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Khanafer A, Henkes H, Bücke P, Hennersdorf F, Bäzner H, Forsting M, von Gottberg P. Triple platelet inhibition in intracranial thrombectomy with additional acute cervical stent angioplasty due to tandem lesion: a retrospective single-center analysis. BMC Neurol 2024; 24:99. [PMID: 38500074 PMCID: PMC10946095 DOI: 10.1186/s12883-024-03597-0] [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: 01/09/2024] [Accepted: 03/11/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Acute stroke treatment with intracranial thrombectomy and treatment of ipsilateral carotid artery stenosis/occlusion ("tandem lesion", TL) in one session is considered safe. However, the risk of stent restenosis after TL treatment is high, and antiplatelet therapy (APT) preventing restenosis must be well balanced to avoid intracranial hemorrhage. We investigated the safety and 90-day outcome of patients receiving TL treatment under triple-APT, focused on stent-patency and possible disadvantageous comorbidities. METHODS Patients receiving TL treatment in the setting of acute stroke between 2013 and 2022 were analyzed regarding peri-/postprocedural safety and stent patency after 90 days. All patients received intravenous eptifibatide and acetylsalicylic acid and one of the three drugs prasugrel, clopidogrel, or ticagrelor. Duplex imaging was performed 24 h after treatment, at discharge and 90 days, and digital subtraction angiography was performed if restenosis was suspected. RESULTS 176 patients were included. Periprocedural complications occurred in 2.3% of the patients at no periprocedural death, and in-hospital death in 13.6%. Discharge mRS score was maintained or improved at the 90-day follow-up in 86%, 4.54% had an in-stent restenosis requiring treatment at 90 days. No recorded comorbidity considered disadvantageous for stent patency showed statistical significance, the duration of the endovascular procedure had no significant effect on outcome. CONCLUSION In our data, TL treatment with triple APT resulted in a low restenosis rate, low rates of sICH and a comparably high number of patients with favorable outcome. Aggressive APT in the initial phase may therefore have the potential to prevent recurrent stroke better than restrained platelet inhibition. Comorbidities did not influence stent patency.
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Affiliation(s)
- Ali Khanafer
- Neuroradiological Clinic, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiological Clinic, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Philipp Bücke
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Florian Hennersdorf
- Department of Diagnostic and Interventional Neuroradiology, University of Tübingen, Tübingen, Germany
| | - Hansjörg Bäzner
- Neurological Clinic, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Michael Forsting
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Philipp von Gottberg
- Neuroradiological Clinic, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany.
- Klinik für Neuroradiologie, Klinikum Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Germany.
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Latacz P, Popiela T, Brzegowy P, Lasocha B, Kwiecień K, Simka M. Safety and Efficacy of Low-Dose Eptifibatide for Tandem Occlusions in Acute Ischemic Stroke. Neurol Int 2024; 16:253-262. [PMID: 38392958 PMCID: PMC10892545 DOI: 10.3390/neurolint16010017] [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: 12/28/2023] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 02/25/2024] Open
Abstract
OBJECTIVES The optimal treatment strategy for ischemic stroke in patients presenting with tandem occlusions of the internal carotid artery remains controversial. Several studies have demonstrated better clinical outcomes after eptifibatide, which is a short half-life antiplatelet agent. This retrospective analysis focused on the safety and efficacy of low-dose eptifibatide administration in stroke patients with tandem lesions. METHODS We evaluated the results of endovascular treatment in 148 stroke patients with tandem lesions. Patients in whom balloon angioplasty alone resulted in satisfactory cerebral flow did not receive eptifibatide (33 patients); others received this drug together with stent implantation (115 patients). Eptifibatide was given as an intravenous bolus of 180 μg/kg and then in a modified low dose of 1 μg/kg/min for 24 hours. RESULTS There were no statistically significant differences between both groups regarding 30-day mortality, frequency of thrombotic events, or hemorrhagic complications. An analysis of clinical status at 30-day follow-up revealed that the administration of eptifibatide was associated with a statistically significant better outcome: a higher rate of either no neurological symptoms or only mild symptoms (4 NIHSS points maximally). CONCLUSIONS The administration of eptifibatide in stroke patients presenting with tandem lesions is relatively safe. Moreover, treatment with this drug can improve clinical outcomes in these challenging patients.
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Affiliation(s)
- Paweł Latacz
- Department of Vascular Surgery and Angiology, Brothers of Mercy St. John of God Hospital, 31-061 Krakow, Poland; (P.L.); (K.K.)
| | - Tadeusz Popiela
- Chair of Radiology, Jagiellonian University Medical College, 31-008 Krakow, Poland; (T.P.); (P.B.)
| | - Paweł Brzegowy
- Chair of Radiology, Jagiellonian University Medical College, 31-008 Krakow, Poland; (T.P.); (P.B.)
| | | | - Krzysztof Kwiecień
- Department of Vascular Surgery and Angiology, Brothers of Mercy St. John of God Hospital, 31-061 Krakow, Poland; (P.L.); (K.K.)
| | - Marian Simka
- Institute of Medical Sciences, University of Opole, 45-040 Opole, Poland
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3
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Zapata-Arriaza E, Medina-Rodríguez M, Moniche Álvarez F, de Albóniga-Chindurza A, Aguilar-Pérez M, Ainz-Gómez L, Baena-Palomino P, Zamora A, Pardo-Galiana B, Delgado-Acosta F, Valverde Moyano R, Jiménez-Gómez E, Bravo Rey I, Oteros Fernández R, Escudero-Martínez I, Vielba-Gomez I, Morales Caba L, Díaz Pérez J, García Molina E, Mosteiro S, Castellanos Rodrigo MDM, Amaya Pascasio L, Hidalgo C, Freijo Guerrero MDM, González Díaz E, Ramírez Moreno JM, Fernández Prudencio L, Terceño Izaga M, Bashir Viturro S, Gamero-García MÁ, Jiménez Jorge S, Rosso Fernández C, Montaner J, González García A. Statistical analysis plan for the multicenter, open, randomized controlled clinical trial to assess the efficacy and safety of intravenous tirofiban vs aspirin in acute ischemic stroke due to tandem lesion, undergoing recanalization therapy by endovascular treatment (ATILA trial). Trials 2024; 25:35. [PMID: 38195586 PMCID: PMC10775524 DOI: 10.1186/s13063-023-07817-9] [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] [Received: 07/12/2023] [Accepted: 11/21/2023] [Indexed: 01/11/2024] Open
Abstract
RATIONALE In-stent reocclusion after endovascular therapy has a negative impact on outcomes in acute ischemic stroke (AIS) due to tandem lesions (TL). Optimal antiplatelet therapy approach in these patients to avoid in-stent reocclusion is yet to be elucidated. AIMS To assess efficacy and safety of intravenous tirofiban versus intravenous aspirin in patients undergoing MT plus carotid stenting in the setting of AIS due to TL. SAMPLE SIZE ESTIMATES Two hundred forty patients will be enrolled, 120 in every treatment arm. METHODS AND DESIGN A multicenter, prospective, randomized, controlled (aspirin group), assessor-blinded clinical trial will be conducted. Patients fulfilling the inclusion criteria will be randomized at MT onset to the experimental or control group (1:1). Intravenous aspirin will be administered at a 500-mg single dose and tirofiban at a 500-mcg bolus followed by a 200-mcg/h infusion during the first 24 h. All patients will be followed for up to 3 months. STUDY OUTCOMES Primary efficacy outcome will be the proportion of patients with carotid in-stent thrombosis within the first 24 h after MT. Primary safety outcome will be the rate of symptomatic intracranial hemorrhage. DISCUSSION This will be the first clinical trial to assess the best antiplatelet therapy to avoid in-stent thrombosis after MT in patients with TL. TRIAL REGISTRATION The trial is registered as NCT05225961. February, 7th, 2022.
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Affiliation(s)
- Elena Zapata-Arriaza
- Stroke Unit, Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain.
- Interventional Neuroradiology Department, Virgen del Rocío University Hospital, Neurovascular Research Laboratory, Institute of Biomedicine of Seville (IBIS), Av Manuel Siurot sn, Seville, 41013, Spain.
| | - Manuel Medina-Rodríguez
- Stroke Unit, Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
- Neurology Department, Virgen del Rocío University Hospital, Sevilla, Spain
| | - Francisco Moniche Álvarez
- Stroke Unit, Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
- Neurology Department, Virgen del Rocío University Hospital, Sevilla, Spain
| | - Asier de Albóniga-Chindurza
- Stroke Unit, Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
- Neurology Department, Virgen del Rocío University Hospital, Sevilla, Spain
| | - Marta Aguilar-Pérez
- Stroke Unit, Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
- Interventional Neuroradiology Department, Virgen del Rocío University Hospital, Neurovascular Research Laboratory, Institute of Biomedicine of Seville (IBIS), Av Manuel Siurot sn, Seville, 41013, Spain
| | - Leire Ainz-Gómez
- Stroke Unit, Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
- Neurology Department, Virgen del Rocío University Hospital, Sevilla, Spain
| | - Pablo Baena-Palomino
- Stroke Unit, Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
- Neurology Department, Virgen del Rocío University Hospital, Sevilla, Spain
| | - Aynara Zamora
- Stroke Unit, Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
| | - Blanca Pardo-Galiana
- Stroke Unit, Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
- Neurology Department, Virgen del Rocío University Hospital, Sevilla, Spain
| | | | | | - Elvira Jiménez-Gómez
- Interventional Neuroradiology Department, Reina Sofía University Hospital, Córdoba, Spain
| | - Isabel Bravo Rey
- Interventional Neuroradiology Department, Reina Sofía University Hospital, Córdoba, Spain
| | | | | | - Isabel Vielba-Gomez
- Interventional Neuroradiology Department, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Lluis Morales Caba
- Interventional Neuroradiology Department, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Jose Díaz Pérez
- Interventional Neuroradiology Department, Virgen de la Arrixaca University Clinical Hospital, Murcia, Spain
| | | | - Sonia Mosteiro
- Interventional Neuroradiology Department, A Coruña University Hospital Complex, Coruña, Spain
| | | | | | - Carlos Hidalgo
- Interventional Neuroradiology Department, Torrecardenas University Hospital, Almería, Spain
| | | | - Eva González Díaz
- Interventional Neuroradiology Department, Cruces University Hospital, Vizcaya, Spain
| | | | | | - Mikel Terceño Izaga
- Department of Neurology, Doctor Josep Trueta Hospital, Girona, Spain
- Interventional Neuroradiology Unit, Doctor Josep Trueta Hospital, Girona, Spain
| | - Saima Bashir Viturro
- Department of Neurology, Doctor Josep Trueta Hospital, Girona, Spain
- Interventional Neuroradiology Unit, Doctor Josep Trueta Hospital, Girona, Spain
| | - Miguel Ángel Gamero-García
- Stroke Unit, Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
- Neurology Department, Virgen Macarena University Hospital, Seville, Spain
| | - Silvia Jiménez Jorge
- Clinical Research and Clinical Trials Unit (CTU), Virgen del Rocío Hospital, Seville, Spain
| | - Clara Rosso Fernández
- Clinical Research and Clinical Trials Unit (CTU), Virgen del Rocío Hospital, Seville, Spain
| | - Joan Montaner
- Stroke Unit, Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
- Neurology Department, Virgen Macarena University Hospital, Seville, Spain
| | - Alejandro González García
- Stroke Unit, Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
- Interventional Neuroradiology Department, Virgen del Rocío University Hospital, Neurovascular Research Laboratory, Institute of Biomedicine of Seville (IBIS), Av Manuel Siurot sn, Seville, 41013, Spain
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Pop R, Burel J, Finitsis SN, Papagiannaki C, Severac F, Mangin PH, Mihoc D, Leonard-Lorant I, Gheoca R, Wolff V, Chibbaro S, Sibon I, Richard S, Beaujeux R, Marnat G, Gory B. Comparison of three antithrombotic strategies for emergent carotid stenting during stroke thrombectomy: a multicenter study. J Neurointerv Surg 2023; 15:e388-e395. [PMID: 36759180 DOI: 10.1136/jnis-2022-019875] [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: 11/11/2022] [Accepted: 01/30/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Periprocedural antithrombotic treatment is a key determinant for the risk-benefit balance of emergent carotid artery stenting (eCAS) during stroke thrombectomy. We aimed to assess the safety and efficacy of three types of antithrombotic treatment. METHODS Retrospective review of prospectively collected endovascular databases in four comprehensive stroke centers, including consecutive cases of eCAS for tandem lesion strokes between January 2019 and July 2021. During this period, each center prospectively applied one of three periprocedural protocols: (a) two centers administered aspirin (250 mg IV); (b) one center administered aspirin and heparin (bolus+24 hours infusion); and (c) one center applied an aggressive antiplatelet strategy consisting of aspirin and clopidogrel (loading doses), with added intravenous tirofiban if in-stent thrombosis was observed during thrombectomy. Dichotomized comparisons of outcomes were performed between aggressive versus non-aggressive strategy (aspirin±heparin) and aspirin+heparin versus aspirin-alone groups. RESULTS Among 161 included patients, 62 received aspirin monotherapy, 38 aspirin+heparin, and 61 an aggressive treatment. Aggressive antiplatelet treatment was associated with an increased rate of excellent (modified Thrombolysis in Cerebral Infarction (mTICI) 2c-3) recanalization and reduced carotid stent thrombosis at day 1 (3.5% vs 16.3%), compared with non-aggressive strategy. There were no significant differences in hemorrhagic transformation or 90-day mortality. There was a tendency towards better clinical outcome with aggressive treatment, without reaching statistical significance. Addition of heparin to aspirin was not associated with an increased rate of carotid stent patency. CONCLUSIONS Aggressive antiplatelet treatment was associated with improved intracranial recanalization and carotid stent patency, without safety concerns. These findings have implications for randomized trials and may be of utility for clinicians when making antithrombotic treatment choices.
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Affiliation(s)
- Raoul Pop
- Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, France
- Interventional Radiology, Institut de Chirurgie Guidée par l'Image, Strasbourg, France
- INSERM, EFS Grand-Est, BPPS UMR-S1255, FMTS, F-67065, University of Strasbourg, Strasbourg, France
| | - Julien Burel
- Radiology, University Hospital Centre Rouen, Rouen, France
| | | | | | - Francois Severac
- Public Healthcare Department, University Hospitals Strasbourg, Strasbourg, France
| | - Pierre H Mangin
- INSERM, EFS Grand-Est, BPPS UMR-S1255, FMTS, F-67065, University of Strasbourg, Strasbourg, France
| | - Dan Mihoc
- Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, France
| | - Ian Leonard-Lorant
- Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, France
| | - Roxana Gheoca
- Neurology, University Hospitals Strasbourg, Strasbourg, France
| | - Valerie Wolff
- Neurology, University Hospitals Strasbourg, Strasbourg, France
| | | | - Igor Sibon
- Neurology, University Hospital Center Bordeaux, Bordeaux, France
| | - Sébastien Richard
- Neurology Stroke Unit, University Hospital Centre Nancy, Nancy, France
| | - Remy Beaujeux
- Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, France
| | - Gaultier Marnat
- Interventional and Diagnostic Neuroradiology, University Hospital Centre Bordeaux, Bordeaux, France
| | - Benjamin Gory
- Department of Diagnostic and Interventional Neuroradiology, Centre hospitalier regional universitaire de Nancy, Nancy, France
- Université de Lorraine, Nancy, France
- IADI, INSERM U1254, Nancy, France
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5
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Keil F, Stahn S, Reitz SC, Lieschke F, du Mesnil de Rochemont R, Hattingen E, Berkefeld J. Elective carotid stenting fulfills quality standards defined in guidelines. ROFO-FORTSCHR RONTG 2023. [PMID: 37963550 DOI: 10.1055/a-2175-4029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
PURPOSE According to evidence from randomized trials and current guidelines, elective carotid artery stenting (CAS) is still considered second-line therapy compared with carotid endarterectomy (CEA). However, the publication of randomized comparative trials for patients with symptomatic stenoses occurred well over 10 years ago. In view of problems regarding German quality assurance when differentiating elective from emergency interventions and low case numbers for CAS indications, it seemed reasonable to present neurologically controlled CAS results and to investigate whether elective CAS consistently fulfills the strict quality criteria and what differences exist with respect to emergency CAS interventions in acute ischemic stroke. MATERIALS AND METHODS Between 01/2012 and 07/2022, 141 elective CAS procedures were performed to treat patients with symptomatic (n = 123) and asymptomatic (n = 18) stenoses. Protection by a filter system was achieved in 134 of these elective procedures (95 %). During the same period, 158 patients underwent carotid stenting for acute stroke. Complication rates were determined using neurologically controlled data. CAS-related complications (stent thrombosis, stent-associated vascular damage, thromboembolism, and symptomatic hemorrhage) were extracted from emergency interventions, and clinical outcome (NIHSS progression) was determined during the inpatient stay. RESULTS The rate of stroke and death determined during the inpatient stay for elective symptomatic patients was 0.8 %. Early treatment within the first 7 days after the index event, age > 70 years, and operator experience were not significant risk factors for the occurrence of complications. No complications were observed after CAS of asymptomatic stenoses. The procedure-related complication rate for emergency procedures was 7.8 %, which was significantly higher than after elective CAS, as expected (p < 0.006). CONCLUSION Even with limited indications and limited case numbers, compliance with the strict quality criteria of the current S3 Guideline 2022 for elective CAS interventions is possible for both symptomatic and asymptomatic stenoses in an experienced center. Emergency CAS interventions have significantly higher complication rates under other conditions and must be considered separately with regard to quality assurance. KEY POINTS · Elective carotid stenting fulfills the strict quality criteria of the current S3 guideline 2022.. · Emergency carotid stenting has significantly higher complication rates than elective procedures.. · Elective and emergency carotid stenting cannot be meaningfully compared.. CITATION FORMAT · Keil F, Stahn S, Reitz SC et al. Elective carotid stenting fulfills quality standards defined in guidelines. Fortschr Röntgenstr 2023; DOI: 10.1055/a-2175-4029.
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Affiliation(s)
- Fee Keil
- Neuroradiology, Hospital of the Goethe University Frankfurt Institute of Neuroradiology, Frankfurt am Main, Germany
| | - Simon Stahn
- Radiology, Hospital Nordwest Frankfurt, Germany
| | - Sarah Christina Reitz
- Neurosurgery, Hospital of the Goethe University Frankfurt Center of Neurology and Neurosurgery, Frankfurt am Main, Germany
| | - Franziska Lieschke
- Neurology, Hospital of the Goethe University Frankfurt Center of Neurology and Neurosurgery, Frankfurt am Main, Germany
| | | | - Elke Hattingen
- Neuroradiology, Hospital of the Goethe University Frankfurt Institute of Neuroradiology, Frankfurt am Main, Germany
| | - Joachim Berkefeld
- Neuroradiology, Hospital of the Goethe University Frankfurt Institute of Neuroradiology, Frankfurt am Main, Germany
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Marnat G, Finistis S, Moreno R, Sibon I, Pop R, Mazighi M, Clarençon F, Rosso C, Dargazanli C, Darcourt J, Olivot JM, Boulouis G, Janot K, Moulin S, Bourcier R, Consoli A, Richard S, Arquizan C, Vannier S, Richter S, Gentric JC, Papagiannaki C, Naggara O, Eker OF, Lapergue B, Caroff J, Gory B. Aspirin versus aggressive antiplatelet therapy for acute carotid stenting plus thrombectomy in tandem occlusions: ETIS Registry results. J Neurointerv Surg 2023; 15:e248-e254. [PMID: 36357169 DOI: 10.1136/jnis-2022-019527] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 10/24/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Patients treated with acute carotid stenting (CAS) may have higher odds of a favorable outcome than those treated without CAS during thrombectomy in tandem occlusions. Antiplatelet therapy is associated with CAS to avoid stent thrombosis, which occurs in around 20% of patients and negatively impacts outcomes. In this study we compared two antiplatelet strategies in tandem occlusion strokes treated with CAS and intracranial thrombectomy in clinical practice. METHODS The Endovascular Treatment in Ischemic Stroke Registry is an ongoing prospective observational study involving 21 comprehensive stroke centers performing thrombectomy in France. We analyzed patients with atherosclerotic tandem occlusions treated with acute CAS and intracranial thrombectomy who received at least one antiplatelet agent. Aggressive antiplatelet therapy included oral or intravenous glycoprotein (GP) IIb/IIIa or P2Y12 inhibitors. The primary outcome was cervical carotid artery patency at day 1 imaging follow-up. RESULTS Among the 187 included patients, 124 (66.3%) received aspirin alone and 63 (33.7%) received aggressive antiplatelet therapy. There was no significant difference regarding safety outcomes, especially in symptomatic intracerebral hemorrhage, parenchymal hematoma, and procedural complications. There was a significantly higher rate of carotid stent patency at day 1 in the aggressive antiplatelet therapy group (81.7% vs 97.1%, aOR 17.49, 95% CI 1.10 to 277.2, p=0.042). Odds of favorable functional outcome (90-day modified Rankin Scale score 0-2) were similar between the groups (OR 3.04, 95% CI 0.64 to 14.25, p=0.158). CONCLUSIONS In tandem occlusions treated with CAS plus thrombectomy, an aggressive antiplatelet regimen was associated with an increased rate of carotid stent patency at day 1 without safety concerns. Randomized trials are warranted to confirm these findings.
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Affiliation(s)
- Gaultier Marnat
- Interventional and Diagnostic Neuroradiology, CHU Bordeaux GH Pellegrin, Bordeaux, France
| | - Stefanos Finistis
- Neurosurgery, Aristotle University of Thessaloniki, Thessaloniki, Central Macedonia, Greece
| | - Ricardo Moreno
- Neuroradiology, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Igor Sibon
- Neurology, CHU de Bordeaux, Bordeaux, France
| | - Raoul Pop
- Neuroradiolology, CHU Strasbourg, Strasbourg, France
| | - Mikaël Mazighi
- Interventional Neuroradiology, Fondation Rothschild, Paris, France
- Neurology, GH Lariboisiere Fernand-Widal, Paris, France
| | - Frédéric Clarençon
- Neuroradiology, Hopital Universitaire Pitie Salpetriere, Paris, France
- Sorbonne University, Paris, France
| | - Charlotte Rosso
- Neurology, Hopital Universitaire Pitie Salpetriere, Paris, France
| | - Cyril Dargazanli
- Neuroradiology, University Hospital Centre Montpellier, Montpellier, France
| | | | | | | | | | - Solène Moulin
- Neurology, University Hospital Centre Reims, Reims, France
| | | | | | - Sébastien Richard
- Neurology Stroke Unit, University Hospital Centre Nancy, Nancy, France
| | | | | | | | | | | | | | - Omer F Eker
- Neuroradiology, Hospices Civils de Lyon, Bron, France
| | | | - Jildaz Caroff
- Interventional Neuroradiology, NEURI Brain Vascular Center, Bicêtre Hospital, APHP, Le Kremlin Bicêtre, France
| | - Benjamin Gory
- Diagnostic and Interventional Neuroradiology, Centre Hospitalier Universitaire de Nancy, Nancy, France
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7
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Pop R, Severac F, Hasiu A, Mihoc D, Mangin PH, Chibbaro S, Simu M, Tudor R, Gheoca R, Quenardelle V, Wolff V, Beaujeux R. Conservative versus aggressive antiplatelet strategy for emergent carotid stenting during stroke thrombectomy. Interv Neuroradiol 2023; 29:268-276. [PMID: 35253529 PMCID: PMC10369108 DOI: 10.1177/15910199221083112] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/07/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND There is no consensus regarding optimal antiplatelet regimen for emergent carotid stenting during stroke thrombectomy. We aimed to assess the safety and efficacy of an aggressive periprocedural antiplatelet strategy focused on preserving stent patency, in comparison with conservative antiplatelet strategy consisting of aspirin monotherapy. MATERIALS AND METHODS Retrospective review of a prospectively collected database in a comprehensive stroke center, including all cases of emergent carotid stenting for tandem lesions stroke between 01.03.2012-01.06.2021. Aggressive antiplatelet strategy consisted of dual antiplatelet therapy (DAPT) with aspirin and clopidogrel loading doses, with added intravenous (IV) tirofiban if in-stent thrombosis was observed during thrombectomy. Clinical and radiological outcomes were compared between conservative and aggressive antiplatelet treatment groups using inverse probability of treatment weighting (IPTW) analysis based on propensity scores. RESULTS We included 132 cases (76.5% atheroma, 22.7% dissection, 0.7% carotid web). Forty-five patients (34%) cases received conservative antiplatelet therapy. The remaining 87 (65.9%) received aggressive antiplatelet therapy: 66 (75.8%) treated with DAPT, 21 (24.1%) with DAPT and tirofiban. Periprocedural heparin was avoided in all cases. In adjusted analysis of the weighted samples, aggressive antiplatelet strategy was associated with improved carotid stent patency (aOR 0.23, 95% CI 0.07-0.80, p = 0.021), higher proportion of moderate clinical outcome (mRS ≤ 3, aOR 2.72, 95% CI 1.01-7.30, p = 0.04), with no significant differences in mortality and hemorrhagic transformation (HT) rates. CONCLUSIONS In this retrospective study, aggressive periprocedural antiplatelet strategy led to improved stent patency and clinical outcomes, without increased HT. Further prospective randomized research is warranted to identify the optimal combination of antiplatelet agents for emergent carotid stenting in the setting of acute stroke.
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Affiliation(s)
- Raoul Pop
- Interventional Neuroradiology Department, Strasbourg University Hospitals, Strasbourg, France
- Institut de Chirurgie Minime Invasive Guidée par l’Image, Strasbourg, France
- University of Strasbourg, INSERM, EFS Grand-Est, BPPS UMR-S1255, FMTS, Strasbourg, France
| | - François Severac
- Public Healthcare Department, Strasbourg University Hospitals, Strasbourg, France
| | - Anca Hasiu
- Interventional Neuroradiology Department, Strasbourg University Hospitals, Strasbourg, France
| | - Dan Mihoc
- Interventional Neuroradiology Department, Strasbourg University Hospitals, Strasbourg, France
| | - Pierre H Mangin
- University of Strasbourg, INSERM, EFS Grand-Est, BPPS UMR-S1255, FMTS, Strasbourg, France
| | - Salvatore Chibbaro
- Neurosurgery Department, Strasbourg University Hospitals, Strasbourg, France
| | - Mihaela Simu
- Neurology Department, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania
| | - Raluca Tudor
- Neurology Department, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania
| | - Roxana Gheoca
- Stroke Unit, Strasbourg University Hospitals, Strasbourg, France
| | | | - Valérie Wolff
- Stroke Unit, Strasbourg University Hospitals, Strasbourg, France
| | - Rémy Beaujeux
- Interventional Neuroradiology Department, Strasbourg University Hospitals, Strasbourg, France
- Institut de Chirurgie Minime Invasive Guidée par l’Image, Strasbourg, France
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Yahia MI, Marnat G, Finitsis S, Sibon I, Olivot JM, Pop R, Anadani M, Richard S, Gory B. Acute carotid stenting plus aspirin during thrombectomy of tandem occlusions: A matched case-control study. Interv Neuroradiol 2023:15910199231175375. [PMID: 37229632 DOI: 10.1177/15910199231175375] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND AND PURPOSE Acute carotid artery stenting (CAS) for ischemic stroke patients with anterior circulation tandem occlusion requires periprocedural antiplatelet therapy to prevent stent thrombosis. However, due to the lack of randomized trials and inconsistent published results, there is no reliable information regarding the safety of additional antiplatelet treatment. Therefore, we compared the safety and functional outcomes of patients treated with acute CAS plus Aspirin during tandem occlusions thrombectomy with isolated intracranial occlusions patients treated with thrombectomy alone. METHODS Two prospectively acquired mechanical databases from August 2017 to December 2021 were reviewed. Patients were included if they had carotid atherosclerotic tandem occlusions treated with acute CAS and Aspirin (intravenous bolus 250 mg) during thrombectomy. Any antiplatelet agent was added after thrombectomy and before the 24-h control imaging. This group was compared with a matched group of isolated intracranial occlusions treated with thrombectomy alone. RESULTS A total of 1557 patients were included and 70 (4.5%) had an atherosclerotic tandem occlusion treated with acute CAS plus Aspirin during thrombectomy. In exact coarse matched weight adjusted analysis, the rate of symptomatic intracerebral hemorrhage was similar in both groups (OR, 3.06; 95% CI, 0.66-14.04; P = 0.150), parenchymal hematoma type 2 (OR, 1.15; 95% CI, 0.24-5.39; P = 0.856), any intracerebral hemorrhage (OR, 1.84; 95% CI, 0.75-4.53; P = 0.182), and 90-day mortality (OR, 0.79; 95% CI, 0.24-2.60; P = 0.708). Rates of early neurological improvement and 90-day modified Rankin Scale score 0-2 were comparable. CONCLUSIONS Acute CAS plus Aspirin during thrombectomy for tandem occlusion stroke appears safe. Randomized trials are warranted to confirm these findings.
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Affiliation(s)
- Mohamed-Ismaël Yahia
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, CHRU-Nancy, Nancy, France
| | - Gaultier Marnat
- Department of Diagnostic and Interventional Neuroradiology, CHU Bordeaux, France
| | - Stephanos Finitsis
- Aristotle University of Thessaloniki, Ahepa Hospital, Thessaoniki, Greece
| | - Igor Sibon
- Department of Neurology, Stroke Center, CHU Bordeaux, France
| | | | - Raoul Pop
- Department of Interventional Neuroradiology, CHRU Strasbourg, France
| | - Mohammad Anadani
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - Sébastien Richard
- Department of Neurology, Université de Lorraine, CHRU-Nancy, Nancy, France
- CIC-P 1433, INSERM U1116, CHRU-Nancy, Nancy, France
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, CHRU-Nancy, Nancy, France
- Université de Lorraine, IADI, Nancy, France
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9
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Masoud HE, Nguyen TN, Broderick JP. Early Stent Patency After Endovascular Therapy for Tandem or Isolated Carotid Steno-Occlusive Disease. Stroke 2023; 54:132-134. [PMID: 36542069 DOI: 10.1161/strokeaha.122.040879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Hesham E Masoud
- Department of Neurology, Neurosurgery and Radiology, Upstate Medical University, Syracuse, NY (H.E.M.)
| | - Thanh N Nguyen
- Department of Neurology and Radiology, Boston Medical Center, MA (T.N.N.)
| | - Joseph P Broderick
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, OH (J.P.B.)
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10
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Allard J, Delvoye F, Pop R, Labreuche J, Maier B, Marnat G, Sibon I, Zhu F, Lapergue B, Consoli A, Spelle L, Denier C, Richard S, Piotin M, Gory B, Mazighi M, Redjem H, Escalard S, Dessilles JP, Delvoye F, Smajda S, Maier B, Solène H, Mazighi M, Obadia M, Sabben C, Pierre S, Igor R, Corabianu O, de Broucker T, Manchon E, Taylor G, Maacha MB, Thion LA, Augustin L, Julien S, Wang A, Evrard S, Tchikviladze M, Ajili N, WeisenburgerLile D, Gorza L, Buard G, Coskun O, Di Maria F, Rodesh G, Zimatore S, Leguen M, Gratieux J, Pico F, Rakotoharinandrasana H, Tassan P, Poll R, Marinier S, Barreau X, Berge J, Menegon P, Lucas L, Olindo S, Renou P, Sagnier S, Poli M, Debruxelles S, Rouanet F, Tourdias T, Liegey JS, Briau P, Pangon N, Coussy A, Papillon L, Papaxanthos J, Detraz L, Daumas-Duport B, Alexandre PL, Roy M, Lenoble C, Desal H, Guillon B, de Gaalon S, Preterre C, Bracard S, Anxionnat R, Braun M, Derelle AL, Tonnelet R, Liao L, Zhu F, Schmitt E, Planel S, Humbertjean L, Lacour JC, Riou-Comte N, Voicu M, Alb L, Reitter M, Brezeanu M, Masson A, Tabarna A, Podar I, Macian-Montoro F, Saleme S, Mounayer C, Rouchaud A, Costalat V, Arquizan C, Dargazanli C, Gascou G, Lefèvre PH, Derraz I, Riquelme C, Gaillard N, Mourand I, Corti L, Cagnazzo F, Ter Schiphorst A, Ferre JC, Raoult H, Ronziere T, Lassale M, Paya C, Gauvrit JY, Tracol C, Langnier-Lemercier S. 24-Hour Carotid Stent Patency and Outcomes After Endovascular Therapy: A Multicenter Study. Stroke 2023; 54:124-131. [PMID: 36542074 DOI: 10.1161/strokeaha.122.039797] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Management of extracranial internal carotid artery steno-occlusive lesion during endovascular therapy remains debated. Stent occlusion within 24 hours of endovascular therapy is a frequent event after acute carotid artery stenting, and we currently lack large population results. We investigated the incidence, predictors, and clinical impact of stent occlusion after acute carotid artery stenting in current clinical practice. METHODS Patients treated by endovascular therapy with acute carotid artery stenting between 2015 and 2019 in 5 large-volume endovascular-capable centers were retrospectively analyzed. Patients were separated in 2 groups according to the stent patency at 24 hours after carotid artery stenting. We compared baseline characteristics, treatment modalities, and clinical outcome depending on 24-hour stent patency. Primary end point was favorable outcome, defined as a modified Rankin Scale score 0-2 at 3 months. RESULTS A stent occlusion was observed in 47/225 patients (20.9%). Patients with stent patency had a lower baseline National Institutes of Health Stroke Scale (median [interquartile range]: 13 [7-17] versus 18 [12-21]) and had more often stroke of atherothrombotic origin (77.0% versus 53.2%). A higher stent patency rate was found for patients treated with P2Y12 antagonists at the acute phase (odds ratio [OR]' 2.95 [95% CI' 1.10-7.91]; P=0.026) and treated with angioplasty (OR' 2.42 [95% CI' 1.24-4.67]; P=0.008). A better intracranial angiographic reperfusion was observed in patients with 24-hour stent patency compared with patients without stent patency (OR' 8.38 [95% CI' 3.07-22.78]; P<0.001). Patients with a stent patency at 24 hours had a higher chance of favorable outcome (OR' 3.29 [95% CI, 1.66-6.52]; P<0.001) and a lower risk of death (OR' 0.32 [95% CI, 0.13-0.76]; P=0.009). CONCLUSIONS One out of 5 patients treated with carotid artery stenting during endovascular therapy presented a stent occlusion within 24 hours. This event was associated with worse functional outcome. Stroke etiology, P2Y12 antagonist administration, quality of intracranial reperfusion, and angioplasty were associated with 24-hour stent patency.
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Affiliation(s)
- Julien Allard
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (J.A., F.D., B.M., MP, M.M.).,University of Paris' France (J.A., M.M.)
| | - François Delvoye
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (J.A., F.D., B.M., MP, M.M.)
| | - Raoul Pop
- Department of Neuroradiolology, CHU Strasbourg, France (R.P.).,Institut de Chirurgie Minime Invasive Guidée par l'Image, Strasbourg, France (R.P.).,University of Strasbourg, INSERM UMR-S1255, France (R.P.)
| | - Julien Labreuche
- Department of Biostatistics, CHU Lille, University of Lille, France (J.L.)
| | - Benjamin Maier
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (J.A., F.D., B.M., MP, M.M.).,LVTS, INSERM U1148, University of Paris, France (BM., M.M.)
| | - Gaultier Marnat
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Bordeaux, France (G.M.)
| | - Igor Sibon
- Department of Neurology, Stroke Center, University Hospital of Bordeaux, France (I.S.)
| | - François Zhu
- Department of Diagnostic and Therapeutic Neuroradiology, CHRU-Nancy, Université de Lorraine, France (B.G., F.Z.)
| | - Bertrand Lapergue
- Department of Neurology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France (B.L.)
| | - Arturo Consoli
- Diagnostic and Interventional Neuroradiology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France (A.C.)
| | - Laurent Spelle
- Department of Neuroradiolology, CHU Kremlin-Bicêtre, Le Kremlin Bicêtre, France (L.S.)
| | - Christian Denier
- Department of Neurology, CHU Kremlin-Bicêtre, Le Kremlin Bicêtre, France (C.D.)
| | - Sébastien Richard
- Department of Neurology, Stroke Unit, Université de Lorraine, CHRU-Nancy, France (S.R.).,CIC-P 1433, INSERM U1116, CHRU-Nancy, France (S.R.)
| | - Michel Piotin
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (J.A., F.D., B.M., MP, M.M.)
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, CHRU-Nancy, Université de Lorraine, France (B.G., F.Z.).,IADI, INSERM U1254, Université de Lorraine, Nancy, France (B.G.)
| | - Mikael Mazighi
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (J.A., F.D., B.M., MP, M.M.).,LVTS, INSERM U1148, University of Paris, France (BM., M.M.).,University of Paris' France (J.A., M.M.)
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11
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Medina-Rodríguez M, Moniche F, de Albóniga-Chindurza A, Ortega-Quintanilla J, Ainz-Gómez L, Pardo-Galiana B, Cabezas-Rodríguez JA, Aguilar-Pérez M, Zamora A, Delgado-Acosta F, Jiménez-Gómez E, Bravo Rey I, Oteros Fernández R, Freijo Guerrero MDM, González Díaz E, Escudero-Martínez I, Morales Caba L, Vielba-Gomez I, Mosteiro S, Castellanos Rodrigo MDM, Amaya Pascasio L, Hidalgo C, Fernandez Prudencio L, Ramirez Moreno JM, Díaz Pérez J, Sanz-Fernandez G, Baena-Palomino P, Gamero-García MÁ, Jiménez Jorge S, Rosso Fernández C, Montaner J, González García A, Zapata-Arriaza E. Safety and efficacy of tirofiban in acute ischemic stroke due to tandem lesions undergoing mechanical thrombectomy: A multicenter randomized clinical trial (ATILA) protocol. Eur Stroke J 2022; 8:380-386. [PMID: 37021200 PMCID: PMC10069213 DOI: 10.1177/23969873221146383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 11/22/2022] [Indexed: 12/30/2022] Open
Abstract
Background: In-stent thrombosis after mechanical thrombectomy (MT) worsen outcomes in acute ischemic stroke (AIS) due to tandem lesions (TL). Although an optimal antiplatelet therapy is needed, the best approach to avoid in-stent thrombosis is yet to be elucidated. Hypothesis: Low-dose intravenous tirofiban is superior to intravenous aspirin in avoiding in-stent thrombosis in patients undergoing MT plus carotid stenting in the setting of AIS due to TL. Methods: The ATILA-trial is a multicenter, prospective, phase IV, randomized, controlled (aspirin group as control), assessor-blinded clinical trial. Patients fulfilling inclusion criteria (AIS due to TL, ASPECTS ⩾ 6, pre-stroke modified Rankin Scale ⩽2 and onset <24 h) will be randomized (1:1) at MT onset to experimental (intravenous tirofiban) or control group (intravenous aspirin). Intravenous aspirin will be administered at a 500 mg single dose and tirofiban at a 500 µg bolus followed by a 200 µg/h infusion during first 22 h. All patients will be followed up to 3 months. Sample size estimated is 240 patients. Outcomes: The primary efficacy outcome is the proportion of patients with carotid in-stent thrombosis within the first 24 h after MT. The primary safety outcome is the rate of symptomatic intracranial hemorrhage. Secondary outcomes include functional independence defined as modified Rankin Scale 0–2, proportion of patients undergoing rescue therapy due to in-stent aggregation during MT and carotid reocclusion at 30 days. Discussion: ATILA-trial will be the first clinical trial regarding the best antiplatelet therapy to avoid in-stent thrombosis after MT in patients with TL. Trial registration: NCT0522596.
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Affiliation(s)
- Manuel Medina-Rodríguez
- Stroke Unit, Neurology Department, Virgen del Rocío University Hospital, Sevilla, Spain
- Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
| | - Francisco Moniche
- Stroke Unit, Neurology Department, Virgen del Rocío University Hospital, Sevilla, Spain
- Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
| | - Asier de Albóniga-Chindurza
- Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
- Interventional Neuroradiology Department, Virgen del Rocío University Hospital, Sevilla, Spain
| | - Joaquin Ortega-Quintanilla
- Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
- Interventional Neuroradiology Department, Virgen del Rocío University Hospital, Sevilla, Spain
| | - Leire Ainz-Gómez
- Stroke Unit, Neurology Department, Virgen del Rocío University Hospital, Sevilla, Spain
- Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
| | - Blanca Pardo-Galiana
- Stroke Unit, Neurology Department, Virgen del Rocío University Hospital, Sevilla, Spain
- Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
| | - Juan Antonio Cabezas-Rodríguez
- Stroke Unit, Neurology Department, Virgen del Rocío University Hospital, Sevilla, Spain
- Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
| | - Marta Aguilar-Pérez
- Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
- Interventional Neuroradiology Department, Virgen del Rocío University Hospital, Sevilla, Spain
| | - Aynara Zamora
- Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
| | | | - Elvira Jiménez-Gómez
- Interventional Neuroradiology Department, Reina Sofía University Hospital, Córdoba, Spain
| | - Isabel Bravo Rey
- Interventional Neuroradiology Department, Reina Sofía University Hospital, Córdoba, Spain
| | | | | | - Eva González Díaz
- Interventional Neuroradiology Department, Cruces University Hospital, Vizcaya, Spain
| | | | - Lluis Morales Caba
- Interventional Neuroradiology Department, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Isabel Vielba-Gomez
- Interventional Neuroradiology Department, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Sonia Mosteiro
- Interventional Neuroradiology Department, A Coruña University Hospital Complex, A Coruña, Spain
| | | | | | - Carlos Hidalgo
- Interventional Neuroradiology Department, Torrecardenas University Hospital, Almería, Spain
| | | | | | - Jose Díaz Pérez
- Interventional Neuroradiology Department, Virgen de la Arrixaca University Clinical Hospital, Murcia, Spain
| | | | - Pablo Baena-Palomino
- Stroke Unit, Neurology Department, Virgen del Rocío University Hospital, Sevilla, Spain
- Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
| | - Miguel Ángel Gamero-García
- Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
- Neurology Department, Virgen Macarena University Hospital, Seville, Spain
| | - Silvia Jiménez Jorge
- Clinical Research and Clinical Trials Support Unit, Virgen del Rocio University Hospital, Sevilla, Spain
| | - Clara Rosso Fernández
- Clinical Research and Clinical Trials Support Unit, Virgen del Rocio University Hospital, Sevilla, Spain
| | - Joan Montaner
- Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
- Neurology Department, Virgen Macarena University Hospital, Seville, Spain
| | - Alejandro González García
- Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
- Interventional Neuroradiology Department, Virgen del Rocío University Hospital, Sevilla, Spain
| | - Elena Zapata-Arriaza
- Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
- Interventional Neuroradiology Department, Virgen del Rocío University Hospital, Sevilla, Spain
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12
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Zapata-Arriaza E, Medina-Rodriguez M, Ortega-Quintanilla J, De Albóniga-Chindurza A, Ainz-Gómez L, Pardo-Galiana B, Cabezas-Rodriguez JA, Lebrato-Herández L, Barragán-Prieto A, Pérez-Sánchez S, Zamora A, Montaner J, González García A, Moniche F. Relevance of Carotid Reocclusion in Tandem Lesions. J Atheroscler Thromb 2022. [PMID: 35989291 DOI: 10.5551/jat.63560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
AIMS Carotid reocclusion (CRO) after mechanical thrombectomy (MT) in acute ischemic stroke (AIS) due to tandem lesion (TL) or isolated internal carotid occlusion (ICO) is associated with worse clinical outcomes. Our aim was to analyze the predictors and clinical impact of CRO. METHODS A retrospective single-center analysis of all patients with anterior circulation strokes who underwent MT prospectively included in a registry between 2017 and 2020 was performed. ICO and TL as stroke causes were included. Stent deployment was left to the discretion of the interventionist. All patients received at least intravenous aspirin during MT. CRO was assessed using ultrasound within the first 24 h after MT. Efficacy and safety of stenting were assessed. RESULTS Among 1304 AIS cases, 218 (16.7%) were related to TL or ICO. Of them, 5% (n=11) were associated with internal CRO 24 h after the endovascular procedure. After adjusting per confounders, multivariate analysis showed that the independent variables associated with CRO were the TICI recanalization grade [TICI 2b-3; OR 0.1, 95% confidence interval (CI) 0.01-0.89, p=0.040], pial collateral circulation presence (OR 0.09, 95% CI 0.02-0.45, p=0.03), stent deployment during MT (OR 0.17, 95% CI 0.03-0.84, p=0.030), and general anesthesia use (OR 2.92, 95% CI 1.13-7.90, p=0.034). CRO showed a trend toward worst outcomes (modified Rankin scale 3-6) at 3 months (OR 3.4, 95% CI 0.96-12, p=0.057). After multivariate analysis, variables independently associated with worse outcomes at 90 days were intrastent platelet aggregation phenomena during endovascular therapy, admission National Institute of Health Stroke Scale, and age. Conversely, intravenous thrombolysis and TICI 2b-3 recanalization grade were identified as independent predictors of good outcomes at 90 days. CONCLUSIONS CRO has a relevant clinical impact in our study, associating lower rates of good functional outcomes at 3 months. Independent factors of CRO were the recanalization degree, presence of pial collateral circulation, use of a stent as a protective factor, and use of general anesthesia during thrombectomy.
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Affiliation(s)
- Elena Zapata-Arriaza
- Interventional Neurorradiology Department, University Hospital Virgen del Rocio.,Stroke Research Program, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville
| | - Manuel Medina-Rodriguez
- Stroke Research Program, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville.,Neurology department. University Hospital Virgen del Rocio
| | - Joaquin Ortega-Quintanilla
- Interventional Neurorradiology Department, University Hospital Virgen del Rocio.,Stroke Research Program, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville
| | - Asier De Albóniga-Chindurza
- Interventional Neurorradiology Department, University Hospital Virgen del Rocio.,Stroke Research Program, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville
| | - Leire Ainz-Gómez
- Stroke Research Program, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville.,Neurology department. University Hospital Virgen del Rocio
| | - Blanca Pardo-Galiana
- Stroke Research Program, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville.,Neurology department. University Hospital Virgen del Rocio
| | - Juan Antonio Cabezas-Rodriguez
- Stroke Research Program, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville.,Neurology department. University Hospital Virgen del Rocio
| | - Lucía Lebrato-Herández
- Stroke Research Program, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville.,Neurology department. University Hospital Virgen del Rocio
| | - Ana Barragán-Prieto
- Stroke Research Program, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville.,Neurology department. University Hospital Virgen Macarena
| | - Soledad Pérez-Sánchez
- Stroke Research Program, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville.,Neurology department. University Hospital Virgen Macarena
| | - Aynara Zamora
- Stroke Research Program, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville
| | - Joan Montaner
- Stroke Research Program, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville.,Neurology department. University Hospital Virgen Macarena
| | - Alejandro González García
- Interventional Neurorradiology Department, University Hospital Virgen del Rocio.,Stroke Research Program, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville
| | - Francisco Moniche
- Stroke Research Program, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville.,Neurology department. University Hospital Virgen del Rocio
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13
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Pop R, Hasiu A, Mangin PH, Severac F, Mihoc D, Nistoran D, Manisor M, Simu M, Chibbaro S, Gheoca R, Quenardelle V, Rouyer O, Wolff V, Beaujeux R. Postprocedural Antiplatelet Treatment after Emergent Carotid Stenting in Tandem Lesions Stroke: Impact on Stent Patency beyond Day 1. AJNR Am J Neuroradiol 2021; 42:921-925. [PMID: 33602749 DOI: 10.3174/ajnr.a6993] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 11/10/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Postprocedural dual-antiplatelet therapy is frequently withheld after emergent carotid stent placement during stroke thrombectomy. We aimed to assess whether antiplatelet regimen variations increase the risk of stent thrombosis beyond postprocedural day 1. MATERIALS AND METHODS Retrospective review was undertaken of all consecutive thrombectomies for acute stroke with tandem lesions in the anterior circulation performed in a single comprehensive stroke center between January 9, 2011 and March 30, 2020. Patients were included if carotid stent patency was confirmed at day 1 postprocedure. The group of patients with continuous dual-antiplatelet therapy from day 1 was compared with the group of patients with absent/discontinued dual-antiplatelet therapy. RESULTS Of a total of 109 tandem lesion thrombectomies, 96 patients had patent carotid stents at the end of the procedure. The early postprocedural stent thrombosis rate during the first 24 hours was 14/96 (14.5%). Of 82 patients with patent stents at day 1, in 28 (34.1%), dual-antiplatelet therapy was either not initiated at day 1 or was discontinued thereafter. After exclusion of cases without further controls of stent patency, there was no significant difference in the rate of subacute/late stent thrombosis between the 2 groups: 1/50 (2%) in patients with continuous dual-antiplatelet therapy versus 0/22 (0%) in patients with absent/discontinued dual-antiplatelet therapy (P = 1.000). In total, we observed 88 patient days without any antiplatelet treatment and 471 patient days with single antiplatelet treatment. CONCLUSIONS Discontinuation of dual-antiplatelet therapy was not associated with an increased risk of stent thrombosis beyond postprocedural day 1. Further studies are warranted to better assess the additional benefit and optimal duration of dual-antiplatelet therapy after tandem lesion stroke thrombectomy.
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Affiliation(s)
- R Pop
- From the Interventional Neuroradiology Department (R.P., A.H., D.M., D.N., M.M., R.B.), Strasbourg University Hospitals, Strasbourg, France
- Institut de Chirurgie Minime Invasive Guidée par l'Image (R.P., R.B.), Strasbourg, France
| | - A Hasiu
- From the Interventional Neuroradiology Department (R.P., A.H., D.M., D.N., M.M., R.B.), Strasbourg University Hospitals, Strasbourg, France
| | - P H Mangin
- Institut National de la Santé et de la Recherche Médicale (P.H.M.), University of Strasbourg, l'Établissement français du sang Grand-Est, BPPS UMR-S1255, Fédération de Médecine Translationnelle de Strasbourg, Strasbourg, France
| | - F Severac
- Public Healthcare Department (F.S.), Strasbourg University Hospitals, Strasbourg, France
| | - D Mihoc
- From the Interventional Neuroradiology Department (R.P., A.H., D.M., D.N., M.M., R.B.), Strasbourg University Hospitals, Strasbourg, France
| | - D Nistoran
- From the Interventional Neuroradiology Department (R.P., A.H., D.M., D.N., M.M., R.B.), Strasbourg University Hospitals, Strasbourg, France
| | - M Manisor
- From the Interventional Neuroradiology Department (R.P., A.H., D.M., D.N., M.M., R.B.), Strasbourg University Hospitals, Strasbourg, France
| | - M Simu
- Neurology Department (M.S.), Victor Babes University of Medicine and Pharmacy, Timisoara, Romania
| | - S Chibbaro
- Neurosurgery Department (S.C.), Strasbourg University Hospitals, Strasbourg, France
| | - R Gheoca
- Stroke Unit (R.G., V.Q., O.R., V.W.), Strasbourg University Hospitals, Strasbourg, France
| | - V Quenardelle
- Stroke Unit (R.G., V.Q., O.R., V.W.), Strasbourg University Hospitals, Strasbourg, France
| | - O Rouyer
- Stroke Unit (R.G., V.Q., O.R., V.W.), Strasbourg University Hospitals, Strasbourg, France
| | - V Wolff
- Stroke Unit (R.G., V.Q., O.R., V.W.), Strasbourg University Hospitals, Strasbourg, France
| | - R Beaujeux
- From the Interventional Neuroradiology Department (R.P., A.H., D.M., D.N., M.M., R.B.), Strasbourg University Hospitals, Strasbourg, France
- Institut de Chirurgie Minime Invasive Guidée par l'Image (R.P., R.B.), Strasbourg, France
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