Stenting and Angioplasty in Neurothrombectomy: Matched Analysis of Rescue Intracranial Stenting Versus Failed Thrombectomy

Abstract

BACKGROUND: Successful reperfusion is one of the strongest predictors of functional outcomes after mechanical thrombectomy (MT). Despite continuous advancements in MT technology and techniques, reperfusion failure still occurs in ≈15% to 30% of patients with large vessel occlusion strokes undergoing MT. We aim to evaluate the safety and efficacy of rescue intracranial stenting for large vessel occlusion stroke after failed MT. METHODS: The SAINT (Stenting and Angioplasty in Neurothrombectomy) Study is a retrospective analysis of prospectively collected data from 14 comprehensive stroke centers through January 2015 to December 2020. Patients were included if they had anterior circulation large vessel occlusion stroke due to intracranial internal carotid artery and middle cerebral artery-M1/M2 segments and failed MT. The cohort was divided into 2 groups: rescue intracranial stenting and failed recanalization (modified Thrombolysis in Cerebral Ischemia score 0–1). Propensity score matching was used to balance the 2 groups. The primary outcome was the shift in the degree of disability as measured by the modified Rankin Scale at 90 days. Secondary outcomes included functional independence (90-day modified Rankin Scale score 0–2). Safety measures included symptomatic intracranial hemorrhage and 90-day mortality. RESULTS: A total of 499 patients were included in the analysis. Compared with the failed reperfusion group, rescue intracranial stenting had a favorable shift in the overall modified Rankin Scale score distribution (acOR, 2.31 [95% CI, 1.61–3.32]; P <0.001), higher rates of functional independence (35.1% versus 7%; adjusted odds ratio [aOR], 6.33 [95% CI, 3.14–12.76]; P <0.001), and lower mortality (28% versus 46.5%; aOR, 0.55 [95% CI, 0.31–0.96]; P =0.04) at 90 days. Rates of symptomatic intracerebral hemorrhage were comparable across both groups (7.1% versus 10.2%; aOR, 0.99 [95% CI, 0.42–2.34]; P =0.98). The matched cohort analysis demonstrated similar results. Specifically, rescue intracranial stenting (n=107) had a favorable shift in the overall modified Rankin Scale score distribution (acOR, 3.74 [95% CI, 2.16–6.57]; P <0.001), higher rates of functional independence (34.6% versus 6.5%; aOR, 10.91 [95% CI, 4.11–28.92]; P <0.001), and lower mortality (29.9% versus 43%; aOR, 0.49 [95% CI, 0.25–0.94]; P =0.03) at 90 days with similar rates of symptomatic intracerebral hemorrhage (7.5% versus 11.2%; aOR, 0.87 [95% CI, 0.31–2.42]; P =0.79) compared with patients who failed to reperfuse (n=107). There was no heterogeneity of treatment effect across the prespecified subgroups for improvement in functional outcomes. CONCLUSIONS: Acute intracranial stenting appears to be a safe and effective rescue strategy in patients with large vessel occlusion stroke who failed MT. Randomized multicenter trials are warranted.

Rescue intracranial stenting for acute ischemic stroke after the failure of mechanical thrombectomy: A systematic review, meta-analysis, and trial sequential analysis

“…We retrieved 3,934 records from the three databases: 1,587 from Medline, 1,988 from Embase, and 359 from CENTRAL. A total of 15 studies were finally included ( 10 – 12 , 19 – 30 ). Before the full-text screening, we excluded 1,634 duplicates, 1,288 records because of reviews, abstracts only, or conference papers without detailed information, 527 records that reported the effect of mechanical thrombectomy, and 368 records that were not relevant to stenting treatment.…”

“…In the recent 2 years, studies that focused on the effectiveness of rescue stenting for patients with failed MT treatment were emerging ( 10 – 12 ). Among them, one study published in 2022 recruited 499 participants—the largest sample size today ( 12 ), and the study adopted the design of propensity score matching, which balanced the baseline characteristics between the stenting and non-stenting group and therefore generated a more robust result than previous studies did. The addition of these studies in a new systematic review with meta-analysis might further clarify whether rescue stenting is effective and safe for patients with acute ischemia stroke who had at least one failed MT.…”

Intracranial Artery Calcifications Profile as a Predictor of Recanalization Failure in Endovascular Stroke Treatment

“…This translates to improved clinical outcomes due to several reasons such as shorter procedural time, decreased arterial wall damage or thrombus fragmentation, and/or microvascular impairment. 20,21 The feasibility, safety, and efficacy of rescue intracranial stenting after failed thrombectomy in patients with anterior circulation large vessel occlusions had been suggested in 2 retrospective studies [22][23][24] and is being tested in prospective randomized clinical trials (NCT03955835 and NCT03993340). More studies are needed in order to optimize patient selection for these procedures.…”

“…The feasibility, safety, and efficacy of rescue intracranial stenting after failed thrombectomy in patients with anterior circulation large vessel occlusions had been suggested in 2 retrospective studies 22–24 and is being tested in prospective randomized clinical trials (NCT03955835 and NCT03993340). More studies are needed in order to optimize patient selection for these procedures.…”

Eptifibatide use in ischemic stroke patients undergoing endovascular thrombectomy: A matched cohort analysis

“…While these factors do not have an increased ICH risk following EVT, the difference in the stroke mechanism between the EPT and control groups may have contributed to the selection of treatment in these patients which is another limitation of our study. While the use of acute intracranial stenting is infrequently performed in our institution, we recently showed the safety and potential efficacy of acute rescue stenting in large vessel occlusion in a multi-center observational analysis ( 20 ). There was also heterogeneity between the groups (including between the control groups) regarding discharge disposition, precluding interpretation of these results.…”