Carotid angioplasty-assisted mechanical thrombectomy without urgent stenting may be a better option in acute tandem occlusions

Background The aim of the study was to assess the efficacy of balloon angioplasty-assisted mechanical thrombectomy without urgent stenting in the carotid artery as another approach for endovascular treatment of tandem occlusions. Methods Fifteen consecutive cases of tandem occlusions treated with the endovascular approach between January 2014 and May 2016 were reviewed. The study cohort included patients with an etiology of large vessel atherosclerosis. Extracranial carotid stenting was performed in another session if post-thrombectomy mRS modified Rankin Score (mRS) was 0–2. Good clinical outcome was determined by follow-up at 7–10, 30 and 90 days according to the mRS. Results Most patients (80%) were male. Eight (53.4%) patients received intravenous thrombolysis before angiography. Proximal revascularization was successful in 100% of cases with balloon angioplasty internal carotid artery (ICA) origin. Successful recanalization (modified thrombolysis in cerebral infarction (mTICI) 2b-3) (mTICI 2 b–3) occurred in 12 cases (80%) and good clinical outcomes were achieved in 10 patients (66.7%). Cervical ICA stent placement was performed in 10 patients with good clinical outcomes. No symptomatic intracranial hemorrhage occurred after delayed ICA stenting Conclusions This is the first reported case series to evaluate this approach for endovascular treatment of tandem occlusions. Carotid angioplasty-assisted mechanical thrombectomy without urgent stenting seems to be a safer approach.

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Abstract P553: Outcomes of Acute Endovascular Cervical Carotid Revascularization in Anterior Circulation Tandem Occlusions During Mechanical Thrombectomy

Stroke ◽

10.1161/str.52.suppl_1.p553 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Aayushi Garg ◽

Darko Quispe Orozco ◽

Kaustubh Limaye ◽

Cynthia Zevallos ◽

Alan Mendez Ruiz ◽

...

Keyword(s):

Carotid Artery ◽

Clinical Outcomes ◽

Mechanical Thrombectomy ◽

Intravenous Thrombolysis ◽

Tube Placement ◽

Total Hospital Cost ◽

Anterior Circulation ◽

Carotid Revascularization ◽

Discharge Disposition ◽

Tandem Occlusion

Introduction: Acute ischemic strokes with intracranial large vessel occlusion (LVO) and cervical internal carotid artery (ICA) tandem occlusion have traditionally been known to have a poor prognosis. Recent evidence suggests favorable functional outcomes in patients undergoing emergent carotid artery stenting (CAS) following intracranial mechanical thrombectomy (MT). We aimed to evaluate the outcomes of endovascular carotid revascularization (CR) performed acutely after emergent intracranial MT. Methods: We used the Nationwide Readmissions Database 2016-2017 to identify patients admitted with anterior circulation LVO treated with MT. Patients who underwent CAS or carotid artery angioplasty (CAA) during the same hospitalization were also identified. Propensity scores were used to match patients with and without CR in a 1:1 ratio by demographics, comorbidities, use of intravenous thrombolysis and hospital-level characteristics. Logistic regression and survival analyses were used to compare the outcomes. Results: We identified 15,137 hospitalizations meeting the study inclusion criteria (mean±SD age:70.1±14.6, female 51.1%). Of these, 1,214 (8.0%) underwent CAS or CAA during the same hospitalization. After propensity score matching, we obtained 1,063 well matched pairs of patients with and without CR. In the matched cohort, patients who underwent CR had higher odds of hemorrhagic transformation (OR 1.34, 95% CI 1.07-1.69, p 0.011) and higher total hospital cost (mean difference $6,232, 95% CI 3,606-8,858, p 0.001) but other clinical outcomes including gastrostomy tube placement, decompressive craniectomy, prolonged mechanical ventilation, in-hospital mortality, length of stay, and discharge disposition did not differ between the two groups. Patients with CR were less likely to have an unplanned 30-day readmission (HR 0.67, 95% CI 0.51-0.87, p 0.004). Further, they had more readmissions due to ICH (HR 1.06, 95% CI 0.41-2.71) and less readmissions due to ischemic events (HR 0.39, 95% CI 0.14-1.08), although the difference was not statistically significant. Conclusion: If indicated, early endovascular CR for anterior circulation tandem occlusions seems to be safe with clinical outcomes comparable to patients undergoing MT alone.

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Endovascular treatment for large vessel occlusion stroke in patients with ventricular assist devices

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2018-014645 ◽

2019 ◽

Vol 11 (12) ◽

pp. 1205-1209 ◽

Cited By ~ 2

Author(s):

Yoshinori Kadono ◽

Hajime Nakamura ◽

Shunsuke Saito ◽

Takeo Nishida ◽

Masatoshi Takagaki ◽

...

Keyword(s):

Endovascular Treatment ◽

Mechanical Thrombectomy ◽

Intravenous Thrombolysis ◽

Large Vessel ◽

Ventricular Assist Devices ◽

Study Cohort ◽

Cardiac Transplant ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Ventricular Assist

BackgroundEmbolic stroke with large vessel occlusion (LVO) is a major adverse event during ventricular assist device (VAD) support. In this study we aimed to clarify the efficacy of, and problems associated with, endovascular treatment (EVT) of LVO in patients with VAD support.MethodsWe retrospectively reviewed EVT for LVO in patients with VAD support between 2006 and 2017 at our institute and evaluated baseline characteristics, treatment variables, outcomes, and complications.ResultsThe study cohort comprised 12 consecutive patients (age 35.4±20.4 years), with 15 LVO events involving 20 arterial occlusions, who had undergone EVT. The median Alberta Stroke Program Early CT score was 10 and good collaterals were observed in 10 of 17 occluded middle cerebral artery areas. No study patients had received intravenous thrombolysis therapy. EVT was performed on 18 of the 20 occluded arteries and mechanical thrombectomy on 13 vessels. The successful reperfusion (modified Thrombolysis in Cerebral Infarction grade ≥2 b) rate was 67% in all EVTs and 85% with mechanical thrombectomy. Histological analysis showed fibrin-rich thrombi in four of five samples. Seven of 12 patients (58%) maintained their neurological function (modified Rankin Scale score ≤2 or equal to pre-stroke score) at 90 days. Periprocedural complications comprised two symptomatic intracranial hemorrhages and the 90-day mortality rate was 13%. Seven of 10 cardiac transplant candidates (70%) returned to the waiting list and three of them received transplants.ConclusionsEndovascular therapy for acute LVO stroke is feasible even in patients with VAD support.

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Mechanical Thrombectomy in Stroke. Experience from Switching from Stent Retriever Only to Stent Retriever Combined with Aspiration Catheter

Journal of Clinical Medicine ◽

10.3390/jcm10091802 ◽

2021 ◽

Vol 10 (9) ◽

pp. 1802

Author(s):

Grzegorz Meder ◽

Paweł Żuchowski ◽

Wojciech Skura ◽

Violetta Palacz-Duda ◽

Milena Świtońska ◽

...

Keyword(s):

Endovascular Treatment ◽

Clinical Outcomes ◽

Mechanical Thrombectomy ◽

Statistical Significance ◽

Stent Retriever ◽

Single Center Experience ◽

Significant Difference ◽

First Pass ◽

Need To Evaluate ◽

The Difference

Endovascular treatment is a rapidly evolving technique; therefore, there is a constant need to evaluate this method and its modifications. This paper discusses a single-center experience and the results of switching from the stent retriever only (SO) mechanical thrombectomy (MT) to the combined approach (CA), with a stent retriever and aspiration catheters. Methods: The study involved a retrospective analysis of 70 patients undergoing MT with the use of either SO or CA. The primary endpoint was the frequency of perfect reperfusion defined as grade 3 of the modified Thrombolysis in Cerebral Infarction scale (mTICI) after the first pass. The secondary endpoints were the procedure success, defined as mTICI grades 2b-3; time of the procedure; clinical outcome, measured by 90 days’ modified Rankin Scale (mRS) score; Δ NIHSS, defined as the difference between National Institutes of Health Stroke Scale (NIHSS) score at patients’ admission and discharge; and the total number of device passes. Results: Out of the 70 patients included, 33 were treated with SO and 37 with CA. In both groups, a total number of 42 patients received intravenous recombined tissue plasminogen activator (iv-rTPA: 20 patients (60.6%) in the SO group and 22 patients (59.5%) in the CA group (p = 1.000). There was a significant difference between the groups regarding first-pass success rate, with 46% in the CA group and 18% in the SO group, (OR 3.83, 95% CI 1.28 to 11.44, p = 0.016). Complete procedure success tended to be more frequent in the CA group than in the SO group—94.6% vs. 84.8% (OR 3.13, 95% CI 0.56 to 17.34, p = 0.193)—and CA tended to require a lower number of passes than SO (mean 1.76 vs. 2.09 passes per procedure, p = 0.114), yet these differences did not reach statistical significance. Mean duration of the procedure was significantly shorter in the CA group than in the SO group (49 min vs. 64 min, p = 0.017). There was a significant difference in clinical outcomes, with higher Δ NIHSS (9.3 in the CA group vs. 6.7 in the SO group, p = 0.025) after the procedure and 90-day mRS (median 2 in the CA group vs. 4 in the SO group, p = 0.031). Conclusions: Combining stent retrievers with aspiration catheters may offer a beneficial effect on angiographic results and clinical outcomes in stroke patients undergoing endovascular treatment.

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Abstract P101: Mechanical Thrombectomy in COVID-19 Positive Patients With Large Vessel Occlusion: Pooled Review of Individual Case Series

Stroke ◽

10.1161/str.52.suppl_1.p101 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Muhammad Z Memon ◽

Taha Nisar ◽

Amit Singla ◽

Anil Nanda ◽

Gaurav Gupta ◽

...

Keyword(s):

Clinical Outcomes ◽

Mechanical Thrombectomy ◽

Case Reports ◽

Case Series ◽

Individual Case ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Historic Data ◽

Meta Analyses

Background: COVID-19 has been shown to induce a hypercoagulable state thereby increasing the risk of arterial thrombosis resulting in Large Vessel Occlusion Stroke (LVOs) Objective: We performed a systematic review of published reports to study the clinical characteristics, and outcomes of COVID-19 acute ischemic stroke (AIS) patients with LVO treated with mechanical thrombectomy (MT) and compared them with historical controls. Methods: We conducted a systematic literature search from December 2019 to July 2020 using multiple combinations of keywords from PubMed and Ovid databases according to the PRISMA meta-analyses and systemic reviews guidelines and then pooled data from individual case series. We included studies where COVID -19 associated LVO cases were treated with MT and their clinical outcomes were reported. We then compared these findings with the historic patient data from the five landmark randomized MT trials, the Hermes collaborators (HC). Results: An initial search generated 12 studies but after excluding case reports and multiple reports comprising of the same series of patients, a total of five reports consisting of 51 patients were analyzed. The mean age of patients was 59 years (IQR 36-75), and 40 (78 %) were men. Median NIHSS on presentation was 20 (IQR 10-29). AIS with LVO was the presenting manifestation of COVID-19 in 16 (20%) of patients. Intracranial ICA was the most common site of occlusion found in 27 (53%) of patients with multi-territory occlusion in 10 (20 %). Final recanalization TICI ≥ 2b was achieved in 33 (64%) of patients but reocclusion was noted in 7 (14 %). Modified Rankin score (mRS) 0-2 was reported in 12 (23 %) of patients with 40 % in-hospital mortality. When compared to historic data from HC, COVID -19 patients were younger (59 vs 69 years), presented with a higher median NIHSS score (20 vs 17), and had a higher prevalence of ICA terminus occlusion (53% vs 21% ). Similarly, patient outcomes were poor in the COVID -19 group with mRs 0-2 in (23 % versus 46 %) and mortality (40 % vs 15 %) compared to Hermes group. Conclusion: COVID -19 AIS patients with LVO who underwent MT were younger, had multiple territory occlusions with a propensity for ICA terminus location, and had poor angiographic and clinical outcomes as compared to historic data.

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Neurointerventional management of carotid webs associated with recurrent and acute cerebral ischemic syndromes

Interventional Neuroradiology ◽

10.1177/1591019916633245 ◽

2016 ◽

Vol 22 (4) ◽

pp. 432-437 ◽

Cited By ~ 21

Author(s):

AH Elmokadem ◽

SA Ansari ◽

R Sangha ◽

S Prabhakaran ◽

A Shaibani ◽

...

Keyword(s):

Ischemic Stroke ◽

Carotid Artery ◽

Surgical Resection ◽

Mechanical Thrombectomy ◽

Carotid Stenting ◽

Large Vessel ◽

Definitive Treatment ◽

Atheromatous Plaque ◽

Left Middle Cerebral Artery ◽

Computed Tomographic

Background A carotid web can be defined as an endoluminal shelf-like projection often noted at the origin of the internal carotid artery (ICA) just beyond the bifurcation. Diagnosis of a carotid web as an underlying cause of recurrent ischemic stroke is infrequent and easily misdiagnosed as an atheromatous plaque. Surgery has traditionally been used to resect symptomatic lesions while there is no enough evidence supporting medical therapy as the sole management. To our knowledge there is only one report about carotid artery stenting (CAS) as a definite management of carotid web and no previous reports of acute large-vessel occlusions undergoing mechanical thrombectomy in the setting of carotid web as the etiology. Case report We report two cases: The first presented with recurrent ischemic stroke in the same arterial territory and the other with an emergent left middle cerebral artery (MCA) occlusion that underwent endovascular mechanical thrombectomy in which initial computed tomographic angiograms (CTA) suggested carotid web etiologies. Following confirmation with digital subtraction angiography (DSA), both patients ultimately underwent endovascular carotid stenting instead of surgical resection for definitive carotid web treatment. Conclusions Carotid webs are a rare cause of ischemic stroke in young and middle-aged adults that can readily be identified by CTA. Endovascular management may include emergent mechanical thrombectomy for large-vessel thromboembolic complications, and for definitive treatment with carotid stenting across the carotid web as an alternative to surgical resection and medical management for secondary stroke prevention.

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Combined intravenous and endovascular treatment versus primary mechanical thrombectomy. The Italian Registry of Endovascular Treatment in Acute Stroke

International Journal of Stroke ◽

10.1177/1747493019851279 ◽

2019 ◽

Vol 14 (9) ◽

pp. 898-907 ◽

Cited By ~ 5

Author(s):

Ilaria Casetta ◽

Giovanni Pracucci ◽

Andrea Saletti ◽

Valentina Saia ◽

Marina Padroni ◽

...

Keyword(s):

Confidence Interval ◽

Endovascular Treatment ◽

Odds Ratio ◽

Mechanical Thrombectomy ◽

Combined Treatment ◽

Case Fatality ◽

Intravenous Thrombolysis ◽

Lower Probability ◽

Modified Rankin Scale ◽

Vessel Occlusion

Background Whether mechanical thrombectomy alone may achieve better or at least equal clinical outcome than mechanical thrombectomy combined with intravenous thrombolysis is a matter of debate. Methods From the Italian Registry of Endovascular Stroke Treatment, we extracted all cases treated with intravenous thrombolysis followed by mechanical thrombectomy or with primary mechanical thrombectomy for anterior circulation stroke due to proximal vessel occlusion. We included only patients who would have qualified for intravenous thrombolysis. We compared outcomes of the two groups by using multivariate regression analysis and propensity score method. Results We included 1148 patients, treated with combined intravenous thrombolysis and mechanical thrombectomy therapy (n = 635; 55.3%), or with mechanical thrombectomy alone (n = 513; 44.7%). Demographic and baseline clinical characteristics did not differ between the two groups, except for a shorter onset to groin puncture time (p < 0.05) in the mechanical thrombectomy group. A shift in the 90-day modified Rankin Scale distributions toward a better outcome was found in favor of the combined treatment (adjusted common odds ratio = 1.3; 95% confidence interval: 1.04–1.66). Multivariate analyses on binary outcome show that subjects who underwent combined treatment had higher probability to survive with modified Rankin Scale 0–3 (odds ratio = 1.42; 95% confidence interval: 1.04–1.95) and lower case fatality rate (odds ratio = 0.6; 95% confidence interval: 0.44–0.9). Hemorrhagic transformation did not differ between the two groups. Conclusion These data seem to indicate that combined intravenous thrombolysis and mechanical thrombectomy could be associated with lower probability of death or severe dependency after three months from stroke due to large vessel occlusion, supporting the current guidelines of treating eligible patients with intravenous thrombolysis before mechanical thrombectomy.

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What Have We Learned from the Imaging in Carotid Angioplasty and Risk of Stroke (ICAROS) Study?

Vascular ◽

10.1258/rsmvasc.12.1.62 ◽

2004 ◽

Vol 12 (1) ◽

pp. 62-68 ◽

Cited By ~ 6

Author(s):

Giorgio M. Biasi ◽

Alberto Froio ◽

Gaetano Deleo ◽

Claudia Piazzoni ◽

Valter Camesasca

Keyword(s):

Risk Factor ◽

Clinical Practice ◽

Carotid Artery ◽

Carotid Artery Stenting ◽

Carotid Plaque ◽

Independent Risk Factor ◽

Carotid Stenting ◽

Computer Assisted ◽

Carotid Angioplasty ◽

Cerebral Embolization

Carotid artery stenting (CAS) is used widely to treat carotid lesions. Indication to CAS is mostly based, both in trial and in clinical practice, on the percentage of stenosis and the presence or absence of preprocedural neurologic symptoms, whereas the features of the plaque are somehow disregarded and ignored. The most severe complication of CAS is stroke, related to cerebral embolization from carotid plaque. Several studies showed that echolucent plaques generate a higher number of embolic particles following carotid stenting. Echolucency can be measured using the gray scale median, which is an objective and quantitative computer-assisted grading of the echogenicity of carotid plaques. As previously demonstrated in the ICAROS study, carotid plaque echolucency is an independent risk factor for stroke in carotid stenting. Carotid plaque echolucency is one of the parameters that should be mandatory to be considered for indication to treatment.

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Carotid Angioplasty: Is it Safe?

Journal of Endovascular Therapy ◽

10.1177/152660289600300111 ◽

1996 ◽

Vol 3 (1) ◽

pp. 35-41 ◽

Cited By ~ 4

Author(s):

Jean-Pierre Becquemin ◽

Peter Qvarfordt ◽

Yves Castier ◽

Didier Melliere

Keyword(s):

Carotid Artery ◽

Balloon Angioplasty ◽

Personal Experience ◽

Neurologic Complications ◽

Carotid Angioplasty ◽

Review Of The Literature ◽

Long Term Follow Up ◽

Evolutionary Pace

For 15 years, balloon angioplasty has been cautiously applied to carotid artery occlusive lesions. Procedural results have, by and large, been satisfactory, but the potential for significant neurologic complications and a dearth of controlled studies with long-term follow-up have impeded the development of carotid angioplasty until recently. This review of the literature chronicles the slow but steady evolutionary pace of carotid angioplasty from its beginnings in 1980 to today's shifting focus to the use of stents. Based on these existing reports and significant personal experience, the advantages and risks of endoluminal carotid interventions are enumerated, along with suggested criteria for the application of carotid angioplasty.

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Endovascular Treatment of Stroke Caused by Carotid Artery Dissection

Brain Sciences ◽

10.3390/brainsci10110800 ◽

2020 ◽

Vol 10 (11) ◽

pp. 800

Author(s):

Grzegorz Meder ◽

Milena Świtońska ◽

Piotr Płeszka ◽

Violetta Palacz-Duda ◽

Dorota Dzianott-Pabijan ◽

...

Keyword(s):

Ischemic Stroke ◽

Carotid Artery ◽

Endovascular Treatment ◽

Small Proportion ◽

Mechanical Thrombectomy ◽

Carotid Artery Dissection ◽

Large Vessel ◽

Artery Dissection ◽

Large Vessel Occlusion ◽

Vessel Occlusion

Ischemic stroke due to large vessel occlusion (LVO) is a devastating condition. Most LVOs are embolic in nature. Arterial dissection is responsible for only a small proportion of LVOs, is specific in nature and poses some challenges in treatment. We describe 3 cases where patients with stroke caused by carotid artery dissection were treated with mechanical thrombectomy and extensive stenting with good outcome. We believe that mechanical thrombectomy and stenting is a treatment of choice in these cases.

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Wrap-Clipping for Patients with Ruptured Blood Blister–Like Aneurysms of the Internal Carotid Artery: Case Series and Literature Review

Journal of Neurological Surgery Part A Central European Neurosurgery ◽

10.1055/s-0041-1731756 ◽

2021 ◽

Author(s):

Xiao-Dong Zhai ◽

Bing-Wei Song ◽

Si-Shi Xiang ◽

Jian Ren ◽

Gui-Lin Li ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Clinical Outcomes ◽

Internal Carotid ◽

Case Series ◽

Large Sample Size ◽

Digital Subtraction ◽

Intraoperative Bleeding ◽

Ica Stenosis

Abstract Objective Blood blister–like aneurysms (BBAs) of the internal carotid artery (ICA) are challenging to treat. We assessed the clinical and radiologic outcomes in patients with ruptured BBAs of the ICA treated with wrap-clipping. Methods From November 2016 to January 2020, the clinical and radiologic data of patients with subarachnoid hemorrhage (SAH) caused by ICA BBAs who underwent wrap-clipping were retrospectively analyzed. The clinical outcomes were evaluated according to the modified Rankin Scale (mRS). Radiologic follow-up examinations included digital subtraction angiography (DSA), computed tomography angiography (CTA), and magnetic resonance angiography (MRA). Results Seven patients were enrolled in this study. All BBAs were wrap-clipped successfully, including two BBAs that exhibited intraoperative bleeding and required balloon-assistance during surgery. All patients had favorable clinical outcomes during follow-up. Among the six patients who completed the radiologic follow-up visit, one patient presented ICA occlusion at the 6-month DSA follow-up, but no neurologic dysfunction was noted. We did not observe the progression of ICA stenosis in other patients. Conclusion All BBAs in this study were wrap-clipped successfully and completely occluded. Wrap-clipping is effective for BBAs of the ICA and has favorable clinical outcomes. A multicenter study with a large sample size and a longer radiologic follow-up is necessary.

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