Rescue Stenting for Refractory Large Vessel Occlusions in the Thrombectomy Era: Intracranial Use of Coronary Stents in Low-mid Economic Settings

Abstract

Background: Failed mechanical thrombectomy due to a refractory emergent large vessel occlusion (RELVO) in patients presenting with an acute stroke poses a major challenge to the outcomes. Objective: We demonstrate the use of coronary stents in the intracranial circulation as rescue stenting for an already expensive mechanical thrombectomy procedure in a mid-low socioeconomic setting. Methods: A retrospective, multicenter study was conducted between December 2015 and January 2021. The studied cohort were patients who required the use of a rescue stenting using a coronary stent for emergent large vessel occlusion to avoid failed recanalization. Failed recanalization was defined as failed vessel recanalization after at least two passes. Patient demographic data, procedure specifics, type of stent used, and procedural outcomes were collected. Results: A total of 26 patients with acute ischemic stroke were included from eight different centers across India. Out of 26 patients, 19 (73.0%) were male and seven were female (26.9%). The mean age was 53.6 years, the youngest patient was 23 years old and the eldest was 68 years old. Seven patients (26.9%) had posterior circulation stroke due to occlusion of the vertebral or basilar artery and 19 patients (73.0%) had anterior circulation stroke median NIHSS at presentation was 16 (range 10 to 28) in anterior circulation stroke and 24 (range 16 to 30) in posterior circulation stroke. Intravenous thrombolysis with tissue plasminogen activator (IV tPA) was given in three patients (11.5%). The hospital course of two patients was complicated by symptomatic intracranial hemorrhage (sICH), which was fatal. Favorable revascularization outcome and favorable functional outcome was achieved in 22 patients (84.6%), three patients passed away (11.5%), and one patient was lost to follow up. Conclusions: Overall, our study finds that rescue stenting using coronary stents can potentially improve outcomes in refractory large vessel occlusions while minimizing costs in low-mid economic settings.

Rescue Stenting in Mechanical Thrombectomy Refractory Occlusions: A Single Center Multiethnic Cohort

“…The overall rates of recanalization were comparable to prior reported cohorts (13, 24-27) (Table 2), despite less utilization of angioplasty in our cohort compared to the above-mentioned cohorts. However, the main difference in our cohort is adherence to an aggressive platelet inhibition with glycoprotein IIb/IIIa inhibitors protocol after stenting in the majority of cases (90.9%) while in other cohorts it was left to the treating physician at times or reported in less than 42% of cases.…”

“…Unsurprisingly, our non-MENA cohort (composed mostly of South Asians) mirrored the Indian cohort reported by Sajja et al(27) in age.…”

Rescue intracranial permanent stenting for refractory occlusion following thrombectomy: a propensity matched analysis

“…Among plausible issues to improve the outcome of patients treated for an AIS due to LVO, RIS has been increasingly used and reported to increase the rates of recanalization after standard MT failure or early reocclusions,3–6 12 and several dedicated trials are underway 13.…”

“…Patients with refractory occlusions harbor a very severe prognosis, in terms of functional outcome and mortality. Intracranial stenting is increasingly reported in acute conditions as a rescue technique for maintaining vessel permeability 3–6. Rescue intracranial stenting (RIS) poses several challenges in the context of AIS, most notably for the management of antithrombotic regimens.…”