Effects of Emergent Carotid Stenting Performed before or after Mechanical Thrombectomy in the Endovascular Management of Patients with Tandem Lesions: A Multicenter Retrospective Matched Analysis
Year: 2024
Type: article
Study design: Observational Study
Abstract: BACKGROUND AND PURPOSE: Mechanical thrombectomy (MT) along with emergent carotid stent placement (eCAS) has been suggested to have a greater benefit in patients with tandem lesions (TL), compared with other strategies of treatment. Nonetheless, there is no agreement on whether the intracranial occlusion should be treated before the cervical ICA lesion, or vice versa. In this retrospective multicenter study, we sought to compare clinical and procedural outcomes of the 2 different treatment approaches in patients with TL. MATERIALS AND METHODS: The prospective databases of 17 comprehensive stroke centers were screened for consecutive patients with TL who received MT and eCAS. Patients were divided in 2 groups based on whether they received MT before eCAS (MT-first approach) or eCAS before MT (eCAS-first approach). Propensity score matching was used to estimate the effect of the retrograde-versus-anterograde approach on procedure-related and clinical outcome measures. These included the modified TICI score 2b-3, other procedure-related parameters and adverse events after the endovascular procedure, and the ordinal distribution of the 90-day mRS scores. RESULTS: A total of 295 consecutive patients were initially enrolled. Among them, 208 (70%) received MT before eCAS. After propensity score matching, 56 pairs of patients were available for analysis. In the matched population, the MT-first approach resulted in a higher rate of successful intracranial recanalization (91% versus 73% in the eCAS-first approach, P = .025) and a mean shorter groin-to-reperfusion time (72 [SD, 38] minutes versus 93 [SD, 50] minutes in the anterograde approach, P = .017). Despite a higher rate of efficient recanalization in the MT-first group, we did not observe a significant difference regarding the ordinal distribution of the 90-day mRS scores. Rates of procedure-related adverse events and the occurrence of both parenchymal hemorrhage types 1 and 2 were comparable. CONCLUSIONS: Our study demonstrates that in patients with TL undergoing endovascular treatment, prioritizing the intracranial occlusion is associated with an increased rate of efficient MT and faster recanalization time. However, this strategy does not have an advantage in long-term clinical outcome. Future controlled studies are needed to determine the optimal treatment technique.
DOI: 10.3174/ajnr.a8421
Authors: Luca Scarcia, Francesca Colò, Andrea M. Alexandre, Valerio Brunetti, Alessandro Pedicelli, Francesco Arba, Maria Ruggiero, Mariangela Piano, Joseph D. Gabrieli, Valerio Da Ros, Daniele G. Romano, Anna Cavallini, Giancarlo Salsano, Pietro Panni, Nicola Limbucci, Antonio A. Caragliano, Riccardo Russo, Guido Bigliardi, Luca Milonia, Vittorio Semeraro, Emilio Lozupone, Luigi Cirillo, Frederic Clarençon, Andrea Zini, Aldobrando Broccolini, the Emergent Carotid Artery Stenting Study Group
Institutions: Centre Hospitalier Universitaire Henri-Mondor, Hôpitaux Universitaires Henri-Mondor, Università Cattolica del Sacro Cuore, Agostino Gemelli University Polyclinic, Istituti di Ricovero e Cura a Carattere Scientifico, Azienda Ospedaliero-Universitaria Careggi, Ospedale “M. Bufalini” di Cesena, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, University of Padua, Azienda Ospedale - Università Padova, University of Rome Tor Vergata, AOU San Giovanni di Dio e Ruggi d'Aragona, Fondazione Istituto Neurologico Nazionale Casimiro Mondino, Ospedale Policlinico San Martino, IRCCS Ospedale San Raffaele, Azienda Ospedaliera Universitaria Policlinico "G. Martino", Azienda Ospedaliera Citta' della Salute e della Scienza di Torino, Policlinico Umberto I, Ospedale Vito Fazzi, Ospedale Maggiore Carlo Alberto Pizzardi, Istituto delle Scienze Neurologiche di Bologna, Pitié-Salpêtrière Hospital
Language: English
Subfield: Clinical Neurology
Field: Medicine
Domain: Health Sciences
Open Access status: hybrid
OpenAlex ID: W4400768944