intracranial angiographic reperfusion was observed in patients with 24-hour stent patency compared with patients without stent patency (OR' 8.38 [95% CI' 3.07-22.78]; P<0.001). Patients with a stent patency at 24 hours had a higher chance of favorable outcome (OR' 3.29 [95% CI, 1.66-6.52]; P<0.001) and a lower risk of death (OR' 0.32 [95% CI, 0.13-0.76]; P=0.009). CONCLUSIONS One out of 5 patients treated with carotid artery stenting during endovascular therapy presented a stent occlusion within 24 hours. This event was associated with worse functional outcome. Stroke etiology, P2Y12 antagonist administration, quality of intracranial reperfusion, and angioplasty were associated with 24-hour stent patency.
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Affiliation(s)
- Julien Allard
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (J.A., F.D., B.M., MP, M.M.).,University of Paris' France (J.A., M.M.)
| | - François Delvoye
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (J.A., F.D., B.M., MP, M.M.)
| | - Raoul Pop
- Department of Neuroradiolology, CHU Strasbourg, France (R.P.).,Institut de Chirurgie Minime Invasive Guidée par l'Image, Strasbourg, France (R.P.).,University of Strasbourg, INSERM UMR-S1255, France (R.P.)
| | - Julien Labreuche
- Department of Biostatistics, CHU Lille, University of Lille, France (J.L.)
| | - Benjamin Maier
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (J.A., F.D., B.M., MP, M.M.).,LVTS, INSERM U1148, University of Paris, France (BM., M.M.)
| | - Gaultier Marnat
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Bordeaux, France (G.M.)
| | - Igor Sibon
- Department of Neurology, Stroke Center, University Hospital of Bordeaux, France (I.S.)
| | - François Zhu
- Department of Diagnostic and Therapeutic Neuroradiology, CHRU-Nancy, Université de Lorraine, France (B.G., F.Z.)
| | - Bertrand Lapergue
- Department of Neurology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France (B.L.)
| | - Arturo Consoli
- Diagnostic and Interventional Neuroradiology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France (A.C.)
| | - Laurent Spelle
- Department of Neuroradiolology, CHU Kremlin-Bicêtre, Le Kremlin Bicêtre, France (L.S.)
| | - Christian Denier
- Department of Neurology, CHU Kremlin-Bicêtre, Le Kremlin Bicêtre, France (C.D.)
| | - Sébastien Richard
- Department of Neurology, Stroke Unit, Université de Lorraine, CHRU-Nancy, France (S.R.).,CIC-P 1433, INSERM U1116, CHRU-Nancy, France (S.R.)
| | - Michel Piotin
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (J.A., F.D., B.M., MP, M.M.)
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, CHRU-Nancy, Université de Lorraine, France (B.G., F.Z.).,IADI, INSERM U1254, Université de Lorraine, Nancy, France (B.G.)
| | - Mikael Mazighi
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (J.A., F.D., B.M., MP, M.M.).,LVTS, INSERM U1148, University of Paris, France (BM., M.M.).,University of Paris' France (J.A., M.M.)
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12
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Bücke P, Cohen JE, Horvath T, Cimpoca A, Bhogal P, Bäzner H, Henkes H. What You Always Wanted to Know about Endovascular Therapy in Acute Ischemic Stroke but Never Dared to Ask: A Comprehensive Review. Rev Cardiovasc Med 2022; 23:340. [PMID: 39077121 PMCID: PMC11267361 DOI: 10.31083/j.rcm2310340] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/08/2022] [Accepted: 06/08/2022] [Indexed: 07/31/2024] Open
Abstract
In 2015, mechanical thrombectomy (MT) in combination with intravenous thrombolysis was demonstrated to be superior to best medical treatment alone in patients with anterior circulation stroke. This finding resulted in an unprecedented boost in endovascular stroke therapy, and MT became widely available. MT was initially approved for patients presenting with large vessel occlusion in the anterior circulation (intracranial internal carotid artery or proximal middle cerebral artery) within a 6-hour time window. Eventually, it was shown to be beneficial in a broader group of patients, including those without known symptom-onset, wake-up stroke, or patients with posterior circulation stroke. Technical developments and the implementation of novel thrombectomy devices further facilitated endovascular recanalization for acute ischemic stroke. However, some aspects remain controversial. Is MT suitable for medium or very distal vessel occlusions? Should emergency stenting be performed for symptomatic stenosis or recurrent occlusion? How should patients with large vessel occlusion without disabling symptoms be treated? Do certain patients benefit from MT without intravenous thrombolysis? In the era of personalized decision-making, some of these questions require an individualized approach based on comorbidities, imaging criteria, and the severity or duration of symptoms. Despite its successful development in the past decade, endovascular stroke therapy will remain a challenging and fascinating field in the years to come. This review aims to provide an overview of patient selection, and the indications for and execution of MT in patients with acute ischemic stroke.
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Affiliation(s)
- Philipp Bücke
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, 3012 Bern, Switzerland
| | - Jose E. Cohen
- Department of Neurosurgery, Hadassah Medical Center, Hebrew University Jerusalem, 91905 Jerusalem, Israel
| | - Thomas Horvath
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, 3012 Bern, Switzerland
| | - Alexandru Cimpoca
- Neuroradiologische Klinik, Klinikum Stuttgart, 70174 Stuttgart, Germany
| | - Pervinder Bhogal
- Interventional Neuroradiology Department, The Royal London Hospital, E1 1FR London, UK
| | - Hansjörg Bäzner
- Neurologische Klinik, Klinikum Stuttgart, 70174 Stuttgart, Germany
| | - Hans Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, 70174 Stuttgart, Germany
- Medical Faculty, Universität Duisburg-Essen, 45141 Essen, Germany
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13
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Černík D, Bartoš R, Neradová J, Frenštátská N, Cihlář F, Brušáková Š, Sameš M. Case report: Combined acute revascularization in early bilateral carotid stent occlusion. Front Neurol 2022; 13:992685. [PMID: 36188359 PMCID: PMC9523162 DOI: 10.3389/fneur.2022.992685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 08/29/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction The introduction of a carotid stent involves the use of effective antiplatelet therapy to maintain stent patency. We present a case report of combined acute revascularization in a patient with occlusion in recently introduced stents of both carotid arteries. Methods The patient (male, 73 years) was admitted for stroke recurrence upon discontinuation of antiplatelet therapy. According to the CTA, the closure of implanted stents of both carotid arteries was confirmed. Intravenous thrombolysis and mechanical thrombectomy were performed with complete recanalization of the left carotid stent. At 3 days apart, clinical deterioration was found with progressive stent restenosis. Percutaneous transluminal stent angioplasty, mechanical embolectomy and prolonged low-dose intravenous thrombolysis have been used repeatedly. Results With the impossibility of maintaining the patency of carotid stents even on the maximum drug therapy and despite endovascular procedures, bilateral neurosurgical revascularization of the middle cerebral arteries using ECIC bypasses was successfully performed. Prolonged low-dose intravenous thrombolysis (20 mg recombinant plasminogen aktivator (rTPA)/10 h) has proven to be an acute bridging therapy until surgery. Conclusion Early occlusion of the carotid stent is a significant complication of endovascular treatment of stenotic arteries. ECIC bypass revascularization of the middle cerebral artery can be a highly effective therapeutic procedure.
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Affiliation(s)
- David Černík
- Comprehensive Stroke Center, Neurology, Masaryk Hospital, Ústí nad Labem, Czechia
- *Correspondence: David Černík
| | - Robert Bartoš
- Department of Neurosurgery, Masaryk Hospital, J. E. Purkinje University, Ústí nad Labem, Czechia
| | - Jarmila Neradová
- Comprehensive Stroke Center, Neurology, Masaryk Hospital, Ústí nad Labem, Czechia
| | - Nicol Frenštátská
- Comprehensive Stroke Center, Neurology, Masaryk Hospital, Ústí nad Labem, Czechia
| | - Filip Cihlář
- Department of Radiology, Masaryk Hospital, J. E. Purkinje University, Ústí nad Labem, Czechia
| | - Štěpánka Brušáková
- Comprehensive Stroke Center, Neurology, Masaryk Hospital, Ústí nad Labem, Czechia
| | - Martin Sameš
- Department of Neurosurgery, Masaryk Hospital, J. E. Purkinje University, Ústí nad Labem, Czechia
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14
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Zapata-Arriaza E, Medina-Rodriguez M, Ortega-Quintanilla J, De Albóniga-Chindurza A, Ainz-Gómez L, Pardo-Galiana B, Cabezas-Rodriguez JA, Lebrato-Herández L, Barragán-Prieto A, Pérez-Sánchez S, Zamora A, Montaner J, González García A, Moniche F. Relevance of Carotid Reocclusion in Tandem Lesions. J Atheroscler Thromb 2022. [PMID: 35989291 DOI: 10.5551/jat.63560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
AIMS Carotid reocclusion (CRO) after mechanical thrombectomy (MT) in acute ischemic stroke (AIS) due to tandem lesion (TL) or isolated internal carotid occlusion (ICO) is associated with worse clinical outcomes. Our aim was to analyze the predictors and clinical impact of CRO. METHODS A retrospective single-center analysis of all patients with anterior circulation strokes who underwent MT prospectively included in a registry between 2017 and 2020 was performed. ICO and TL as stroke causes were included. Stent deployment was left to the discretion of the interventionist. All patients received at least intravenous aspirin during MT. CRO was assessed using ultrasound within the first 24 h after MT. Efficacy and safety of stenting were assessed. RESULTS Among 1304 AIS cases, 218 (16.7%) were related to TL or ICO. Of them, 5% (n=11) were associated with internal CRO 24 h after the endovascular procedure. After adjusting per confounders, multivariate analysis showed that the independent variables associated with CRO were the TICI recanalization grade [TICI 2b-3; OR 0.1, 95% confidence interval (CI) 0.01-0.89, p=0.040], pial collateral circulation presence (OR 0.09, 95% CI 0.02-0.45, p=0.03), stent deployment during MT (OR 0.17, 95% CI 0.03-0.84, p=0.030), and general anesthesia use (OR 2.92, 95% CI 1.13-7.90, p=0.034). CRO showed a trend toward worst outcomes (modified Rankin scale 3-6) at 3 months (OR 3.4, 95% CI 0.96-12, p=0.057). After multivariate analysis, variables independently associated with worse outcomes at 90 days were intrastent platelet aggregation phenomena during endovascular therapy, admission National Institute of Health Stroke Scale, and age. Conversely, intravenous thrombolysis and TICI 2b-3 recanalization grade were identified as independent predictors of good outcomes at 90 days. CONCLUSIONS CRO has a relevant clinical impact in our study, associating lower rates of good functional outcomes at 3 months. Independent factors of CRO were the recanalization degree, presence of pial collateral circulation, use of a stent as a protective factor, and use of general anesthesia during thrombectomy.
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Affiliation(s)
- Elena Zapata-Arriaza
- Interventional Neurorradiology Department, University Hospital Virgen del Rocio.,Stroke Research Program, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville
| | - Manuel Medina-Rodriguez
- Stroke Research Program, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville.,Neurology department. University Hospital Virgen del Rocio
| | - Joaquin Ortega-Quintanilla
- Interventional Neurorradiology Department, University Hospital Virgen del Rocio.,Stroke Research Program, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville
| | - Asier De Albóniga-Chindurza
- Interventional Neurorradiology Department, University Hospital Virgen del Rocio.,Stroke Research Program, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville
| | - Leire Ainz-Gómez
- Stroke Research Program, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville.,Neurology department. University Hospital Virgen del Rocio
| | - Blanca Pardo-Galiana
- Stroke Research Program, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville.,Neurology department. University Hospital Virgen del Rocio
| | - Juan Antonio Cabezas-Rodriguez
- Stroke Research Program, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville.,Neurology department. University Hospital Virgen del Rocio
| | - Lucía Lebrato-Herández
- Stroke Research Program, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville.,Neurology department. University Hospital Virgen del Rocio
| | - Ana Barragán-Prieto
- Stroke Research Program, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville.,Neurology department. University Hospital Virgen Macarena
| | - Soledad Pérez-Sánchez
- Stroke Research Program, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville.,Neurology department. University Hospital Virgen Macarena
| | - Aynara Zamora
- Stroke Research Program, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville
| | - Joan Montaner
- Stroke Research Program, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville.,Neurology department. University Hospital Virgen Macarena
| | - Alejandro González García
- Interventional Neurorradiology Department, University Hospital Virgen del Rocio.,Stroke Research Program, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville
| | - Francisco Moniche
- Stroke Research Program, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville.,Neurology department. University Hospital Virgen del Rocio
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15
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Ter Schiphorst A, Peres R, Dargazanli C, Blanc R, Gory B, Richard S, Marnat G, Sibon I, Guillon B, Bourcier R, Denier C, Spelle L, Labreuche J, Consoli A, Lapergue B, Costalat V, Obadia M, Arquizan C. Endovascular treatment of ischemic stroke due to isolated internal carotid artery occlusion: ETIS registry data analysis. J Neurol 2022; 269:4383-4395. [PMID: 35357557 DOI: 10.1007/s00415-022-11078-y] [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: 12/20/2021] [Revised: 03/09/2022] [Accepted: 03/09/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The best treatment for acute ischemic stroke (AIS) due to isolated cervical internal carotid artery occlusion (CICAO) (i.e., without associated occlusion of the circle of Willis) is still unknown. In this study, we aimed to describe EVT safety and clinical outcome in patients with CICAO. METHODS We analyzed data of all consecutive patients, included in the Endovascular Treatment in Ischemic Stroke (ETIS) Registry between 2013 and 2020, who presented AIS and proven CICAO on angiogram and underwent EVT. We assessed carotid recanalization, procedural complications, National Institutes of Health Stroke Scale (NIHSS) at 24 h post-EVT, and 3-month favorable outcome (modified Rankin Scale, mRS ≤ 2 or equal to the pre-stroke value). RESULTS Forty-five patients were included (median age: 70 years; range: 62-82 years). The median NIHSS before EVT was 14 (9-21). Carotid stenting was performed in 23 (51%) patients. Carotid recanalization at procedure end and on control imaging was observed in 37 (82%) and 29 (70%) patients, respectively. At day 1 post-EVT, the NIHSS remained stable or decreased in 25 (60%) patients; 12 (29%) patients had early neurologic deterioration (NIHSS ≥ 4 points). The rate of procedural complications was 36%, including stent thrombosis (n = 7), intracranial embolism (n = 7), and symptomatic intracranial hemorrhage (n = 1). At 3 months, 18 (40%) patients had a favorable outcome, and 10 (22%) were dead. CONCLUSION Our study suggests that EVT in AIS patients with moderate/severe initial deficit due to CICAO led to high rate of recanalization at day 1, and a 40% rate of favorable outcome at 3 months. There was a high rate of procedural complication which is of concern. Randomized controlled trials assessing the superiority of EVT in patients with CICAO and severe deficits are needed.
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Affiliation(s)
- Adrien Ter Schiphorst
- Department of Neurology, CHRU Gui de Chauliac, University Hospital of Montpellier, 80 Avenue Augustin Fliche, 34295, Montpellier, France
| | - Roxane Peres
- Department of Neurology, Fondation Rothschild Hospital, Paris, France
| | - Cyril Dargazanli
- Department of Interventional Neuroradiology, CHRU Gui de Chauliac, University Hospital of Montpellier, Montpellier, France
| | - Raphaël Blanc
- Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, INSERM U1254, Université de Lorraine, CHRU-Nancy, 54000, Nancy, France
| | - Sébastien Richard
- Department of Neurology, Stroke Unit, INSERM U1116, 54000, Nancy, France
| | - Gaultier Marnat
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Bordeaux, Bordeaux, France
| | - Igor Sibon
- Department of Neurology, Stroke Center, University Hospital of Bordeaux, Bordeaux, France
| | - Benoit Guillon
- Department of Neurology, University Hospital of Nantes, Nantes, France
| | - Romain Bourcier
- Department of Neuroradiology, University Hospital of Nantes, Nantes, France
| | - Christian Denier
- Department of Neurology, CHU Bicêtre, Le Kremlin Bicêtre, France
| | - Laurent Spelle
- Department of Interventional Neuroradiology, CHU Bicêtre, Le Kremlin Bicêtre, France
| | - Julien Labreuche
- ULR 2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Université de Lille, CHU Lille, 59000, Lille, France
| | - Arturo Consoli
- Department of Neuroradiology, Foch Hospital, Suresnes, France
| | | | - Vincent Costalat
- Department of Interventional Neuroradiology, CHRU Gui de Chauliac, University Hospital of Montpellier, Montpellier, France
| | - Michael Obadia
- Department of Neurology, Fondation Rothschild Hospital, Paris, France
| | - Caroline Arquizan
- Department of Neurology, CHRU Gui de Chauliac, University Hospital of Montpellier, 80 Avenue Augustin Fliche, 34295, Montpellier, France.
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16
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Pop R, Hasiu A, Mangin PH, Severac F, Mihoc D, Nistoran D, Manisor M, Simu M, Chibbaro S, Gheoca R, Quenardelle V, Rouyer O, Wolff V, Beaujeux R. Postprocedural Antiplatelet Treatment after Emergent Carotid Stenting in Tandem Lesions Stroke: Impact on Stent Patency beyond Day 1. AJNR Am J Neuroradiol 2021; 42:921-925. [PMID: 33602749 DOI: 10.3174/ajnr.a6993] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 11/10/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Postprocedural dual-antiplatelet therapy is frequently withheld after emergent carotid stent placement during stroke thrombectomy. We aimed to assess whether antiplatelet regimen variations increase the risk of stent thrombosis beyond postprocedural day 1. MATERIALS AND METHODS Retrospective review was undertaken of all consecutive thrombectomies for acute stroke with tandem lesions in the anterior circulation performed in a single comprehensive stroke center between January 9, 2011 and March 30, 2020. Patients were included if carotid stent patency was confirmed at day 1 postprocedure. The group of patients with continuous dual-antiplatelet therapy from day 1 was compared with the group of patients with absent/discontinued dual-antiplatelet therapy. RESULTS Of a total of 109 tandem lesion thrombectomies, 96 patients had patent carotid stents at the end of the procedure. The early postprocedural stent thrombosis rate during the first 24 hours was 14/96 (14.5%). Of 82 patients with patent stents at day 1, in 28 (34.1%), dual-antiplatelet therapy was either not initiated at day 1 or was discontinued thereafter. After exclusion of cases without further controls of stent patency, there was no significant difference in the rate of subacute/late stent thrombosis between the 2 groups: 1/50 (2%) in patients with continuous dual-antiplatelet therapy versus 0/22 (0%) in patients with absent/discontinued dual-antiplatelet therapy (P = 1.000). In total, we observed 88 patient days without any antiplatelet treatment and 471 patient days with single antiplatelet treatment. CONCLUSIONS Discontinuation of dual-antiplatelet therapy was not associated with an increased risk of stent thrombosis beyond postprocedural day 1. Further studies are warranted to better assess the additional benefit and optimal duration of dual-antiplatelet therapy after tandem lesion stroke thrombectomy.
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Affiliation(s)
- R Pop
- From the Interventional Neuroradiology Department (R.P., A.H., D.M., D.N., M.M., R.B.), Strasbourg University Hospitals, Strasbourg, France
- Institut de Chirurgie Minime Invasive Guidée par l'Image (R.P., R.B.), Strasbourg, France
| | - A Hasiu
- From the Interventional Neuroradiology Department (R.P., A.H., D.M., D.N., M.M., R.B.), Strasbourg University Hospitals, Strasbourg, France
| | - P H Mangin
- Institut National de la Santé et de la Recherche Médicale (P.H.M.), University of Strasbourg, l'Établissement français du sang Grand-Est, BPPS UMR-S1255, Fédération de Médecine Translationnelle de Strasbourg, Strasbourg, France
| | - F Severac
- Public Healthcare Department (F.S.), Strasbourg University Hospitals, Strasbourg, France
| | - D Mihoc
- From the Interventional Neuroradiology Department (R.P., A.H., D.M., D.N., M.M., R.B.), Strasbourg University Hospitals, Strasbourg, France
| | - D Nistoran
- From the Interventional Neuroradiology Department (R.P., A.H., D.M., D.N., M.M., R.B.), Strasbourg University Hospitals, Strasbourg, France
| | - M Manisor
- From the Interventional Neuroradiology Department (R.P., A.H., D.M., D.N., M.M., R.B.), Strasbourg University Hospitals, Strasbourg, France
| | - M Simu
- Neurology Department (M.S.), Victor Babes University of Medicine and Pharmacy, Timisoara, Romania
| | - S Chibbaro
- Neurosurgery Department (S.C.), Strasbourg University Hospitals, Strasbourg, France
| | - R Gheoca
- Stroke Unit (R.G., V.Q., O.R., V.W.), Strasbourg University Hospitals, Strasbourg, France
| | - V Quenardelle
- Stroke Unit (R.G., V.Q., O.R., V.W.), Strasbourg University Hospitals, Strasbourg, France
| | - O Rouyer
- Stroke Unit (R.G., V.Q., O.R., V.W.), Strasbourg University Hospitals, Strasbourg, France
| | - V Wolff
- Stroke Unit (R.G., V.Q., O.R., V.W.), Strasbourg University Hospitals, Strasbourg, France
| | - R Beaujeux
- From the Interventional Neuroradiology Department (R.P., A.H., D.M., D.N., M.M., R.B.), Strasbourg University Hospitals, Strasbourg, France
- Institut de Chirurgie Minime Invasive Guidée par l'Image (R.P., R.B.), Strasbourg, France
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17
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Jost A, Roels C, Brown M, Janjua R, Heck D. Low-Dose Eptifibatide for Tandem Occlusion in Stroke: Safety and Carotid Artery Patency. AJNR Am J Neuroradiol 2021; 42:738-742. [PMID: 33541892 DOI: 10.3174/ajnr.a6985] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 10/21/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Maintaining carotid patency and avoiding symptomatic intracranial hemorrhage are competing concerns in tandem occlusions. This study provides data regarding the safety and efficacy of eptifibatide in stroke from tandem occlusion of the extracranial carotid artery and the intracranial carotid or middle cerebral artery. MATERIALS AND METHODS This is a retrospective analysis of 58 consecutive patients who received low-dose eptifibatide (135-mcg/kg bolus, 1-mcg/kg/min infusion) during treatment of tandem occlusions. Brain imaging and carotid sonography were performed at 24-36 hours. mRS was documented at 90 days, and carotid sonography, at 30-60 days. RESULTS The median age and NIHSS score were 64 years and 15, respectively. Twenty-five patients (43%) received tPA. ASPECTSs were 8-10 in 47 (81%) and 5-7 in 11 (19%) patients. Thirty-eight patients had angioplasty/stent placement acutely; 20 had angioplasty alone. Symptomatic intracranial hemorrhage occurred in 1 patient (2%). TICI 2b or higher was achieved in 56 patients (96%). Fifty-seven of 58 patients had clinical follow-up at 90 days (1 lost to follow up). The 90-day mRS was 0-2 in 42 patients (72%). There were 4/58 (7%) re-occlusions within 24-36 hours, all originally treated with stent placement. Forty-nine of 53 surviving patients had carotid sonography at 30-60 days, with 3 delayed re-occlusions, 2 with stents and 1 with angioplasty alone. The overall carotid patency at 30-60 days was 42/49 (86%). Carotid re-occlusion was not associated with clinical decline. CONCLUSIONS Low-dose eptifibatide seemed to be safe in tandem occlusions (symptomatic intracranial hemorrhage, 2%), although asymptomatic cervical carotid artery re-occlusions still occurred in 14% of patients.
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Affiliation(s)
- A Jost
- From the Wake Forest School of Medicine (A.J.), Winston Salem, North Carolina
| | - C Roels
- Departments of Pharmacy (C.R.)
| | - M Brown
- Triad Radiology Associates (M.B., D.H.), Forsyth Medical Center, Winston Salem, North Carolina
| | - R Janjua
- Neurosurgery (R.J.), Novant Health, Forsyth Medical Center, Winston Salem, North Carolina
| | - D Heck
- Triad Radiology Associates (M.B., D.H.), Forsyth Medical Center, Winston Salem, North Carolina
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18
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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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19
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Neuberger U, Moteva K, Vollherbst DF, Schönenberger S, Reiff T, Ringleb PA, Bendszus M, Pfaff JAR, Möhlenbruch M. Tandem occlusions in acute ischemic stroke - impact of antithrombotic medication and complementary heparin on clinical outcome and stent patency. J Neurointerv Surg 2020; 12:1088-1093. [PMID: 31937604 DOI: 10.1136/neurintsurg-2019-015596] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 12/28/2019] [Accepted: 01/01/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND AND PURPOSE Mechanical thrombectomy (MT) and acute carotid stenting (ACS) of patients with acute ischemic stroke due to tandem occlusions (TO) of the anterior circulation was proven to be safe and effective, but the implications of periprocedural antithrombotic medications are only known to a limited extent. METHODS We conducted a retrospective analysis of 162 consecutive patients who presented with TO and were treated with MT and ACS in our center. Patients initially either received dual antiplatelet therapy (DAT) or tirofiban periprocedurally. Some patients were also treated with unfractionated heparin. The frequency of intracranial hemorrhages (ICH), as well as the impact on clinical outcome and stent patency of different medical regimes, were evaluated using univariate tests and adjusted multivariate logistic regressions. RESULTS Patients who received supportive treatment with heparin had significantly higher occurrences of any (OR, 2.46; 95% CI, 1.15 to 5.28) and symptomatic ICH (OR, 3.71; 95% CI, 1.18 to 14.95). Additionally, these patients were less likely to have a moderate clinical outcome after 90 days (modified Rankin scale 0-3; OR, 0.33; 95% CI, 0.15 to 0.72), but were more likely to have a fatal outcome after 90 days (OR, 2.84; 95% CI 1.10 to 7.31). These findings persisted in patients who received both DAT and heparin, but not for patients who received both tirofiban and heparin. CONCLUSION Supportive administration of heparin in patients with TO and treatment with MT and ACS should be carefully considered, especially in patients who primarily receive DAT.
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Affiliation(s)
- Ulf Neuberger
- Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | | | | | | | - Tilman Reiff
- Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Martin Bendszus
- Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
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20
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Complication Rates Using CASPER Dual-Layer Stents for Carotid Artery Stenting in Acute Stroke : A 3-Year Single Center Experience. Clin Neuroradiol 2019; 31:173-179. [PMID: 31822934 DOI: 10.1007/s00062-019-00860-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Accepted: 11/18/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND PURPOSE The number of acute and early stent occlusions after emergency stenting of the internal carotid artery (ICA) in patients with tandem lesions is unclear and only mentioned in a small number of publications, ranging from 0-20%. A recent article by Yilmaz et al. reported a high rate of acute in-stent occlusions of 45% within 72 h after deployment of CASPER dual layer stents. METHODS All patients with acute ischemic stroke treated with a CASPER stent between August 2014 and April 2018 were retrospectively evaluated for occlusion rates, periinterventional medication and early complications. A total of 66 patients, 45 with tandem pathologies and 21 with proximal ICA stenosis only were enrolled. RESULTS Thrombotic complications occurred in 16 out of 66 patients (24%) and hemorrhagic complications in 8/66 (12%) and 15 of the 16 thrombotic complications and 7/8 symptomatic intracranial hemorrhages (sICH) occurred in patients with tandem lesions and accessory intracranial thrombectomy. Of the patients with sICH five were treated in a prolonged or unknown time window. In patients with intraprocedural thrombotic complications ultrasound imaging showed patent stents in 13 of the 14 patients CONCLUSIONS: The CASPER stent system showed a high technical success rate in patients with acute stroke. The number of patients with sICH was not higher than the numbers reported in the published literature despite the early use of Gp IIb/IIIA inhibitors, whereas the number of thrombotic complications was smaller than that reported in recent studies. The majority of sICH occurred in patients treated because of tandem lesions in an unknown or prolonged time window.
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