A systematic review and meta-analysis of observational evidence for the use of bailout self-expandable stents following failed anterior circulation stroke thrombectomy

Abstract

BackgroundThe crucial role of thrombectomy in the management of emergent large vessel occlusive stroke is not disputed but there is a technical failure rate in a significant minority of patients whose outcomes are often poor. Our objective was to perform a systematic review and meta-analysis to assess the safety and efficacy of permanent self-expandable stent deployment as a bailout procedure in cases of failed anterior circulation thrombectomy.MethodsTwo independent reviewers searched the Pubmed (Medline) database for studies reporting outcomes following failed endovascular thrombectomy with subsequent rescue therapy employing self-expandable stents.ResultsEight studies (one prospective, seven retrospective) originating from Europe, Asia, and America comprising 160 patients met the inclusion criteria. Estimated baseline National Institutes of Health Stroke Scale score was 17.1 (95% CI 15.7 to 18.4). Following failed thrombetcomy and stent deployment, the rate of favorable outcome (modified Rankin Scale score 0–2) was 43% (95% CI 34% to 53%). Pooled mortality was 21% (95% CI 13% to 33%). Successful recanalization (Thrombolysis in Cerebral Infarction (TICI) 2b–3 or Thrombolysis in Myocardial Infarction (TIMI) 2–3) was 71% (95% CI 63% to 77%). Symptomatic intracerebral hemorrhage was seen in 12% (95% CI 7% to 18%). The Solitaire stent (Medtronic) was the most commonly deployed stent following failed thrombectomy attempts (66%; 95% CI 31% to 89%). Pre- or post-stent angioplasty was performed in 39%of patients (95% CI 29% to 48%). Glycoprotein IIb/IIIa inhibitors were used in 89% (95% CI 71% to 97%). 95% of patients received postprocedural antiplatelet therapy.ConclusionA rescue stent procedure seems reasonable as a last resort following failed thrombectomy but currently the level of evidence is limited. Prospective registries may aid in guiding future recommendations.

Intracranial Stenting After Failed Thrombectomy in Patients With Moderately Severe Stroke: A Multicenter Cohort Study

“…In our study on ICS for moderately severe stroke, 2/41 patients experienced sICH. This result is comparable to those in the HERMES meta-analysis with 4.4% and is unexpectedly low compared to the latest acute ICS studies that reported on sICH rates ranging from 8 to 17% (1,12). Antithrombotic medication was administered periinterventionally in all our cases, some even in combination with IVT.…”

“…Recent retrospective case series have suggested reconsidering ICS as a bailout strategy when MT fails to recanalize LVOs (11,19). All these ICS studies report on typical thrombectomy cohorts with a median admission NIHSS ranging from 14 to 19 (12). However, there are currently no reports on ICS after failed thrombectomy for a homogenous group of less severe stroke patients.…”

“…Recently, acute intracranial stenting (ICS) has been reported to be a highly promising bailout strategy for theses frustrating thrombectomy cases with predictably poor outcomes (6)(7)(8)(9)(10)(11). Since these cases are still rare, past retrospective studies mostly analyzed heterogeneous cohorts, including a wide range of stroke severities (12).…”

Stenting with Acclino (flex) for symptomatic intracranial stenosis as secondary stroke prevention

“…These RCTs still represent the best available evidence for ICS in patients with symptomatic intracranial stenosis. Currently, ICS achieved promising results for intracranial stenosis in the setting of acute ischemic stroke after failed mechanical thrombectomy 6 7. However, elective ICS (eICS) as an endovascular treatment option for secondary stroke prevention has remained unpopular, although recurrence rates of stroke are high in patients with symptomatic intracranial stenosis despite best medical treatment 8.…”

Management of Acute Ischemic Stroke

“…Wareham et al in their analysis reported the rate of successful recanalization as 71% and favorable outcome in 43% of the patients. 60 But the studies included were mostly retrospective and heterogenous. However, use of self-expandable stents as a bailout procedure appears to be a reasonable approach.…”