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Yousefian Jazi E, Wiesmann M, Reich A, Gombert A, Pinho J, Kotelis D, Nikoubashman O. Risk for Additional Infarction in Emergency Carotid Artery Endarterectomy in Thrombectomy Acute Stroke Patients. Vasc Endovascular Surg 2022; 56:571-580. [DOI: 10.1177/15385744221095669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: Thromboembolic occlusion of the middle cerebral artery with tandem occlusion of the internal carotid artery is a life-threatening condition with unfavorable neurological outcome. We perform emergency carotid endarterectomy in the same anesthesia session as thrombectomy in our angiography suite whenever needed despite the absence of electrophysiological neuromonitoring. Methods: We evaluated 47 thrombectomy patients with emergency CEA in our clinic between June 2013 and November 2020. To determine whether there were additional infarctions due to the surgical procedure, we assessed the initial diagnostic CT imaging for previously infarcted areas, cerebral perfusion, and vascular anatomy, including collateralization in the Circle of Willis (CoW). We then analyzed follow-up imaging with respect to new infarctions that could not be explained by the initial stroke. Results: 5 of 47 (11%) patients had a complete CoW. There was contralateral internal carotid artery (ICA) stenosis or occlusion in 18/47 (38%) patients. Surgical procedure was eversion CEA in 34 (72%) and with a patch graft CEA in 13 (28%) cases. Shunts were used during surgery in 17/47 (36%) patients. Two patients suffered from an additional infarction in a new territory, however this was not caused by the surgical procedure but due to embolism during endovascular thrombectomy. In 1 of these 2 patients a hemodynamic border zone infarction was also observed, which could have developed during thrombectomy as well as during surgery, although this could not be attributed with absolute certainty to the surgery. The final infarction size was significantly larger in patients with contralateral ICA stenosis or occlusion ( P = .038). Neither CoW anatomy nor the absence of a shunt during surgery could be identified as risk factors for additional infarction. Conclusion: Emergency surgery in the angiography suite without neuromonitoring was not associated with an increased additional stroke rate in our patient cohort.
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Affiliation(s)
- Ehsan Yousefian Jazi
- Department of Neuroradiology, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Martin Wiesmann
- Department of Neuroradiology, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Arno Reich
- Department of Neurology, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Alex Gombert
- Department of Vascular Surgery, University Hospital, RWTH Aachen University, Aachen, Germany
| | - João Pinho
- Department of Neurology, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Drosos Kotelis
- Department of Vascular Surgery, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Omid Nikoubashman
- Department of Neuroradiology, University Hospital, RWTH Aachen University, Aachen, Germany
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Dumas V, Kaesmacher J, Ognard J, Forestier G, Dargazanli C, Janot K, Behme D, Shotar E, Chabert E, Velasco S, Bricout N, Ben Hassen W, Veunac L, Geismar M, Eugene F, Detraz L, Darcourt J, L'Allinec V, Eker OF, Consoli A, Maus V, Gariel F, Marnat G, Papanagiotou P, Papagiannaki C, Escalard S, Meyer L, Lobsien D, Abdullayev N, Chalumeau V, Neau JP, Guillevin R, Boulouis G, Rouchaud A, Styczen H, Fauché C. Carotid artery direct access for mechanical thrombectomy: the Carotid Artery Puncture Evaluation (CARE) study. J Neurointerv Surg 2021; 14:1180-1185. [PMID: 34916267 DOI: 10.1136/neurintsurg-2021-017935] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 11/28/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND In acute ischemic stroke due to anterior large vessel occlusion (AIS-LVO), accessing the target occluded vessel for mechanical thrombectomy (MT) is sometimes impossible through the femoral approach. We aimed to evaluate the safety and efficacy of direct carotid artery puncture (DCP) for MT in patients with failed alternative vascular access. METHODS We retrospectively analyzed data from 45 stroke centers in France, Switzerland and Germany through two research networks from January 2015 to July 2019. We collected physician-centered data on DCP practices and baseline characteristics, procedural variables and clinical outcome after DCP. Uni- and multivariable models were conducted to assess risk factors for complications. RESULTS From January 2015 to July 2019, 28 149 MT were performed, of which 108 (0.39%) resulted in DCP due to unsuccessful vascular access. After DCP, 77 patients (71.3%) had successful reperfusion (modified Thrombolysis In Cerebral Infarction (mTICI) score ≥2b) and 28 (25.9%) were independent (modified Rankin Scale (mRS) score 0-2) at 3 months. 20 complications (18.5%) attributed to DCP occurred, all of them during or within 1 hour of the procedure. Complications led to extension of the intubation time in the intensive care unit in 7 patients (6.4%) and resulted in death in 3 (2.8%). The absence of use of a hemostatic closure device was associated with a higher complication risk (OR 3.04, 95% CI 1.03 to 8.97; p=0043). CONCLUSION In this large multicentric study, DCP was scantly performed for vascular access to perform MT (0.39%) in patients with AIS-LVO and had a high rate of complications (18.5%). Our results provide arguments for not closing the cervical access by manual compression after MT.
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Affiliation(s)
- Victor Dumas
- Radiology Department, Poitiers University Medical Center, LabCom I3M, DACTIM-MIS team, LMA CNRS 7348, Poitiers, Vienne, France
| | - Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Bern, Switzerland
| | - Julien Ognard
- Interventional Neuroradiology, CHRU de Brest, Brest, Bretagne, France
| | - Géraud Forestier
- Neuroradiology Department, XLIM CNRS, UMR7252, Centre Hospitalier Universitaire de Limoges, Limoges, Limousin, France
| | - Cyril Dargazanli
- Department of Neuroradiology, INSERM U1191, University Hospital Center Montpellier, Montpellier, Occitanie, France
| | - Kevin Janot
- Neuroradiology Department, University Hospital of Tours, Tours, Indre et Loire, France
| | - Daniel Behme
- Institute for Diagnostic and Interventional Neuroradiology, University of Gottingen, Goettingen, Germany
| | - Eimad Shotar
- Neuroradiology Department, Pitié-Salpêtrière Hospital, Paris, France
| | - Emmanuel Chabert
- Neuroradiology Department, Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | - Stéphane Velasco
- Radiology Department, Poitiers University Medical Center, Poitiers, Vienne, France
| | - Nicolas Bricout
- Department of Interventional Neuroradiology, Centre Hospitalier Regional Universitaire de Lille, Lille, France
| | - Wagih Ben Hassen
- Interventional Neuroradiology, CH Sainte-Anne, INSERM UMR 1266, Paris, Île-de-France, France
| | - Louis Veunac
- Department of Radiology, Bayonne Hospital, Bayonne, France
| | - Maxime Geismar
- Neuroradiology Department, Centre Hospitalier Universitaire de Caen, Caen, France
| | | | - Lili Detraz
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nantes, Nantes, France
| | - Jean Darcourt
- Neuroradiology Department, CHU Toulouse, Toulouse, Midi-Pyrénées, France
| | | | - Omer F Eker
- Neuroradiology Department, Neurologic Hospital, Bron, France
| | - Arturo Consoli
- Interventional Neuroradiology, Hospital Foch, Suresnes, France
| | - Volker Maus
- Institute of Radiology, Neuroradiology and Nuclear Medicine, Knappschaftskrankenhaus Bochum, Ruhr-University, Bochum, Germany
| | - Florent Gariel
- Interventional and Diagnostic Neuroradiology, Bordeaux University Hospital, Bordeaux, Aquitaine, France
| | - Gaultier Marnat
- Interventional and Diagnostic Neuroradiology, Bordeaux University Hospital, Bordeaux, Aquitaine, France
| | - Panagiotis Papanagiotou
- Department of Diagnostic and Interventional Neuroradiology, Hospitals Bremen-Mitte, Bremen-Ost, Germany
| | | | - Simon Escalard
- Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, Ile de France, France
| | - Lukas Meyer
- Diagnostic and Interventional Neuroradiology, Universitatsklinikum Hamburg Eppendorf Klinik und Poliklinik fur Neuroradiologische Diagnostik und Intervention, Hamburg, Germany
| | - Donald Lobsien
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, Helios Klinikum Erfurt, Erfurt, Germany
| | - Nuran Abdullayev
- Diagnostic and Interventional Radiology Department, University Hospital Cologne, Köln, Germany
| | - Vanessa Chalumeau
- Interventional Neuroradiology, CHU Bicêtre, Le Kremlin-Bicêtre, Paris, France
| | | | - Rémy Guillevin
- Radiology Department, Poitiers University Medical Center, LabCom I3M, DACTIM-MIS team, LMA CNRS 7348, Poitiers, Vienne, France
| | - Gregoire Boulouis
- Neuroradiology Department, University Hospital of Tours, Tours, Indre et Loire, France
| | - Aymeric Rouchaud
- Neuroradiology Department, XLIM CNRS, UMR7252, Centre Hospitalier Universitaire de Limoges, Limoges, Limousin, France
| | - Hanna Styczen
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Cédric Fauché
- Radiology Department, Poitiers University Medical Center, Poitiers, Vienne, France
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Jonsson M, Aro E, Björses K, Holmin S, Ijäs P, Martinez-Majander N, Vikatmaa P, Wahlgren CM, Venermo M, Björck M. Carotid Endarterectomy After Intracranial Endovascular Thrombectomy for Acute Ischaemic Stroke in Patients with Carotid Artery Stenosis. Eur J Vasc Endovasc Surg 2021; 63:371-378. [PMID: 34887207 DOI: 10.1016/j.ejvs.2021.10.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 09/29/2021] [Accepted: 10/10/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Recent randomised controlled trials demonstrated the benefit of intracranial endovascular thrombectomy (EVT) in acute ischaemic stroke. There is no consensus, however, on how to treat concomitant extracranial carotid artery stenosis after EVT. The aim of this study was to evaluate the outcome in patients treated with carotid endarterectomy (CEA) after EVT, comparing complication rates among patients undergoing CEA for stroke without previous EVT. METHODS This was a registry study of all patients (n = 3 780) treated with CEA after stroke in Sweden and the capital Helsinki region, Finland, from January 2011 to September 2020. Sixty three patients (1.7%; 0.5% 2011, 4.3% 2019) underwent EVT prior to CEA. The primary outcome was 30 day stroke and death rate. RESULTS The EVT+CEA group had major stroke as the qualifying neurological event (QNE) in 79%, but just 5.9% had this in the CEA only group (p < .001). Intravenous thrombolysis was administered before EVT in 54% of patients in the EVT+CEA group, but in just 12% in those receiving CEA only (p < .001). The combined stroke and death rate at 30 days for EVT+CEA was 0.0% (95% confidence interval [CI] 0.0 - 5.7). One patient had a post-operative TIA, none had post-operative intracerebral or surgical site haemorrhage. CEA was performed within a median of seven days (interquartile range 4, 15) after QNE, and 75% had CEA ≤14 days from QNE. The main reason to postpone CEA was an infarct larger than one third of the middle cerebral artery territory. The stroke and death rate in patients treated with CEA only was 3.7% (95% CI 3.2 - 4.4), CEA was performed a median of eight days after QNE, and in 79.7% in ≤14 days. The three year survival after EVT+CEA was 93% (95% CI 85 - 100), compared with 87% (95% CI 86 - 88) after CEA only. Cox regression analysis adjusting for age showed no increased all cause mortality after EVT+CEA (HR 1.3, 95% CI 0.6 - 2.7, p = .52). CONCLUSION These results indicate that CEA is safe to perform after previous successful EVT for acute ischaemic stroke. Results were comparable with those undergoing CEA only, despite the EVT+CEA patients having more severe stroke symptoms prior to surgery, and timing was similar.
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Affiliation(s)
- Magnus Jonsson
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden.
| | - Ellinoora Aro
- Vascular Surgery, Helsinki University Hospital and University of Helsinki, Finland
| | | | - Staffan Holmin
- Department of Clinical Neuroscience, Karolinska Institute and Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Petra Ijäs
- Neurology, Helsinki University Hospital and University of Helsinki, Finland
| | | | - Pirkka Vikatmaa
- Vascular Surgery, Helsinki University Hospital and University of Helsinki, Finland
| | - Carl-Magnus Wahlgren
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Maarit Venermo
- Vascular Surgery, Helsinki University Hospital and University of Helsinki, Finland
| | - Martin Björck
- Department of Surgical Sciences, Uppsala University, Sweden
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Hadler F, Singh R, Wiesmann M, Reich A, Nikoubashman O. Increased Rates of Hemorrhages after Endovascular Stroke Treatment with Emergency Carotid Artery Stenting and Dual Antiplatelet Therapy. Cerebrovasc Dis 2021; 50:162-170. [PMID: 33472192 DOI: 10.1159/000512204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 10/09/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND While endovascular stroke treatment (EST) of large vessel occlusions in acute ischemic stroke (AIS) is proven to be safe and effective, there are subgroups of patients with increased rates of hemorrhages. Our goal was to identify risk factors for intracerebral hemorrhage and to assess whether acute carotid artery stenting (CAS) was associated with increased bleeding rates. METHODS We performed a retrospective analysis of our monocentric prospective stroke registry in the period from May 2010 to May 2018 and compared AIS patients receiving EST with (n = 73) versus without acute CAS (n = 548). Patients with intracranial stents, intra-arterial thrombolysis, or dissection of the carotid artery were excluded. RESULTS Parenchymal hemorrhage rates (PH2 according to the ECASS classification) and symptomatic hemorrhage (sICH) rates were increased in EST patients receiving CAS with odds being 6.3 (PH2) and 6.5 (sICH) times higher (PH2 17.8 vs. 3.3%, p < 0.001 and sICH: 16.4 vs. 2.9%, p < 0.001). Additional systemic thrombolysis with rtPA (IVRTPA) was no risk factor for cerebral hemorrhage (p = 0.213). CONCLUSION AIS patients receiving EST with acute CAS and consecutive tirofiban or dual antiplatelet therapy suffered from an increased risk of relevant secondary intracranial bleeding. After adjusting for confounders, tirofiban and dual antiplatelet therapy were associated with higher bleeding rates.
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Affiliation(s)
- Felix Hadler
- Department of Neurology, University Hospital RWTH, Aachen, Germany,
| | - Raveena Singh
- Department of Diagnostic and Interventional Neuroradiology, University Hospital RWTH, Aachen, Germany
| | - Martin Wiesmann
- Department of Diagnostic and Interventional Neuroradiology, University Hospital RWTH, Aachen, Germany
| | - Arno Reich
- Department of Neurology, University Hospital RWTH, Aachen, Germany
| | - Omid Nikoubashman
- Department of Diagnostic and Interventional Neuroradiology, University Hospital RWTH, Aachen, Germany
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