Platelet inhibition strategies in rescue stenting after failed thrombectomy: a large retrospective multicenter registry

Aikaterini Anastasiou¹, Alex Brehm¹, Johannes Kaesmacher^{2

3}, Adnan Mujanovic², Marta de Dios Lascuevas⁴, Tomás Carmona Fuentes⁴, Alfonso López-Frías⁵, Blanca Hidalgo Valverde⁶, Ansgar Berlis⁷, Christoph J Maurer⁷, Thanh N Nguyen⁸, Mohamad Abdalkader⁸, Piers Klein⁸, Guillaume Thevoz⁹, Patrik Michel⁹, Bruno Bartolini⁹, Marius Kaschner¹⁰, Daniel Weiss¹⁰, Andrea M Alexandre¹¹, Alessandro Pedicelli^{11

12}, Paolo Machi¹³, Gianmarco Bernava¹³, Shuntaro Kuwahara¹⁴, Kazutaka Uchida¹⁴, Jason Wenderoth^{15

16}, Anirudh Joshi^{15

16}, Grzegorz Karwacki¹⁷, Manuel Bolognese¹⁸, Agostino Tessitore¹⁹, Sergio Lucio Vinci^{19

20}, Amedeo Cervo²¹, Claudia Rollo²¹, Ferdinand Hui²², Aaisha Siddiqua Mozumder²², Daniele Giuseppe Romano²³, Giulia Frauenfelder²³, Nitin Goyal^{24

25}, Vivek Batra^{24

25}, Violiza Inoa^{24

25}, Christophe Cognard²⁶, Matúš Hoferica²⁶, Riitta Rautio²⁷, Daniel P O Kaiser^{28

29}, Johannes C Gerber^{28

29}, Julian Clarke³⁰, Michael R Levitt³⁰, Marcel N Wolf³¹, Ahmed E Othman³¹, Luca Scarcia³², Erwah Kalsoum³², Diana Melancia^{33

34

35}, Diana Aguiar de Sousa^{33

34}, Maria Porzia Ganimede³⁶, Vittorio Semeraro³⁶, Flavio Giordano³⁷, Massimo Muto³⁷, Aristeidis Katsanos³⁸, Umesh Bonala³⁸, Anil M Tuladhar^{39

40}, Sjoerd F M Jenniskens⁴¹, Victoria Hellstern⁴², Ilka Kleffner⁴³, Paolo Remida⁴⁴, Susanna Diamanti⁴⁵, Leonardo Renieri⁴⁶, Elena Ballabio⁴⁷, Luca Valvassori⁴⁸, Nikki Rommers⁴⁹, Mira Katan⁵⁰, Victor Schulze-Zachau⁵¹, Marios-Nikos Psychogios¹

Affiliations

¹ Diagnostic & Interventional Neuroradiology Department, University Hospital Basel, Basel, Switzerland.
² Department of Diagnostic and Interventional Neuroradiology, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland.
³ Diagnostic and Interventional Neuroradiology, CIC-IT 1415, CHRU de Tours, Tours, France.
⁴ Interventional Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain.
⁵ Interventional Neuroradiology, Hospital Clínico San Carlos, Madrid, Spain.
⁶ Stroke Unit, Department of Neurology, Hospital Clínico San Carlos, Madrid, Spain.
⁷ Diagnostic and Interventional Neuroradiology, University Hospital Augsburg, Augsburg, Germany.
⁸ Department of Radiology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
⁹ Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland.
¹⁰ Department of Diagnostic and Interventional Radiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.
¹¹ UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.
¹² Università Cattolica del Sacro Cuore, Roma, Italy.
¹³ Division of Neuroradiology, Geneva University Hospitals, Geneva, Switzerland.
¹⁴ Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan.
¹⁵ Institute of Neurological Sciences, Prince of Wales Hospital, Randwick, NSW, Australia.
¹⁶ Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia.
¹⁷ Department of Radiology and Nuclear Medicine, Cantonal Hospital Lucerne, Lucerne, Switzerland.
¹⁸ Neurocenter, Cantonal Hospital of Lucerne, Lucerne, Switzerland.
¹⁹ Neuroradiology Unit, University Hospital A.O.U. "G. Martino"-Messina, Messina, Italy.
²⁰ Department of Biomedical, Dental and Morphological and Functional Imaging (BIOMORF), University of Messina, Messina, Italy.
²¹ Department of Neuroradiology of Grande Ospedale Metropolitano Niguarda, Milan, Italy.
²² Neuroscience Institute, The Queen's Medical Center, University of Hawaii, Honolulu, HI, USA.
²³ Unit of Interventional Neuroradiology, University Hospital AOU Salerno, Salerno, Italy.
²⁴ Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.
²⁵ Department of Neurological Surgery, Semmes-Murphey Clinic, Memphis, TN, USA.
²⁶ Neuroradiology Department, Toulouse University Hospital, Toulouse, France.
²⁷ Turku University Hospital and University of Turku, Turku, Finland.
²⁸ Institute of Neuroradiology, Technische Universität Dresden, University Hospital Carl Gustav Carus, Dresden, Germany.
²⁹ Dresden Neurovascular Center, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
³⁰ Department of Neurological Surgery, University of Washington, Seattle, WA, USA.
³¹ Department of Neuroradiology, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany.
³² Department of Neuroradiology, Henri Mondor Hospital, Créteil, France.
³³ Stroke Center, Department of Neurosciences, Lisbon Central University Hospital-ULS São José, Lisbon, Portugal.
³⁴ Institute of Pharmacology and Neurosciences, Faculty of Medicine, University of Lisbon, Lisbon, Portugal.
³⁵ Faculdade de Medicina, Universidade de Lisboa, and Gulbenkian Institute for Molecular Medicine, Lisbon, Portugal.
³⁶ Diagnostic and Interventional Neuroradiology, SS. Annunziata Hospital, Taranto, Italy.
³⁷ Neuroradiology Department, AORN Cardarelli, Naples, Italy.
³⁸ Division of Neurology, McMaster University and Population Health Research Institute, Hamilton, ON, Canada.
³⁹ Department of Neurology, Radboud University Medical Center, Nijmegen, The Netherlands.
⁴⁰ Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, The Netherlands.
⁴¹ Department of Radiology & Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.
⁴² Interventional Neuroradiology Department, Radiology and Nuclear Medicine Network, Kantonsspital St. Gallen, HOCH Health Ostschweiz, Switzerland.
⁴³ Stroke Medicine and Neurocritical Care Palliative Care, Neurovascular Ultrasound, Knappschaft Kliniken, University Hospital Bochum, Bochum, Germany.
⁴⁴ Neuroradiology-Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.
⁴⁵ Neurology-Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.
⁴⁶ Neurovascular Interventional Unit, Careggi University Hospital, Florence, Italy.
⁴⁷ Department of Neurology, ASST Santi Paolo e Carlo, Milan, Italy.
⁴⁸ Department of Neuroradiology, ASST Santi Paolo e Carlo, Milan, Italy.
⁴⁹ Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland.
⁵⁰ Department of Neurology, Stroke Center, University Hospital of Basel, Basel, Switzerland.
⁵¹ Diagnostic & Interventional Neuroradiology Department, University Hospital Basel, Petersgraben 4, Basel 4031, Switzerland.

PMID: 40860647
PMCID: PMC12374045
DOI: 10.1177/17562864251360913

Platelet inhibition strategies in rescue stenting after failed thrombectomy: a large retrospective multicenter registry

Aikaterini Anastasiou et al. Ther Adv Neurol Disord. 2025.

. 2025 Aug 21:18:17562864251360913.

doi: 10.1177/17562864251360913. eCollection 2025.

Authors

Affiliations

¹ Diagnostic & Interventional Neuroradiology Department, University Hospital Basel, Basel, Switzerland.
² Department of Diagnostic and Interventional Neuroradiology, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland.
³ Diagnostic and Interventional Neuroradiology, CIC-IT 1415, CHRU de Tours, Tours, France.
⁴ Interventional Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain.
⁵ Interventional Neuroradiology, Hospital Clínico San Carlos, Madrid, Spain.
⁶ Stroke Unit, Department of Neurology, Hospital Clínico San Carlos, Madrid, Spain.
⁷ Diagnostic and Interventional Neuroradiology, University Hospital Augsburg, Augsburg, Germany.
⁸ Department of Radiology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
⁹ Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland.
¹⁰ Department of Diagnostic and Interventional Radiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.
¹¹ UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.
¹² Università Cattolica del Sacro Cuore, Roma, Italy.
¹³ Division of Neuroradiology, Geneva University Hospitals, Geneva, Switzerland.
¹⁴ Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan.
¹⁵ Institute of Neurological Sciences, Prince of Wales Hospital, Randwick, NSW, Australia.
¹⁶ Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia.
¹⁷ Department of Radiology and Nuclear Medicine, Cantonal Hospital Lucerne, Lucerne, Switzerland.
¹⁸ Neurocenter, Cantonal Hospital of Lucerne, Lucerne, Switzerland.
¹⁹ Neuroradiology Unit, University Hospital A.O.U. "G. Martino"-Messina, Messina, Italy.
²⁰ Department of Biomedical, Dental and Morphological and Functional Imaging (BIOMORF), University of Messina, Messina, Italy.
²¹ Department of Neuroradiology of Grande Ospedale Metropolitano Niguarda, Milan, Italy.
²² Neuroscience Institute, The Queen's Medical Center, University of Hawaii, Honolulu, HI, USA.
²³ Unit of Interventional Neuroradiology, University Hospital AOU Salerno, Salerno, Italy.
²⁴ Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.
²⁵ Department of Neurological Surgery, Semmes-Murphey Clinic, Memphis, TN, USA.
²⁶ Neuroradiology Department, Toulouse University Hospital, Toulouse, France.
²⁷ Turku University Hospital and University of Turku, Turku, Finland.
²⁸ Institute of Neuroradiology, Technische Universität Dresden, University Hospital Carl Gustav Carus, Dresden, Germany.
²⁹ Dresden Neurovascular Center, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
³⁰ Department of Neurological Surgery, University of Washington, Seattle, WA, USA.
³¹ Department of Neuroradiology, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany.
³² Department of Neuroradiology, Henri Mondor Hospital, Créteil, France.
³³ Stroke Center, Department of Neurosciences, Lisbon Central University Hospital-ULS São José, Lisbon, Portugal.
³⁴ Institute of Pharmacology and Neurosciences, Faculty of Medicine, University of Lisbon, Lisbon, Portugal.
³⁵ Faculdade de Medicina, Universidade de Lisboa, and Gulbenkian Institute for Molecular Medicine, Lisbon, Portugal.
³⁶ Diagnostic and Interventional Neuroradiology, SS. Annunziata Hospital, Taranto, Italy.
³⁷ Neuroradiology Department, AORN Cardarelli, Naples, Italy.
³⁸ Division of Neurology, McMaster University and Population Health Research Institute, Hamilton, ON, Canada.
³⁹ Department of Neurology, Radboud University Medical Center, Nijmegen, The Netherlands.
⁴⁰ Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, The Netherlands.
⁴¹ Department of Radiology & Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.
⁴² Interventional Neuroradiology Department, Radiology and Nuclear Medicine Network, Kantonsspital St. Gallen, HOCH Health Ostschweiz, Switzerland.
⁴³ Stroke Medicine and Neurocritical Care Palliative Care, Neurovascular Ultrasound, Knappschaft Kliniken, University Hospital Bochum, Bochum, Germany.
⁴⁴ Neuroradiology-Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.
⁴⁵ Neurology-Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.
⁴⁶ Neurovascular Interventional Unit, Careggi University Hospital, Florence, Italy.
⁴⁷ Department of Neurology, ASST Santi Paolo e Carlo, Milan, Italy.
⁴⁸ Department of Neuroradiology, ASST Santi Paolo e Carlo, Milan, Italy.
⁴⁹ Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland.
⁵⁰ Department of Neurology, Stroke Center, University Hospital of Basel, Basel, Switzerland.
⁵¹ Diagnostic & Interventional Neuroradiology Department, University Hospital Basel, Petersgraben 4, Basel 4031, Switzerland.

PMID: 40860647
PMCID: PMC12374045
DOI: 10.1177/17562864251360913

Abstract

Background: Rescue stenting (RS) is a bailout strategy for failed thrombectomy. Optimal platelet inhibition strategy after RS remains unclear.

Objectives: We aimed to describe and compare different platelet inhibition strategies during/after RS.

Design: Retrospective cohort study across 34 international centers.

Methods: Patients with large vessel occlusion and RS after failed thrombectomy (2019-2023) were included. Periprocedural and postprocedural platelet inhibition strategies were described and compared, focusing on glycoprotein IIb/IIIa (GPIIb/IIIa) inhibitors, single antiplatelet therapy (SAPT), and dual antiplatelet therapy (DAPT). We assessed the effects of platelet inhibition strategy and potentially covariates on the primary outcome of 90-day modified Rankin Scale (mRS) using ordinal shift analysis with proportional odds models.

Results: RS was performed in 589 patients (mean age 67.9 years, 60.8% male). Numerous combinations of platelet inhibitors were administered. Periprocedural GPIIb/IIIa inhibitors were used in 61.5% of patients. Postprocedural DAPT was administered to 80.5% and SAPT to 13.3%. Functional independence (mRS 0-2) was achieved in 40.7%, while 26.3% died within 90 days. Stent occlusion occurred in 20.5%, with 67.6% of these occlusions within 24 h. Postprocedural stent-occlusion was independently associated with worse functional outcome at 90 days (OR 4.1, 95% CI 2.3-7.2, p < 0.001). No significant association between periprocedural GPIIb/IIIa inhibitors, and 90-day mRS or stent occlusion was found. Postprocedural SAPT was associated with worse functional outcomes (adjusted odds ratio (aOR) 2.4, 95% CI 1.1-5.0, p = 0.02), higher mortality (aOR 2.1, 95% CI 1.05-4.0, p = 0.03), and increased stent occlusion rates (aOR 4.8, 95% CI 2.3-9.7, p < 0.001) compared to postprocedural DAPT. Symptomatic intracranial hemorrhage occurred in 6.8% of patients, with no significant difference between antiplatelet regimens.

Conclusion: Extensive heterogeneity exists in platelet inhibition strategies following RS. Stent occlusion is associated with worse clinical outcomes, and the first 24 h post-RS are critical for stent patency. Compared to SAPT, DAPT was associated with better functional outcome, lower mortality, and lower stent occlusion rates.

Keywords: intracranial arteriosclerosis; ischemic stroke; platelet aggregation inhibitors; stents; thrombectomy.

Plain language summary

When clot removal for stroke fails and a stent is placed, different blood thinner treatments affect risk of stent blockage and outcomes When doctors try to remove a blood clot during a stroke but are unsuccessful, they sometimes place a stent to reopen the blocked artery—a procedure called “rescue stenting.” After placing a stent, patients need blood-thinning medications to prevent the stent from becoming blocked again. However, the best way to manage these medications is unclear. In this study, we looked at 589 patients from 34 hospitals around the world who had rescue stenting between 2019 and 2023. We compared different strategies for using blood thinners, including strong drugs given during the procedure and either one (“single”) or two (“dual”) blood thinners given afterward. We found a lot of variation in how doctors used these medications. Using a strong blood thinner during the procedure didn’t seem to change long-term recovery or the risk of the stent blocking. However, after the procedure, patients who were treated with two blood thinners did better than those who got only one. Patients on dual therapy were more likely to recover well, less likely to die, and less likely to have their stent block again. Importantly, most stent blockages happened within the first 24 hours after the procedure, and patients with stent blockages did worse, highlighting the 24h period as critical for blood thinner treatment.

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Figures

The image is a Sankey diagram illustrating the number of patients under different antiplatelet therapy strategies before and after an operation. — **Figure 1.**
Sankey diagram shows number of patients under different antiplatelet strategies. APT, Antiplatelet therapy; COX-I, Cyclooxygenase-inhibitors, such as Aspirin; DAPT, Dual antiplatelet therapy; GP2b/3a-I, Glycoprotein-IIb/IIIa-inhibitors, such as Tirofiban, Eptifibatide, and Abciximab; P2Y12-A, P2Y12-Antagonists, such as Clopidogrel or Cangrelor; SAPT, Single antiplatelet therapy; TAPT, Triple antiplatelet therapy.

Describe the mRS data in a table with 4 columns — **Figure 2.**
mRS of patients after rescue stenting with single versus dual postprocedural antiplatelet therapy. mRS at 90 days was available for 92.3% of SAPT patients and for 94.9% of DAPT patients. DAPT, dual antiplatelet therapy; mRS, Modified Rankin Scales; SAPT, Single antiplatelet therapy.

See this image and copyright information in PMC

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Platelet inhibition strategies in rescue stenting after failed thrombectomy: a large retrospective multicenter registry

Affiliations

Platelet inhibition strategies in rescue stenting after failed thrombectomy: a large retrospective multicenter registry

Authors

Affiliations

Abstract

Plain language summary

Figures

References

LinkOut - more resources

Full Text Sources