Mechanical Thrombectomy for Tandem Occlusions of the Internal Carotid Artery—Results of a Conservative Approach for the Extracranial Lesion

Abstract

Background: Mechanical thrombectomy (MT) is of clinical benefit for patients with extracranial-intracranial tandem lesions of anterior circulation. However, the optimal approach to the cervical lesion of the internal carotid artery (ICA) during MT has yet to be established. Data on a conservative approach for the proximal lesion during the acute phase are scarce.Methods: A retrospective study on an institutional, prospective database was conducted. We included patients with anterior circulation stroke presenting with a tandem lesion that was approached conservatively during MT.Results: Thirty-five 35 patients were included, of whom 25 (71.4%) had an atheromatous ICA lesion and 10 (28.6%) a dissection. Despite implementing a conservative strategy, acute percutaneous transluminal angioplasty (PTA) and/or stenting was necessary in 8 (22.9%) and 3 patients (8.6%), respectively. Of 27 surviving patients, 7 (25.9%) underwent delayed treatment of the ICA lesion. No new embolic events occurred between MT and delayed treatment. A favorable clinical outcome (mRS ≤ 2) was achieved in 15/35 patients (45.7%) and was associated with higher baseline ASPECTS (OR 1.62, 95% CI 1.08–2.45, p = 0.002) and successful recanalization (OR 9.39, 95% CI 1.92–45.80, p = 0.0005). Successful recanalization (TICI ≥ 2B) itself was observed in 54.3% of patients and was more likely with acute treatment of the proximal ICA lesion (OR 6.3, 95% CI 11–35.67, p = 0.03) and, more importantly, by the use of distal access catheters (OR 16.25, 95% CI 3.06–86.41, p = 0.0001).Conclusion: A conservative approach for ICA lesions during MT is feasible and offers favorable outcomes and successful recanalization for a significant proportion of patients. However, acute treatment of the cervical lesion is often necessary (31.4%) to make the distal occlusion accessible. Clinical outcome is influenced by the size of the baseline ischemic core and by successful recanalization; the latter is strongly favored by the use of distal access catheters to pass the proximal lesion. The fact that acute treatment of the ICA lesion favored intracranial recanalization but had no effect on clinical outcome is probably due to sample size, emphasizing the need for large scale, randomized studies to determine the optimal treatment strategy for this pathology.

Impact of Emergent Cervical Carotid Stenting in Tandem Occlusion Strokes Treated by Thrombectomy: A Review of the TITAN Collaboration

“…Despite the encouraging results of the abovementioned studies demonstrating high successful reperfusion rate and good outcome with carotid artery stenting, the need of antithrombotic agents in the acute phase makes it a less appealing approach prompting some experts to recommend alternative approaches such as MT alone or angioplasty without acute stenting ( 16 ). Two retrospective studies demonstrated a high successful reperfusion rate and good outcome with angioplasty or MT alone ( 17 – 19 ); however, these studies suffered a small sample size. With angioplasty or MT alone approach, antithrombotic agents are often not required; therefore, the risk of hemorrhagic transformation is of lesser concern.…”

“…Actually no deleterious effect of carotid stenting has been already proved ( 19 ). To date, as Blassiau et al said, choice of strategy “may vary between institution and physicians and adapts as a result of personal experience” ( 17 ), though the absence of consensus. This debate highlights the need of a randomized controlled trial for tandem lesions population.…”

Carotid Revascularization: Current Practice and Future Directions

“…67 Even if one adopts a conservative strategy for the management of tandem occlusion, angioplasty or stenting may be necessary in up to 31% of cases, simply to provide access to the intracranial lesion. 68 Those that prefer to avoid stenting advocate angioplasty only to provide access to the intracranial vasculature for thrombectomy. They point to the single-center studies that suggest high in-stent thrombosis and intracranial hemorrhage rates, which may be due to the antithrombotic medications used in stenting.…”

Treatment Strategies for Tandem Occlusions in Acute Ischemic Stroke

“…A favorable clinical outcome (mRS 2) was achieved in 15/35 patients (45.7%) and was associated with higher baseline ASPECTS (OR: 1.62, 95% CI: 1.08-2.45, p ¼ 0.002) and successful recanalization (OR: 9.39, 95% CI: 1.92-45.80, p ¼ 0.0005). 46 Labeyrie et al reported 6 approaches to manage the cervical occlusion in 49 patients with TO (14% of MT): medical treatment alone in 16/64 (25%), stenting/angioplasty in 16/64 (25%), occlusion with coils in 12/64 (19%), angioplasty alone in 9/64 (14%), stent retriever in 8/64 (12%), and/ or thromboaspiration in 3/64 (5%). Early ipsilateral embolic recurrence occurred in 9/64 (14%).…”