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Randomized Controlled Trial
. 2024 Jun;31(6):e16256.
doi: 10.1111/ene.16256. Epub 2024 Feb 26.

Value of intravenous alteplase before thrombectomy among patients with tandem lesions and emergent carotid artery stenting: A subgroup analysis of the SWIFT DIRECT trial

Adnan Mujanovic  1 , Tomas Dobrocky  1 , Waltraud Pfeilschifter  2 , Luca Remonda  3 , Jildaz Caroff  4 , Daniel Behme  5 , David J Seiffge  6 , Carlo W Cereda  7 , Georg Kägi  8 , Joe Leyon  9 , Eike I Piechowiak  1 , Vincent Costalat  10 , Judith Wagner  11   12 , Emmanuel Chabert  13 , Thomas R Meinel  6 , Olav Jansen  14 , Angelika Alonso  15 , Christian Loehr  16 , David S Liebeskind  17 , Jan Gralla  1 , Urs Fischer  6   18 , Johannes Kaesmacher  1 ; SWIFT DIRECT investigators
Affiliations
Randomized Controlled Trial

Value of intravenous alteplase before thrombectomy among patients with tandem lesions and emergent carotid artery stenting: A subgroup analysis of the SWIFT DIRECT trial

Adnan Mujanovic et al. Eur J Neurol. 2024 Jun.

Abstract

Background and purpose: The value of intravenous thrombolysis (IVT) in eligible tandem lesion patients undergoing endovascular treatment (EVT) is unknown. We investigated treatment effect heterogeneity of EVT + IVT versus EVT-only in tandem lesion patients. Additional analyses were performed for patients undergoing emergent internal carotid artery (ICA) stenting.

Methods: SWIFT DIRECT randomized IVT-eligible patients to either EVT + IVT or EVT-only. Primary outcome was 90-day functional independence (modified Rankin Scale score 0-2) after the index event. Secondary endpoints were reperfusion success, 24 h intracranial hemorrhage rate, and 90-day all-cause mortality. Interaction models were fitted for all predefined outcomes.

Results: Among 408 included patients, 63 (15.4%) had a tandem lesion and 33 (52.4%) received IVT. In patients with tandem lesions, 20 had undergone emergent ICA stenting (EVT + IVT: 9/33, 27.3%; EVT: 11/30, 36.7%). Tandem lesion did not show treatment effect modification of IVT on rates of functional independence (tandem lesion EVT + IVT vs. EVT: 63.6% vs. 46.7%, non-tandem lesion EVT + IVT vs. EVT: 65.6% vs. 58.2%; p for interaction = 0.77). IVT also did not increase the risk of intracranial hemorrhage among tandem lesion patients (tandem lesion EVT + IVT vs. EVT: 34.4% vs. 46.7%, non-tandem lesion EVT + IVT vs. EVT: 33.5% vs. 26.3%; p for interaction = 0.15). No heterogeneity was noted for other endpoints (p for interaction > 0.05).

Conclusions: No treatment effect heterogeneity of EVT + IVT versus EVT-only was observed among tandem lesion patients. Administering IVT in patients with anticipated emergent ICA stenting seems safe, and the latter should not be a factor to consider when deciding to administer IVT before EVT.

Keywords: extracranial stent; intravenous thrombolysis; mechanical thrombectomy; randomized controlled trial; tandem lesion.

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Conflict of interest statement

T.D. reports paid consultancy work with Microvention outside the submitted work. D.J.S. reports grants from the Swiss National Science Foundation, Bangerter Rhyner Foundation, Swiss Heart Foundation, and AstraZeneca outside this study; and personal fees from Bayer, Alexion, BioXodes, and VarmX outside the submitted work. J.L. reports paid consultancy work with Medtronic, Stryker Neurovascular, and Microvention Europe outside the submitted work. E.I.P. reports grants from the Swiss National Science Foundation. U.F. reports financial support for the present study from Medtronic; research grants from the Medtronic BEYOND SWIFT registry, the Swiss National Science Foundation, and the Swiss Heart Foundation; and consulting fees from Medtronic, Stryker, and CSL Behring (fees paid to institution). J.K. reports financial support from Medtronic for the BEYOND SWIFT registry (fees paid to institution), and research grants from the Swiss National Science Foundation supporting the TECNO trial (fees paid to institution), Swiss Academy of Medical Sciences supporting MRI research (fees paid to institution), and Swiss Heart Foundation supporting cardiac MRI in the etiological workup of stroke patients (fees paid to institution). None of the other authors has any conflict of interest to disclose.

Figures

FIGURE 1
FIGURE 1
Outcomes stratified on the tandem lesion presence. EVT, endovascular therapy; IVT, intravenous thrombolysis; cs‐eTICI, cross‐sectional extended Thrombolysis in Cerebral Infarction. Functional outcome, evaluated as the shift on the modified Rankin Scale, was comparable between the groups. IVT did not show an association with 90‐day functional independence (odds ratio [OR] = 1.47, 95% confidence interval [CI] = 0.97–2.22). However, IVT increased rates of successful reperfusion (OR = 2.47, 95% CI = 1.07–5.69) and all tandem lesion patients in the EVT + IVT arm (n = 33/33, 100%) had successful reperfusion. IVT did not appear to increase the rates of intracranial hemorrhage, as these were comparable between the EVT + IVT and EVT‐only arms (OR = 1.22, 95% CI = 0.80–1.87).
FIGURE 2
FIGURE 2
Fitted interaction model of primary and secondary outcomes. Presence of a tandem lesion and emergent stenting of the internal carotid artery did not show treatment effect modification of endovascular treatment (EVT) + intravenous thrombolysis (IVT) versus EVT‐only regarding any predefined clinical and technical efficacy parameters including functional independence at 90 days (p for interaction = 0.77), successful reperfusion (p for interaction = 0.27), intracranial hemorrhage at 24 h (p for interaction = 0.15), and mortality rates at 90 days (p for interaction = 0.65). CI, confidence interval; cs‐eTICI, cross‐sectional extended Thrombolysis in Cerebral Infarction.
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