Functional and Safety Outcomes of Carotid Artery Stenting and Mechanical Thrombectomy for Large Vessel Occlusion Ischemic Stroke With Tandem Lesions

Abstract

ImportanceApproximately 10% to 20% of large vessel occlusion (LVO) strokes involve tandem lesions (TLs), defined as concomitant intracranial LVO and stenosis or occlusion of the cervical internal carotid artery. Mechanical thrombectomy (MT) may benefit patients with TLs; however, optimal management and procedural strategy of the cervical lesion remain unclear.ObjectiveTo evaluate the association of carotid artery stenting (CAS) vs no stenting and medical management with functional and safety outcomes among patients with TL-LVOs.Design, Setting, and ParticipantsThis cross-sectional study included consecutive patients with acute anterior circulation TLs admitted across 17 stroke centers in the US and Spain between January 1, 2015, and December 31, 2020. Data analysis was performed from August 2021 to February 2022. Inclusion criteria were age of 18 years or older, endovascular therapy for intracranial occlusion, and presence of extracranial internal carotid artery stenosis (>50%) demonstrated on pre-MT computed tomography angiography, magnetic resonance angiography, or digital subtraction angiography.ExposuresPatients with TLs were divided into CAS vs nonstenting groups.Main Outcomes and MeasuresPrimary clinical and safety outcomes were 90-day functional independence measured by a modified Rankin Scale (mRS) score of 0 to 2 and symptomatic intracranial hemorrhage (sICH), respectively. Secondary outcomes were successful reperfusion (modified Thrombolysis in Cerebral Infarction score ≥2b), discharge mRS score, ordinal mRS score, and mortality at 90 days.ResultsOf 685 patients, 623 (mean [SD] age, 67 [12.2] years; 406 [65.2%] male) were included in the analysis, of whom 363 (58.4%) were in the CAS group and 260 (41.6%) were in the nonstenting group. The CAS group had a lower proportion of patients with atrial fibrillation (38 [10.6%] vs 49 [19.2%], P = .002), a higher proportion of preprocedural degree of cervical stenosis on digital subtraction angiography (90%-99%: 107 [32.2%] vs 42 [20.5%], P < .001) and atherosclerotic disease (296 [82.0%] vs 194 [74.6%], P = .003), a lower median (IQR) National Institutes of Health Stroke Scale score (15 [10-19] vs 17 [13-21], P < .001), and similar rates of intravenous thrombolysis and stroke time metrics when compared with the nonstenting group. After adjustment for confounders, the odds of favorable functional outcome (adjusted odds ratio [aOR], 1.67; 95% CI, 1.20-2.40; P = .007), favorable shift in mRS scores (aOR, 1.46; 95% CI, 1.02-2.10; P = .04), and successful reperfusion (aOR, 1.70; 95% CI, 1.02-3.60; P = .002) were significantly higher for the CAS group compared with the nonstenting group. Both groups had similar odds of sICH (aOR, 0.90; 95% CI, 0.46-2.40; P = .87) and 90-day mortality (aOR, 0.78; 95% CI, 0.50-1.20; P = .27). No heterogeneity was noted for 90-day functional outcome and sICH in prespecified subgroups.Conclusions and RelevanceIn this multicenter, international cross-sectional study, CAS of the cervical lesion during MT was associated with improvement in functional outcomes and reperfusion rates without an increased risk of sICH and mortality in patients with TLs.

Mediation Analysis of Acute Carotid Stenting in Tandem Lesions

“…We previously found that acute CAS for cervical lesions during EVT of TLs was associated with improved functional outcomes and reperfusion rates compared with nonstenting. 3,9 In this subanalysis of a multicenter TL registry, we demonstrate for the first time to our knowledge, that up to 25% of the total treatment effect of acute CAS on the functional outcome in patients with TL undergoing EVT could be explained by its positive additional effect on reperfusion status. Our results also suggest that additional unrecognized characteristics and mechanisms account for the remaining 75% of the treatment effect.…”

“…4 More recently, our group found that patients treated with acute CAS had better mRS scores of 0–2 at 90 days compared with patients treated with acute balloon angioplasty alone or those whose ICA treatment was deferred by 24 hours or more (54.5% vs 36.7%; adjusted OR 1.67). 3 Finally, ongoing trials such as TITAN and EASI-TOC will provide further insights into whether acute CAS offers superior safety and efficacy compared with a non-CAS approach.…”

“…12 In the context of acute TLs, 3 large multicenter cohort studies have shown that when performed during EVT, the use of CAS of the cervical lesion during EVT is associated with higher rates of successful reperfusion (mTICI score ≥2b). 3,4,13 CAS repair of the cervical lesion may provide a synergistic clinical benefit to EVT in patients with acute TLs. However, the extent to which the favorable effect of acute CAS on functional outcomes can be explained by improved reperfusion, potentially due to an improved anterograde hemodynamic status or concomitant use of antiplatelets, remains unknown.…”

Cervical Dissection in Patients With Tandem Lesions Is Associated With Distal Embolism and Lower Recanalization Success

“…22 Clinically relevant variables were used for adjustment for the outcome measures. 5,23 Multiple Imputation by Chained Equations was used for handling the missing observations, and only variables missing <20% data were included. 24 Quality of imputation was assessed graphically through density plots for imputed observations.…”

Safety Outcomes of Mechanical Thrombectomy Versus Combined Thrombectomy and Intravenous Thrombolysis in Tandem Lesions

“…Patient eligibility and methods of collaboration have been reported previously. 24 Briefly, the study included adult patients with TL treated with MT within 24 hours after stroke onset from 16 stroke centers (15 hospitals in the United States and 1 in Spain) between January 2015 and December 2020. TL was defined as an intracranial LVO (petrous, sigmoid, or terminus segment of the internal carotid artery (ICA) or M1 or proximal M2 segment of the middle cerebral artery) with concomitant extracranial ICA stenosis ≥70% according to NASCET (North American Symptomatic Carotid Endarterectomy Trial).…”