Emergent carotid stenting versus no stenting for acute ischemic stroke due to tandem occlusion: a meta-analysis

Abstract

BackgroundEmergent carotid artery stenting (eCAS) is performed during mechanical thrombectomy for acute ischemic stroke due to tandem occlusion. However, the optimal management strategy in this setting is still unclear.ObjectiveTo carry out a systematic review and meta-analysis to investigate the safety and efficacy of eCAS in patients with tandem occlusion.MethodsSystematic review followed the PRISMA guidelines. Medline, EMBASE, and Scopus were searched from January 1, 2004 to March 7, 2022 for studies evaluating eCAS and no-stenting approach in patients with stroke with tandem occlusion. Primary endpoint was the 90-day modified Rankin Scale score 0–2; secondary outcomes were (1) symptomatic intracerebral hemorrhage (sICH), (2) recurrent stroke, (3) successful recanalization (Thrombolysis in Cerebral Infarction score 2b–3), (4) embolization in new territories, and (5) restenosis rate. Meta-analysis was performed using the Mantel-Haenszel method and random-effects modeling.ResultsForty-six studies reached synthesis. eCAS was associated with higher good functional outcome compared with the no-stenting approach (OR=1.52, 95% CI 1.19 to 1.95), despite a significantly increased risk of sICH (OR=1.97, 95% CI 1.23 to 3.15), and higher successful recanalization rate (OR=1.91, 95% CI 1.29 to 2.85). Restenosis rate was lower in the eCAS group than in the no-stenting group (2% vs 9%, p=0.001). Recanalization rate was higher in retrograde than antegrade eCAS (OR=0.51, 95% CI 0.28 to 0.93). Intraprocedural antiplatelets during eCAS were associated with higher rate of good functional outcome (60% vs 46%, p=0.016) and lower rate of sICH (7% vs 11%; p=0.08) compared with glycoprotein IIb/IIIa inhibitors.ConclusionsIn observational studies, eCAS seems to be associated with higher good functional outcome than no-stenting in patients with acute ischemic stroke due to tandem occlusion, despite the higher risk of sICH. Dedicated trials are needed to confirm these results.

Early Stent Patency After Endovascular Therapy for Tandem or Isolated Carotid Steno-Occlusive Disease

“…3 A 2022 meta-analysis comparing acute CAS in patients with a tandem lesion, reported higher functional outcome with acute CAS (90-day modified Rankin Scale score ≤2, odds ratio, 1.52 [95% CI, 1.19–1.95]) but increased risk of symptomatic intracranial hemorrhage (odds ratio, 1.97 [95% CI, 1.23–3.15]). 4 However, this meta-analysis did not differentiate the pathophysiology of the tandem lesion by atherosclerotic versus dissection etiologies.…”

Comparison of three antithrombotic strategies for emergent carotid stenting during stroke thrombectomy: a multicenter study

“…Tandem lesions account for approximately 10–15% of endovascular treatments (EVT) for anterior circulation stroke 1. Several retrospective studies found that treatment of the proximal cervical lesion with emergent carotid artery stenting (eCAS) during EVT leads to increased rates of successful reperfusion and improved clinical outcomes,2–5 but the results of the MR-CLEAN MED trial6 showed that administration of aspirin or heparin during EVT is associated with increased risk of symptomatic intracranial hemorrhage (sICH). Two ongoing randomized trials, TITAN (NCT03978988)7 and EASI-TOC (NCT04261478), are evaluating the safety and efficacy of eCAS during EVT for tandem occlusions.…”

Antithrombotic regimen in emergent carotid stenting for acute ischemic stroke due to tandem occlusion: a meta-analysis of aggregate data

“…Acute ischemic stroke (AIS) due to tandem occlusions, defined as cervical internal carotid artery (ICA) high-grade stenosis or occlusion and ipsilateral intracranial occlusion, accounts for approximately 10–15% of all large vessel occlusions (LVOs) 1. While thrombectomy for intracranial LVO is well established, management of the extracranial stenosis or occlusion remains uncertain, as those tandem occlusions were poorly represented in the acute stroke randomized trials 2–9.…”

“…Evidence is building on the use of emergent carotid artery stenting (eCAS) in the context of mechanical thrombectomy (MT),11–13 with ongoing trials 14 15. A meta-analysis of observational studies1 demonstrated that eCAS carries a significantly increased risk of symptomatic intracerebral hemorrhage (sICH) compared with no stenting. The increase in bleeding risk seemed to be associated with the antithrombotic regimen following eCAS, with glycoprotein IIb/IIIa inhibitors (GPI) carrying a marginal increase in risk compared with antiplatelet therapy (APT), with a potential detrimental impact on long-term good functional outcome 1.…”

“…A meta-analysis of observational studies1 demonstrated that eCAS carries a significantly increased risk of symptomatic intracerebral hemorrhage (sICH) compared with no stenting. The increase in bleeding risk seemed to be associated with the antithrombotic regimen following eCAS, with glycoprotein IIb/IIIa inhibitors (GPI) carrying a marginal increase in risk compared with antiplatelet therapy (APT), with a potential detrimental impact on long-term good functional outcome 1. However, results were limited by the lack of solid data, inconsistent reporting across studies and little insight into intravenous thrombolysis rates in patients undergoing eCAS.…”