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Review
. 2023 Jun 16:14:1181295.
doi: 10.3389/fneur.2023.1181295. eCollection 2023.

Rescue therapy after thrombectomy for large vessel occlusion due to underlying atherosclerosis: review of literature

Tigran Khachatryan  1 , Mohammad Shafie  1 , Hermelinda Abcede  1 , Jay Shah  1 , Masaki Nagamine  1 , Justin Granstein  2 , Ichiro Yuki  2 , Kiarash Golshani  2 , Shuichi Suzuki  2 , Wengui Yu  1
Affiliations
Review

Rescue therapy after thrombectomy for large vessel occlusion due to underlying atherosclerosis: review of literature

Tigran Khachatryan et al. Front Neurol. .

Abstract

In this review article, we summarized the current advances in rescue management for reperfusion therapy of acute ischemic stroke from large vessel occlusion due to underlying intracranial atherosclerotic stenosis (ICAS). It is estimated that 24-47% of patients with acute vertebrobasilar artery occlusion have underlying ICAS and superimposed in situ thrombosis. These patients have been found to have longer procedure times, lower recanalization rates, higher rates of reocclusion and lower rates of favorable outcomes than patients with embolic occlusion. Here, we discuss the most recent literature regarding the use of glycoprotein IIb/IIIa inhibitors, angioplasty alone, or angioplasty with stenting for rescue therapy in the setting of failed recanalization or instant/imminent reocclusion during thrombectomy. We also present a case of rescue therapy post intravenous tPA and thrombectomy with intra-arterial tirofiban and balloon angioplasty followed by oral dual antiplatelet therapy in a patient with dominant vertebral artery occlusion due to ICAS. Based on the available literature data, we conclude that glycoprotein IIb/IIIa is a reasonably safe and effective rescue therapy for patients who have had a failed thrombectomy or have residual severe intracranial stenosis. Balloon angioplasty and/or stenting may be helpful as a rescue treatment for patients who have had a failed thrombectomy or are at risk of reocclusion. The effectiveness of immediate stenting for residual stenosis after successful thrombectomy is still uncertain. Rescue therapy does not appear to increase the risk of sICH. Randomized controlled trials are warranted to prove the efficacy of rescue therapy.

Keywords: balloon angioplasty; failed thrombectomy; intracranial atherosclerosis; intracranial atherosclerosis stenosis; intracranial stenosis; intracranial stenting; literature review; rescue therapy.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
Non-contrast CT head demonstrating hyperdense vessel sign in the left intracranial vertebral artery (arrow).
Figure 2
Figure 2
Diagnostic cerebral angiography, lateral view, demonstrating occlusion of the left vertebral artery past the level of the left posterior inferior cerebellar artery.
Figure 3
Figure 3
Diagnostic cerebral angiography, lateral view, distal reconstitution of the basilar and posterior cerebral arteries via hypoplastic right posterior communicating artery (arrowheads).
Figure 4
Figure 4
Post-thrombectomy angiography, lateral view, showing severe stenosis of the left intracranial vertebral artery (arrow).
Figure 5
Figure 5
Repeat angiography, lateral view, showing reocclusion of the left vertebral artery at the level of the stenosis.
Figure 6
Figure 6
Repeat angiography, lateral view, demonstrating the balloon angioplasty of the stenotic left vertebral artery.
Figure 7
Figure 7
Follow-up angiography 30 min after the balloon angioplasty, lateral view, demonstrating patent left vertebral artery with residual stenosis.
Figure 8
Figure 8
A postoperative MRI of the brain showing a low burden of scattered diffusion restriction in the bilateral cerebellar hemispheres.
Figure 9
Figure 9
A repeat MRI of the brain showing increased burden of diffusion restriction in bilateral cerebellar hemispheres.
See this image and copyright information in PMC

References

    1. Chimowitz MI, Lynn MJ, Derdeyn CP, Turan TN, Fiorella D, Lane BF, et al. . Stenting versus aggressive medical therapy for intracranial arterial stenosis. N Engl J Med. (2011) 365:993–1003. doi: 10.1056/NEJMoa1105335, PMID: - DOI - PMC - PubMed
    1. Gorelick PB, Wong KS, Bae HJ, Pandey DK. Large artery intracranial occlusive disease: a large worldwide burden but a relatively neglected frontier. Stroke. (2008) 39:2396–9. doi: 10.1161/STROKEAHA.107.505776, PMID: - DOI - PubMed
    1. Wong LKS. Global burden of intracranial atherosclerosis. Int J Stroke. (2006) 1:158–9. doi: 10.1111/j.1747-4949.2006.00045.x, PMID: - DOI - PubMed
    1. Kang DH, Kim YWSW, Hwang YH, Park SP, Kim YWSW, Baik SK. Instant reocclusion following mechanical thrombectomy of in situ thromboocclusion and the role of low-dose intra-arterial tirofiban. Cerebrovasc Dis. (2014) 37:350–5. doi: 10.1159/000362435 - DOI - PubMed
    1. Derdeyn CP, Chimowitz MI, Lynn MJ, Fiorella D, Turan TN, Janis LS, et al. . Aggressive medical treatment with or without stenting in high-risk patients with intracranial artery stenosis (SAMMPRIS): The final results of a randomised trial. Lancet. (2014) 383:333–41. doi: 10.1016/S0140-6736(13)62038-3 - DOI - PMC - PubMed