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Multicenter Study
. 2023 Mar 1;6(3):e230736.
doi: 10.1001/jamanetworkopen.2023.0736.

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

Mudassir Farooqui  1 , Osama O Zaidat  2 , Ameer E Hassan  3 , Darko Quispe-Orozco  1 , Nils Petersen  4 , Afshin A Divani  5 , Marc Ribo  6 , Michael Abraham  7 , Johanna Fifi  8 , Waldo R Guerrero  9 , Amer M Malik  10 , James E Siegler  11 , Thanh N Nguyen  12 , Sunil Sheth  13 , Albert J Yoo  14 , Guillermo Linares  15 , Nazli Janjua  16 , Milagros Galecio-Castillo  1 , Wondewossen G Tekle  3 , Victor M Ringheanu  17 , Marion Oliver  18 , Giana Dawod  19 , Jessica Kobsa  4 , Ayush Prasad  4 , Asad Ikram  5 , Eugene Lin  2 , Kristine Below  2 , Cynthia B Zevallos  1 , Marta Olivé Gadea  6 , Abid Qureshi  7 , Andres Dajles  1 , Stavros Matsoukas  8 , Ameena Rana  11 , Mohamad Abdalkader  12 , Sergio Salazar-Marioni  13 , Jazba Soomro  14 , Weston Gordon  15 , Juan Vivanco-Suarez  1 , Charoskhon Turabova  16 , Maxim Mokin  9 , Dileep R Yavagal  10 , Mouhammad A Jumaa  20 , Santiago Ortega-Gutierrez  1
Affiliations
Multicenter Study

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

Mudassir Farooqui et al. JAMA Netw Open. .

Abstract

Importance: Approximately 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.

Objective: To 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 participants: This 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.

Exposures: Patients with TLs were divided into CAS vs nonstenting groups.

Main outcomes and measures: Primary 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.

Results: Of 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 relevance: In 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.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Zaidat reported receiving grants from Penumbra, Stryker, and Microvention outside the submitted work. Dr Hassan reported receiving personal fees from Medtronic, Microvention, Stryker, Penumbra, Cerenovus, Genentech, GE Healthcare, Scientia, Balt, Viz.ai, Insera therapeutics, Proximie, NeuroVasc, NovaSignal, Vesalio, Rapid Medical, Imperative Care, and Galaxy Therapeutics outside the submitted work. Dr Divani reported receiving grants from the Department of Defense Congressionally Directed Medical Research Programs outside the submitted work. Dr Abraham reported receiving consulting and lecture fees from Stryker Corp outside the submitted work. Dr Fifi reported receiving personal fees from Styker Corp, Proctor, Cerenovus, Microvention, and Imperative Care outside the submitted work. Dr Siegler reported serving on the AstraZeneca Speakers Bureau outside the submitted work. Dr Nguyen reported receiving grants from Medtronic and the Society of Vascular and Interventional Neurology outside the submitted work. Dr Yoo reported receiving grants from Cerenovus, Penumbra, Medtronic, Stryker, Genentech, and Vesalio, personal fees from Cerenovus, Penumbra, and Philips, nonfinancial support from Zoll Circulation Inc, having equity interest in Insera Therapeutics, and having stock options in Nicolab outside the submitted work. Dr Mokin reported serving as a consultant for Cerenovus, Medtronic, and Microvention and having stock options in Bendit Technologies, Borvo Medical, BrainQ, Endostream, Serenity Medical, Synchron, Sim&Cure, and Quantanosis.AI. Dr Yavagal reported serving as a consultant for Medtronic and Cerenovus outside the submitted work and as the chair for the global nonprofit campaign Mission Thrombectomy 2020+, which is operated by the Society for Vascular and Interventional Neurology, and giving medicolegal consultation on cases involving thrombectomy for stroke. Dr Ortega-Gutierrez reported receiving grants from National Institute of Neurological Disorders and Stroke, Stryker, Methink, Medtronic, VizAI, and Microvention and personal fees from Stryker, Medtronic, and Microvention outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Flowchart of the Study Patients
ICA indicates internal carotid artery.
Figure 2.
Figure 2.. Distribution of 90-Day Modified Rankin Scale (mRS) Score Among Patients With Carotid Artery Stenting and Nonstenting
Scores range from 0 to 6, with 0 indicating no symptoms; 1, no clinically significant disability; 2, slight disability (the patient is able to look after own affairs without assistance but unable to perform all previous activities); 3, moderate disability (patient requires some help but is able to walk unassisted); 4, moderately severe disability (patient is unable to attend to bodily needs without assistance and unable to walk unassisted); 5, severe disability (patient requires constant nursing care and attention); and 6, death.
Figure 3.
Figure 3.. Adjusted Treatment Estimates of Favorable Outcomes and Symptomatic Intracranial Hemorrhage
ASPECTS indicates Alberta Stroke Program Early CT Score; IV, intravenous; OR, odds ratio.
See this image and copyright information in PMC

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