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Pielenz D, Klisch J, Fiorella D, Gawlitza M, Steinbrecher A, Leinisch E, Lobsien E, Hoffmann KT, Lobsien D. The pEGASUS-HPC stent system for intracranial arterial stenosis: a single-center case series. J Neurointerv Surg 2024:jnis-2024-021737. [PMID: 38760166 DOI: 10.1136/jnis-2024-021737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 05/08/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND Intracranial arterial stenting is a technique for the treatment of symptomatic stenosis. In this single-center retrospective case series we evaluated a novel low profile laser-cut stent with an antithrombogenic hydrophilic polymer coating (pEGASUS-HPC, Phenox GmbH, Bochum, Germany) for the treatment of intracranial stenosis in the setting of acute ischemic stroke and elective cases. METHODS All patients treated with pEGASUS-HPC for one or more intracranial arterial stenoses at our institution were retrospectively included. Clinical, imaging and procedural parameters as well as clinical and imaging follow-up data were collected. RESULTS We performed 43 interventions in 41 patients with 42 stenoses in our neurovascular center between August 2021 and February 2024. Twenty-one patients (51.2%) were female and the mean±SD age was 71±10.8 years. Thirty-seven (86.1%) procedures were performed in the setting of endovascular acute ischemic stroke treatment. Technical or procedural complications occurred in seven patients (16.3%), six in the thrombectomy group and one in the elective group. One stent-related hemorrhagic complication (subarachnoid hemorrhage) occurred in emergency cases and symptomatic intracerebral hemorrhage occurred in one patient treated in an elective setting. Overall stenosis reduction following pEGASUS-HPC stent implantation was 53.0±18.0%. On follow-up imaging, which was available for 16 patients (37.2%) after an average of 32±58.6 days, 62.5% of the stents were patent. CONCLUSION Our single-center case series demonstrates the feasibility of using the pEGASUS-HPC stent system, especially in emergency situations when thrombectomy fails.
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Affiliation(s)
- Daniel Pielenz
- Department of Neuroradiology, Helios Hospital Erfurt, Erfurt, Thüringen, Germany
| | - Joachim Klisch
- Department of Neuroradiology, Helios Hospital Erfurt, Erfurt, Thüringen, Germany
- Department of Neuroradiology, Helios Vogtland Hospital Plauen, Plauen, Sachsen, Germany
| | - David Fiorella
- Department of Neurosurgery, Stony Brook University, Stony Brook, New York, USA
| | - Matthias Gawlitza
- University Hospital Leipzig Institute for Neuroradiology, Leipzig, Sachsen, Germany
| | | | - Elke Leinisch
- Department of Neurology, Helios Hospital Erfurt, Erfurt, Thüringen, Germany
| | - Elmar Lobsien
- Department of Neurology, Helios Hospital Erfurt, Erfurt, Thüringen, Germany
| | - Karl-Titus Hoffmann
- University Hospital Leipzig Institute for Neuroradiology, Leipzig, Sachsen, Germany
| | - Donald Lobsien
- Department of Neuroradiology, Helios Hospital Erfurt, Erfurt, Thüringen, Germany
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Ifergan H, Dargazanli C, Ben Hassen W, Hak JF, Gory B, Ognard J, Premat K, Marnat G, Kerleroux B, Zhu F, Bellanger G, Sporns PB, Charbonnier G, Forestier G, Caroff J, Fauché C, Clarençon F, Janot K, Lapergue B, Boulouis G. Rescue intracranial permanent stenting for refractory occlusion following thrombectomy: a propensity matched analysis. J Neurointerv Surg 2024; 16:115-123. [PMID: 37080770 DOI: 10.1136/jnis-2022-020012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 03/25/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND Rescue intracranial stenting (RIS) can be used in refractory large vessel occlusion (LVO) after mechanical thrombectomy (MT). We aimed to assess the safety and efficacy of RIS versus a propensity matched sample of patients with persistent LVO. METHODS We retrospectively analysed a multicenter retrospective pooled cohort of patients with anterior LVO (2015-2021) treated with MT, and identified patients with at least three passes and a modified Thrombolysis In Cerebral Infarction (mTICI) score of 0 to 2a. Propensity score matching was used to account for determinants of outcome in patients with or without RIS. The study outcomes included 3 months modified Rankin Scale (mRS) and symptomatic hemorrhagic transformation (HT). RESULTS 420 patients with a refractory anterior occlusion were included, of which 101 were treated with RIS (mean age 69 years). Favorable outcome (mRS 0-2) was more frequent in patients with a patent stent at day 1 (53% vs 6%, P<0.001), which was independently associated with an early dual antiplatelet regimen (P<0.05). In the propensity matched sample, patients treated with RIS versus without RIS had similar rates of favorable outcomes (36.8% vs 30.3%, P=0.606). Patients with RIS showed a favorable shift in the overall mRS distributions (common adjusted OR 0.74, 95% CI 0.60 to 0.91, P=0.006). Symptomatic HT was marginally more frequent in the RIS group (9% vs 3%, P=0.07), and there was no difference in 3-month mortality. CONCLUSION In selected patients with a refractory intracranial occlusion despite at least three thrombectomy passes, RIS may be associated with an overall shift towards more favorable clinical outcome, and no significant increase in the odds of symptomatic HT or death.
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Affiliation(s)
- Heloise Ifergan
- Diagnostic and Interventional Neuroradiology, University Hospital of Tours, Tours, Centre, France
| | - Cyril Dargazanli
- Diagnostic and Interventional Neuroradiology, University Hospital Centre Montpellier, Montpellier, Occitanie, France
| | - Wagih Ben Hassen
- Diagnostic and Interventional Neuroradiology, Saint Anne Hospital Centre, Paris, France
| | - Jean-Francois Hak
- Diagnostic and Interventional Neuroradiology, Hospital Timone, University Hospital of Marseille, Marseille, France
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, University of Lorraine, INSERM U1254, IADI, F-54000, University Hospital of Nancy, Nancy, France
| | - Julien Ognard
- Diagnostic and Interventional Neuroradiology, University and Regional Hospital Centre Brest, Brest, France
| | - Kevin Premat
- Diagnostic and Interventional Neuroradiology, University Hospital of Pitié Salpêtrière, APHP, Paris, France
| | - Gaultier Marnat
- Diagnostic and Interventional Neuroradiology, University Hospital of Bordeaux, Bordeaux, France
| | - Basile Kerleroux
- Diagnostic and Interventional Neuroradiology, Saint Anne Hospital Centre, Paris, France
| | - François Zhu
- Diagnostic and Interventional Neuroradiology, University Hospital of Nancy, Nancy, France
| | - Guillaume Bellanger
- Diagnostic and Interventional Neuroradiology, University Hospital of Toulouse, Toulouse, France
| | - Peter B Sporns
- Diagnostic and Interventional Neuroradiology, University Hospital of Basel, Basel, Switzerland
| | - Guillaume Charbonnier
- Diagnostic and Interventional Neuroradiology, University Hospital of Besançon, Besancon, France
| | - Géraud Forestier
- Diagnostic and Interventional Neuroradiology, University Hospital of Limoges, Limoges, France
| | - Jildaz Caroff
- Department of Interventional Neuroradiology - NEURI Brain Vascular Center, Bicêtre Hospital, APHP, Le Kremlin Bicêtre, France
| | - Cédric Fauché
- Diagnostic and Interventional Neuroradiology, University Hospital of Poitiers, Poitiers, France
| | - Frédéric Clarençon
- Diagnostic and Interventional Neuroradiology, University Hospital of Pitié Salpêtrière, APHP, Paris, France
| | - Kevin Janot
- Diagnostic and Interventional Neuroradiology, University Hospital of Tours, Tours, Centre, France
| | - Bertrand Lapergue
- Neurology, Stroke Center, University of Versailles and Saint Quentin en Yvelines, Foch Hospital, Suresnes, France
| | - Gregoire Boulouis
- Diagnostic and Interventional Neuroradiology, University Hospital of Tours, Tours, Centre, France
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3
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Imam YZ, Akhtar N, Kamran S, Garcia-Bermejo P, Al Jerdi S, Zakaria A, Own A, Patro S. Rescue Stent Placement for Acute Ischemic Stroke with Large Vessel Occlusion Refractory to Mechanical Thrombectomy: A Multiethnic Middle Eastern/African/Asian Cohort. J Vasc Interv Radiol 2023; 34:1740-1748. [PMID: 37302471 DOI: 10.1016/j.jvir.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 05/20/2023] [Accepted: 06/04/2023] [Indexed: 06/13/2023] Open
Abstract
PURPOSE To investigate the safety and effectiveness of rescue stent placement in patients who experienced acute stroke in whom mechanical thrombectomy failed. METHODS This was a retrospective review of a multiethnic stroke database. After stent placement, an aggressive antiplatelet protocol was followed with glycoprotein IIb/IIIa infusion. The primary outcomes were incidence of intracerebral hemorrhage (ICH), recanalization score, and favorable prognosis (modified Rankin score ≤ 2) at 90 days. A comparison was made between patients from the Middle East and North Africa (MENA) region and those from other regions. RESULTS Fifty-five patients were included, with 87% being men. The mean age was 51.3 years (SD ±11.8); 32 patients (58%) were from South Asia, 12 (22%) from MENA, 9 (16%) from Southeast Asia, and 2 (4%) from elsewhere. Successful recanalization (modified Thrombolysis in Cerebral Infarction score = 2b/3) was achieved in 43 patients (78%), and symptomatic ICH occurred in 2 patients (4%). A favorable outcome at 90 days was seen in 26 of the 55 patients (47%). Apart from significantly older age-mean, 62.8 years (SD ±13; median, 69 years) versus 48.1 years (SD ±9.3; median, 49 years)-and coronary artery disease burden-4 (33%) versus 1 (2%) (P < .05), patients from MENA had risk factors, stroke severity, recanalization rates, ICH rates, and 90-day outcomes similar to those from South and Southeast Asia. CONCLUSION Rescue stent placement showed good outcomes and a low risk of clinically significant bleeding in a multiethnic cohort of patients from MENA and South and Southeast Asia, similar to that in published literature.
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Affiliation(s)
- Yahia Z Imam
- Neurosceince Institute, Hamad Medical Corporation, Doha, Qatar; Weill Cornell Medicine-Qatar, Doha, Qatar.
| | - Naveed Akhtar
- Neurosceince Institute, Hamad Medical Corporation, Doha, Qatar; Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Saadat Kamran
- Neurosceince Institute, Hamad Medical Corporation, Doha, Qatar; Weill Cornell Medicine-Qatar, Doha, Qatar
| | | | | | - Ayman Zakaria
- Neurosceince Institute, Hamad Medical Corporation, Doha, Qatar
| | - Ahmed Own
- Neurosceince Institute, Hamad Medical Corporation, Doha, Qatar
| | - Satya Patro
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
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Thut MZ, Rhiner N, Thurner P, Madjidyar J, Schubert T, Wegener S, Globas C, Luft AR, Kulcsar Z. Stent reconstruction in intracranial atherosclerotic disease related acute ischemic stroke results in high revascularization rates. J Stroke Cerebrovasc Dis 2023; 32:107232. [PMID: 37453214 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 06/16/2023] [Accepted: 06/20/2023] [Indexed: 07/18/2023] Open
Abstract
OBJECTIVES Intracranial atherosclerotic disease (ICAD) is a major cause of large vessel occlusion (LVO) in acute ischemic stroke (AIS). Our study aimed to analyze the effect of percutaneous transluminal angioplasty and stenting (PTAS) in patients with ICAD undergoing rescue treatment in terms of functional outcome and mortality rate at 90 days and compare the results to LVO with thromboembolic origins. MATERIALS AND METHODS A retrospective review of a mechanical thrombectomy (MT) single center database from 01/2019 to 09/2021 was carried out using chart review and angiogram analysis. From 469 acute stroke patients, 361 patients were enroled in the study, of whom twenty-four (6.6%) were diagnosed with underlying ICAD and treated with angioplasty and stent reconstruction (PTAS) with a standardized medication protocol. Successful reperfusion, peri-procedural complications, and functional independence at 90 days were collected as outcomes. RESULTS There was no difference in age or admission National Institutes of Health Stroke Scale (NIHSS). Onset to groin puncture (median 460 vs 277 min, P = 0.019) was significantly longer in the ICAD group. The procedure time (median 73 vs 60 min, P = 0.137) did not differ. Successful reperfusion was achieved in 95.8% of ICAD and 91.1% of the remaining patients (P = 0.445). Functional independence (mRS ≤ 2) at 90 days was achieved in 45.8% (11/24) and 42.7% (144/337, (P = 0.767)). The mortality rates (mRS 6) at 90 days were similar (29.2% vs 29.4% (P = 0.983)). CONCLUSION Despite significantly longer treatment delays, the outcome and revascularization rates of ICAD patients were similar to the thromboembolic cohort. Our proposed protocol of PTAS and medication protocol in ICAD was effective with a similar safety profile as MT in general.
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Affiliation(s)
- Mara Z Thut
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Nadine Rhiner
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Patrick Thurner
- Department of Neuroradiology, Clinical Neurocenter, University Hospital Zurich, Frauenklinikstrasse 10, Zurich 8091, Switzerland
| | - Jawid Madjidyar
- Department of Neuroradiology, Clinical Neurocenter, University Hospital Zurich, Frauenklinikstrasse 10, Zurich 8091, Switzerland
| | - Tilman Schubert
- Department of Neuroradiology, Clinical Neurocenter, University Hospital Zurich, Frauenklinikstrasse 10, Zurich 8091, Switzerland
| | - Susanne Wegener
- Department of Neurology, Clinical Neurocenter, University Hospital Zurich, Frauenklinikstrasse 26, Zurich 8091, Switzerland
| | - Christoph Globas
- Department of Neurology, Clinical Neurocenter, University Hospital Zurich, Frauenklinikstrasse 26, Zurich 8091, Switzerland
| | - Andreas R Luft
- Department of Neurology, Clinical Neurocenter, University Hospital Zurich, Frauenklinikstrasse 26, Zurich 8091, Switzerland; Cerneo Center for Neurology and Rehabilitation, Seestrasse 18, Vitznau 6354, Switzerland
| | - Zsolt Kulcsar
- Department of Neuroradiology, Clinical Neurocenter, University Hospital Zurich, Frauenklinikstrasse 10, Zurich 8091, Switzerland.
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Juega J, Li J, Palacio-Garcia C, Rodriguez M, Tiberi R, Piñana C, Rodriguez-Luna D, Requena M, García-Tornel Á, Rodriguez-Villatoro N, Rubiera M, Muchada M, Olivé-Gadea M, Rizzo F, Hernandez D, Dios-Lascuevas M, Hernandez-Perez M, Dorado L, Quesada H, Cardona P, De La Torre C, Gallur L, Camacho J, Ramon-Y-Cajal S, Tomasello A, Ribó M, Molina CA, Pagola J. Granulocytes-Rich Thrombi in Cerebral Large Vessel Occlusion Are Associated with Increased Stiffness and Poorer Revascularization Outcomes. Neurotherapeutics 2023; 20:1167-1176. [PMID: 37212981 PMCID: PMC10457261 DOI: 10.1007/s13311-023-01385-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2023] [Indexed: 05/23/2023] Open
Abstract
We aim to identify a profile of intracranial thrombus resistant to recanalization by mechanical thrombectomy (MT) in acute stroke treatment. The first extracted clot of each MT was analyzed by flow cytometry obtaining the composition of the main leukocyte populations: granulocytes, monocytes, and lymphocytes. Demographics, reperfusion treatment, and grade of recanalization were registered. MT failure (MTF) was defined as final thrombolysis in cerebral infarction score IIa or lower and/or need of permanent intracranial stenting as a rescue therapy. To explore the relationship between stiffness of intracranial clots and cellular composition, unconfined compression tests were performed in other cohorts of cases. Thrombi obtained in 225 patients were analyzed. MTF were observed in 30 cases (13%). MTF was associated with atherosclerosis etiology (33.3% vs. 15.9%; p = 0.021) and higher number of passes (3 vs. 2; p < 0.001). Clot analysis of MTF showed higher percentage of granulocytes [82.46 vs. 68.90% p < 0.001] and lower percentage of monocytes [9.18% vs.17.34%, p < 0.001] in comparison to successful MT cases. The proportion of clot granulocytes (aOR 1.07; 95% CI 1.01-1.14) remained an independent marker of MTF. Among thirty-eight clots mechanically tested, there was a positive correlation between granulocyte proportion and thrombi stiffness (Pearson's r = 0.35, p = 0.032), with a median clot stiffness of 30.2 (IQR, 18.9-42.7) kPa. Granulocytes-rich thrombi are harder to capture by mechanical thrombectomy due to increased stiffness, so a proportion of intracranial granulocytes might be useful to guide personalized endovascular procedures in acute stroke treatment.
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Affiliation(s)
- Jesús Juega
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Jiahui Li
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | | | - Maite Rodriguez
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Riccardo Tiberi
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Carlos Piñana
- Department of Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - David Rodriguez-Luna
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Manuel Requena
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Álvaro García-Tornel
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Noelia Rodriguez-Villatoro
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Marta Rubiera
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Marian Muchada
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Marta Olivé-Gadea
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Federica Rizzo
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - David Hernandez
- Department of Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Marta Dios-Lascuevas
- Department of Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - Laura Dorado
- Department of Neurology, Germans Trias I Pujol University Hospital, Badalona, Spain
| | - Helena Quesada
- Department of Neurology, Bellvitge University Hospital, Hospitalet de Llobregat, Spain
| | - Pere Cardona
- Department of Neurology, Bellvitge University Hospital, Hospitalet de Llobregat, Spain
| | - Carolina De La Torre
- Proteomics Unit, Josep Carreras Leukaemia Research Institute (IJC), Badalona, Spain
| | - Laura Gallur
- Hematology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Jessica Camacho
- Department of Pathology, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - Alejandro Tomasello
- Department of Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Marc Ribó
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain.
| | - Carlos A Molina
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Jorge Pagola
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
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Khachatryan T, Shafie M, Abcede H, Shah J, Nagamine M, Granstein J, Yuki I, Golshani K, Suzuki S, Yu W. Rescue therapy after thrombectomy for large vessel occlusion due to underlying atherosclerosis: review of literature. Front Neurol 2023; 14:1181295. [PMID: 37396754 PMCID: PMC10313123 DOI: 10.3389/fneur.2023.1181295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 05/24/2023] [Indexed: 07/04/2023] Open
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.
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Affiliation(s)
- Tigran Khachatryan
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
| | - Mohammad Shafie
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
| | - Hermelinda Abcede
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
| | - Jay Shah
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
| | - Masaki Nagamine
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
| | - Justin Granstein
- Department of Neurological Surgery, University of California, Irvine, Irvine, CA, United States
| | - Ichiro Yuki
- Department of Neurological Surgery, University of California, Irvine, Irvine, CA, United States
| | - Kiarash Golshani
- Department of Neurological Surgery, University of California, Irvine, Irvine, CA, United States
| | - Shuichi Suzuki
- Department of Neurological Surgery, University of California, Irvine, Irvine, CA, United States
| | - Wengui Yu
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
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7
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Ni H, Hang Y, Wang CD, Liu S, Jia ZY, Shi HB, Zhao LB. Balloon Angioplasty Combined with Tirofiban as a First-Line Rescue Treatment After Failed Mechanical Thrombectomy for Middle Cerebral Artery Occlusion with Underlying Atherosclerosis. World Neurosurg 2022; 166:e306-e312. [PMID: 35809841 DOI: 10.1016/j.wneu.2022.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 06/30/2022] [Accepted: 07/01/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The standard rescue modality for patients with intracranial atherosclerotic stenosis after failed mechanical thrombectomy (MT) is not well established. We evaluated the safety and efficacy of balloon dilation in combination with tirofiban as the first-line salvage therapy when MT failed in these patients. METHODS We retrospectively analyzed the records of 47 patients admitted between January 2018 and June 2021, with middle cerebral artery atherosclerotic occlusion, who underwent balloon angioplasty in combination with tirofiban as the first-line salvage therapy after the failure of MT. The recanalization outcome, procedure-related complications, symptomatic intracranial hemorrhage, and functional outcome at 90 days were reviewed. RESULTS Recanalization with a modified Thrombolysis in Cerebral Infarction grade of 2b-3 was achieved in 41 (87.2%) of the 47 patients. Acute stents were deployed in another 6 patients who did not achieve successful re-perfusion after balloon angioplasty. Successful recanalization was achieved in 3 of them. One patient (2.1%, 1/47) experienced re-occlusion several days later due to the withdrawal of antiplatelet therapy for parenchymal hematoma. Seven patients (14.9%, 7/47) underwent stent angioplasty in the stable stage (range: 1-2 months) because severe residual stenosis was detected on follow-up imaging. There was only one event of periprocedural complication, namely ectopic migration of emboli. The good functional outcome rate was 55.3% (26/47), without the events of symptomatic intracranial hemorrhage and mortality. CONCLUSIONS Balloon angioplasty in combination with tirofiban is safe and effective for middle cerebral artery atherosclerotic occlusion after the failure of MT.
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Affiliation(s)
- Heng Ni
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Yu Hang
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Chen-Dong Wang
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Sheng Liu
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Zhen-Yu Jia
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Hai-Bin Shi
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Lin-Bo Zhao
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China.
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8
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Kim JH, Choi JI. Feasibility of rescue stenting technique in patients with acute ischemic stroke due to middle cerebral artery occlusion after failed thrombectomy: A single-center retrospective experience. PLoS One 2022; 17:e0274842. [PMID: 36166451 PMCID: PMC9514649 DOI: 10.1371/journal.pone.0274842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 09/02/2022] [Indexed: 11/18/2022] Open
Abstract
Background
Despite remarkable advancements in intra-arterial mechanical thrombectomy (IAT), recanalization failure rates up to 24% have been reported. Recently, permanent stent placement (rescue stent, RS) during IAT has been suggested as an optional modality for better reperfusion and outcomes in these patients. However, previous studies were limited owing to non-standardized procedure protocols and small sample sizes. Here, we aimed to determine the efficacy and safety of RS in patients with acute ischemic stroke (AIS) with middle cerebral artery (MCA) occlusion.
Methods
Of the 243 patients in our IAT database (2015–2021), 183 were identified as having MCA occlusion alone. Among them, we extracted 53 patients in whom the IAT failed to show thrombolysis in cerebral ischemia (TICI) scores of 2A or worse. Intraoperatively, RS was deployed in 22 patients (RS group), whereas 31 patients (no-stent group) received IAT without stenting. The baseline characteristics and radiologic and clinical outcomes were reviewed. Comparisons between the groups and multivariate logistic analyses for recanalization and good functional outcomes (modified Rankin Scale 0–2) were performed.
Results
No baseline differences were noted (RS vs. no-stent); however, the recanalization outcomes (59.1% vs. 25.8%, p = 0.15) and proportion of good modified Rankin Scale scores (45.5% vs. 19.4%, p = 0.041) were better in the RS group. The parameters of symptomatic ICH (9.7% vs. 9.4%) and mortality (6.5% vs. 5.7%) showed no significant difference. In the multivariate analyses, ‘hypertension’ and ‘RS deployment’ were identified as significantly associated factors with recanalization and good prognosis.
Conclusion
In select patients with MCA occlusion AIS after failed IAT, the RS technique can be an optional rescue treatment modality for acquiring better functional outcomes and delayed recanalization.
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Affiliation(s)
- Jang Hun Kim
- Department of Neurosurgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jong-Il Choi
- Department of Neurosurgery, Korea University Ansan Hospital, Korea University College of Medicine, Gyeonggi-do, Korea
- * E-mail:
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Farooq J, Lee JY. Vascular tortuosity in endovascular mechanical thrombectomy. Brain Circ 2021; 7:3-7. [PMID: 34084969 PMCID: PMC8057096 DOI: 10.4103/bc.bc_5_21] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/02/2020] [Accepted: 12/15/2020] [Indexed: 12/11/2022] Open
Abstract
Endovascular mechanical thrombectomy effectively removes occlusive thrombi from the arterial lumen; however, there is little literature supporting the relevance of vascular geometry on surgical outcomes. Critical vessel characteristics including the degree of angulation and tortuosity influence the ability to advance stent retriever devices toward the site of occlusion. Therefore, it is crucial to evaluate the impact of carotid artery catheter pathway accessibility on the thrombectomy outcomes in acute ischemic stroke (AIS) patients. Traditional imaging modalities generate incomplete pictures of the vascular tortuosity and are prone to clinical judgment errors. Recent three-dimensional computed tomography angiography image analysis techniques circumvent these limitations to calculate accurate tortuosity and angulation measurements. These novel images facilitate classifying common anatomical variant patients into groups that may be treated with specially designed catheter devices. Importantly, this image analysis method reveals significant angulation in the common carotid artery and extracranial internal carotid artery that correlates with delays in reaching the occlusion site. Increased age, which is associated with increased risk of stroke, also increases the incidence of severe tortuosity. The semi-automated measurements technique also demonstrate that full 360° arterial loops are present in nearly 3% of catheter pathways and that the overall degree of angulation differs bilaterally. In this review, we examine the utility of this novel image analysis procedure and evaluate the recent literature relevant to neuroendovascular thrombectomy in AIS patients. Three literature databases – PubMed, Embase, and Web of Science were queried for original articles investigating both preclinical and clinical thrombectomy applications.
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Affiliation(s)
- Jeffrey Farooq
- Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Jea Young Lee
- Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
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