Endovascular treatment of acute carotid atherosclerotic tandem occlusions: Predictors of clinical outcomes as technical aspects and location of tandem occlusions

The T-Top Technique for Tandem Lesions: A Single-Center Retrospective Study

Background: Tandem Lesions (TLs) or Tandem Occlusions (TOs) are characterized by simultaneous high-grade stenosis or occlusion of the proximal extracranial internal carotid artery and the intracranial terminal internal carotid artery or its branches. These lesions can result in stroke and pose significant challenges to endovascular treatment. This study introduces and evaluates the "T-Top technique" as an innovative approach to address TLs, assessing its safety and technical efficacy. Methods: Data from acute ischemic stroke (AIS) patients treated with the T-Top technique between September 2022 and September 2023 were retrospectively analyzed. The technique involves using the pusher wire of a stent retriever as a microwire to guide a monorail angioplastic balloon to the extracranial carotid stenosis, performing angioplasty simultaneously with stent retriever anchorage. Clinical outcomes, procedural data, and safety were assessed. Results: Successful reperfusion (mTICI > 2b) was achieved in 91% of cases, with a median groin puncture to final recanalization time of 50 min. Favorable clinical outcomes (mRS < 3) were observed in 69% of patients, with a low mortality rate of 6% after 90 days. Conclusions: The T-Top technique offers a rapid and reliable strategy for TL treatment, improving reperfusion rates and clinical outcomes. Further studies are warranted to validate its efficacy in larger cohorts. This technique holds promise for enhancing endovascular treatment outcomes in patients with Tandem Lesions.

Repeated Re-occlusion during the Procedure of Mechanical Thrombectomy with Retrograde Approach for Tandem Occlusion Including T Occlusion: A Case Report

Objective

Two mechanical thrombectomy techniques are proposed for tandem occlusion of the anterior circulation: treating the extracranial carotid artery lesion first via an antegrade approach and treating the intracranial lesion first via a retrograde approach. Previous reports show that the retrograde approach has a shorter reperfusion time and a better prognosis, but re-occlusion of the intracranial lesion after recanalization may occur. We describe a case of tandem occlusion with repeated intracranial occlusions for mechanical thrombectomy using the retrograde approach and discuss possible countermeasures.

Case Presentation

A 94-year-old woman presented with acute cerebral ischemia due to tandem carotid T occlusion of the left internal carotid artery (ICA) and severe stenosis of the cervical carotid artery. Mechanical thrombectomy via a retrograde approach was performed using a stent retriever, resulting in complete recanalization of the anterior circulation through the ICA after 1 pass. The thrombus dispersed distally from the cervical artery and re-occluded the M1 twice, requiring thrombus re-retrieval each time.

Conclusion

The retrograde approach to tandem occlusion can result in repeated re-occlusion after recanalization of the intracranial lesion. Thrombi in cervical carotid lesions are usually fragile. Prior thrombus aspiration from the balloon guiding catheter at the carotid lesion may prevent re-occlusion after recanalization of the intracranial lesion without sacrificing the time advantage of early recanalization via the retrograde approach.

Age and Stroke Severity Matter Most for Clinical Outcome in Acute Arteriosclerotic Tandem Lesions

Background: Tandem lesions (TLs) cause up to 15-30% of all acute ischemic strokes (AISs). Endovascular treatment (EVT) is regarded as the first-line treatment; however, uncertainties remain with respect to the treatment and predictive outcome parameters. Here, we aimed to identify the clinical and demographic factors associated with functional short- and long-term outcomes in AIS patients with arteriosclerotic TLs undergoing EVT. Methods: This was a retrospective, mono-centric cohort study of 116 consecutive AIS patients with arteriosclerotic TLs who were endovascularly treated at a stroke center, with analysis of the relevant demographic, procedural, and imaging data. Results: A total of 116 patients were included in this study, with a median age of 72 years (IQR 63-80), 31% of whom were female (n = 36). The median NIHSS on admission was 14 (IQR 7-19), with a median ASPECT score of 9 (IQR 8-10) and median NASCET score of 99% (IQR 88-100%). A total of 52% of the patients received intravenous thrombolysis. In 77% (n = 89) of the patients, an antegrade EVT approach was used, with a good recanalization (mTICI2b3) achieved in 83% of patients (n = 96). Symptomatic intracerebral hemorrhage occurred in 12.7% (n = 15) of patients. A favorable outcome (mRS0-2) and mortality at 3 months were obtained for 40% (n = 47) and 28% of patients (n = 32), respectively. Age and NIHSS on admission were strongly associated with outcome parameters. Diabetes mellitus and previous neurological disorders were independently associated with long-term mortality (median 11 months, IQR 0-42). Conclusions: Younger age, lower stroke severity, and good recanalization were found to be independently associated with a favorable outcome. In contrast, older age, higher stroke severity, previous neurological disorders, and diabetes were correlated with mortality. The endovascular treatment of acute arteriosclerotic tandem lesions is feasible and relatively safe.

Triple platelet inhibition in intracranial thrombectomy with additional acute cervical stent angioplasty due to tandem lesion: a retrospective single-center analysis

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.

Antegrade or Retrograde Approach for the Management of Tandem Occlusions in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

Background: Acute ischemic stroke (AIS) caused by tandem intracranial and extracranial occlusions is not rare. However, optimal strategy between antegrade (extracranial first) or retrograde (intracranial first) approaches still remains elusive. This systematic review and meta-analysis aim to compare the two approaches to provide updated clinical evidence of strategy selection. Methods: PubMed, Ovid, Web of Science, and the Cochrane Library were searched for literature comparing antegrade and retrograde approaches for patients with AIS with concomitant tandem occlusions. Outcomes including successful reperfusion [Throbolysis in Cerebral Infarction (TICI) 2b-3] and 90-day favorable outcome [modified Rankin Scale (mRS) 0-2], any intracerebral hemorrhage, symptomatic intracerebral hemorrhage, procedural complications, and mortality were evaluated. The risk of bias was assessed using the Newcastle-Ottawa Scale and illustrated in the Funnel plot. Heterogeneity was assessed by I ² statistic. Subgroup and sensitivity analyses were also performed. Results: A total of 11 studies accounting 1,517 patients were included. 831 (55%) patients were treated with an antegrade approach and 686 (45%) patients were treated with the retrograde approach. A higher successful reperfusion rate was achieved in retrograde group than that of antegrade group [83.8 vs. 78.0%; odds ratio (OR): 0.63, 95% CI: 0.40-0.99, p = 0.04]. 90-day favorable outcome (mRS 0-2 at 90 days) also showed significantly higher in retrograde group compared with antegrade group (47.3 vs. 40.2%; OR: 0.72, 95% CI: 0.58-0.89, p = 0.002). The incidence of any intracranial hemorrhage (ICH), symptomatic intracranial hemorrhage, 90-day mortality, and other complications did not differ between two groups. Conclusion: In AIS with tandem occlusions, the retrograde approach might achieve a higher successful reperfusion rate and better functional outcome with a comparable safety profile when compared with an antegrade approach. Further prospective controlled studies with more meticulous design and a higher level of evidence are needed to confirm these results. Systematic Review Registration: "PROSPERO" database (CRD 42020199093), https://www.crd.york.ac.uk/PROSPERO/.

[Results of endovascular treatment of acute tandem occlusion of internal carotid and middle cerebral arteries]

OBJECTIVE

To evaluate the results of endovascular treatment of patients with ischemic stroke caused by acute tandem occlusion of the internal carotid and middle cerebral arteries (ICA and MCA).

MATERIAL AND METHODS

Endovascular intervention was performed in 8 patients with tandem occlusion of ICA and MCA. The neurological deficit on admission was 17.4±5.6 NIHSS points and the average ASPECTS score was 9.5±0.8. The time from the onset of neurological symptoms to reperfusion was 224±68 min. Thrombolytic therapy was initiated before brain revascularization and continued intraoperatively in 4 out of 8 patients. ICA stenting after aspiration thrombectomy was required in 6 patients. Both antegrade (n=4) and retrograde (n=2) methods of brain revascularization were used.

RESULTS

The rate of detection of tandem lesion in patients with ischemic stroke who underwent endovascular treatment was 5.4%. Technical success in restoring blood flow in the ICA basin at extra-and intra-cranial levels (mTICI 2b/3) was achieved in 7 (87.5%) patients. Intracranial hemorrhagic complications that affected the outcome of the disease were clinically significant in 25% of patients (n=2). The mortality rate was 37.5% (n=3). A satisfactory clinical result (a deficit of 0-2 mRS scores) was achieved at discharge in one of 5 surviving patients.

CONCLUSION

Further studies of choosing the optimal surgical tactics for tandem occlusion of ICA and MCA, taking into account its effectiveness and safety, are need.