Revascularization of carotid artery occlusion using stenting versus non stenting in endovascular management of tandem occlusion stroke

Abstract

Introduction: The use of extracranial internal carotid artery (ICA) stents after mechanical thrombectomy (MT) may be a source of morbidity and mortality. Studies comparing patients who received stenting to patients who do not receive stenting have a higher number of patients with failed intracranial reperfusion in the non-stenting cohort. In this study, we analyzed the impact of extracranial ICA stenting in tandem occlusion stroke in patients with successfully intracranial reperfusion.

Methods: This monocentric, retrospective cohort observational study reviewed all consecutive MT patients from January 2013 to January 2018. All patients with occlusions in the anterior circulation due to ICA atherosclerotic plaque embolus, TOAST 1, and were successfully reperfusion of at least 50% of the initially occluded target territory were included. Patients with a concomitant extracranial, or tandem, ICA occlusion which required MT and permanent stenting (stenting cohort) were compared to patients with extracranial atheromatous ICA plaques, which did not require permanent carotid stenting but were treated only by MT (non-stenting cohort). The three endpoints of this analysis were mortality rate at 90 days, good functional outcome defined as modified rankin scale (mRS) scores 0-2 at 90 days and symptomatic ICH (sICH). Outcomes were reported as odds ratios (ORs), indicating the odds that the intervention would lead to increased mortality rate, an improvement of at least one point on the mRS in a shift analysis and decreased rate of sICH.

Results: One hundred and two patients were included of which 42 were treated by MT and ICA stenting (stenting cohort) and 60 were treated by MT without stenting (non-stenting cohort). No significant differences observed as it relates to demographic data, stroke characteristics, symptom onset to groin puncture or groin puncture to final reperfusion time intervals. Univariate logistic regression showed a higher probability of mortality at 90 days in the stenting cohort than that in the non-stenting cohort (OR 2.78, 95% CI 1.21-7.25, P=0.03). Stenting was not associated with a significant difference in functional independence at 90 days or rate of sICH compared to the non-stenting cohort.

Conclusion: Stroke patients with successful intracranial reperfusion after MT had a higher probability of mortality within 90 days when concomitant stenting of the extracranial ICA was performed compared those patients who did not receive stenting.

Keywords: Atheromatosis; Carotid; Occlusion; Stent; Stroke; Thrombectomy.