Critical use of balloon angioplasty after recanalization failure with retrievable stent in acute cerebral artery occlusion

Which is the most effective rescue treatment after the failure of mechanical thrombectomy for acute basilar artery occlusion?

Objective

The aim of this study was to evaluate the effectiveness and safety of rescue therapy, a therapy in which rescue devices such as balloon angioplasty, Apollo stent, Wingspan stent, Solitaire stent, or other self-expanding stents are used after the failure of mechanical thrombectomy (MT) and to determine the most effective rescue measure for acute basilar artery occlusion (BAO) after the failure of MT.

Methods

For this study, we recruited patients from the BASILAR registry. All participants were divided into three groups: the recanalized with rescue therapy group, the recanalized without rescue therapy group, and the non-recanalized group. Clinical outcomes at 90 days and 1 year were compared. The association of rescue measures with favorable outcomes (modified Rankin Scale [mRS] score of 0–3) in patients achieving successful recanalization via rescue therapy was estimated using multivariate logistic regression analyses.

Results

Among the participants, recanalization failure was found in 112 patients and successful recanalization in 473 patients, with 218 patients receiving rescue therapy and 255 patients without rescue therapy. Of these, 111 (43.5%) patients in the recanalized without rescue therapy group, 65 (29.8%) patients in the recanalized with rescue therapy group, and nine (8.0%) patients in the non-recanalized group achieved favorable outcomes at 90 days. Both the recanalization with rescue therapy and the recanalization without rescue therapy groups were associated with favorable outcomes at 90 days and 1 year compared with the non-recanalized group. Moreover, in patients receiving rescue therapy, Wingspan stents, Apollo stents, and balloon angioplasty were associated with higher rates of favorable outcomes at 90 days and 1 year than Solitaire stents.

Conclusion

Whether rescue therapy is administered or not, recanalization leads to favorable outcomes in patients with acute BAO. For acute BAO after MT failure, balloon angioplasty, Wingspan stenting, and Apollo stenting could be considered effective and safe rescue options but not Solitaire stenting.

Clinical efficacy of tirofiban combined with a Solitaire stent in treating acute ischemic stroke

This study explores the safety and effect of acute cerebral infarction treatment by microcatheter injection of tirofiban combined with a Solitaire AB stent and/or stent implantation. Emergency cerebral angiograms showing the responsible vascular occlusion of 120 acute cerebral infarction patients who underwent emergency endovascular thrombectomy were included in the study. These patients were randomly divided into two groups using the random number table method: treatment group (n=60) that received thrombectomy (with cerebral artery stents) combined with intracerebral injection of tirofiban and control group (n=60) that only received thrombectomy (with cerebral artery stents alone). The baseline data, cerebral angiography before and after surgery, hospitalization, and follow-up results of patients in these two groups were compared. Furthermore, the incidence of major adverse cerebrovascular events of these two groups was compared (90-day modified Rankin scale, a score of 0–2 indicates a good prognosis). The difference between baseline clinical data and brain angiography between these two groups was not statistically significant. Patients in the treatment group had a higher prevalence of thrombolysis in cerebral infarction grade 2b/3 than patients in the control group (88.3% (53/60) vs 66.7% (40/60), P=0.036). Moreover, the National Institutes of Health Stroke Scale scores 7 days after surgery and the 90-day prognosis were all better for the patients who received tirofiban (P=0.048 and P=0.024). Mechanical thrombectomy with Solitaire AB stents in combination with the injection of tirofiban through a microcatheter appears to be safe and effective for the endovascular treatment of acute ischemic stroke.

Solitaire Stent in the Treatment of Acute Ischemic Stroke with Large Cerebral Artery Occlusion

Objective

To investigate the effect of mechanical thrombectomy with solitaire stent in the treatment of acute ischemic stroke with large cerebral artery occlusion.

Methods

Fifteen acute ischemic stroke patients with a proximal intracranial occlusion in the anterior circulation were included within 6 hours after symptom onset (unknown time of onset allowed in wake upstroke). Patients with a large infarct core or poor collateral circulation on computed tomography (CT) and CT angiography were excluded. All patients were measured by the National Institutes of Health Stroke Scale (NIHSS) before and 24 hours after the procedure. The primary outcomes were reperfusion at 24 hours and a Thrombolysis in Cerebral Infarction (TICI) score of 2b or 3 indicates successful reperfusion. Secondary outcomes included the functional score on the Modified Rankin Scale(MRS) and NIHSS score at 90 days. Good Functional Outcome (GFO), is defined as mRS0–2 at 90 days.

Results

The preoperative TICI grading of these 15 patients were all level 0.14 patients were level 2b to level 3 after the thrombectomy, 1 ipsilateral cervical carotid occlusion patient failed recanalization.14 patients with reperfusion at 24 hours showed good early neurologic improvement. The MRS score of all the 14 patients were<2 point at 90 days. There were no obvious adverse reactions and complications in these patients after mechanical thrombectomy.

Conclusion

The application of mechanical thrombectomy with solitaire stent for the treatment of acute ischemic stroke with large cerebral artery occlusion is safe and time-efficient, which could improve the recanalization rate, decrease or even eliminate the application of thrombolytic drugs and reduce the rate of intracranial hemorrhage. Awake stroke patient can also benefit from thrombectomy.

Combined Use of Mechanical Thrombectomy with Angioplasty and Stenting for Acute Basilar Occlusions with Underlying Severe Intracranial Vertebrobasilar Stenosis: Preliminary Experience from a Single Chinese Center

BACKGROUND AND PURPOSE

Acute basilar occlusions have a poor prognosis without recanalization. Many have underlying severe atherosclerotic intracranial stenosis coexisting with acute thrombosis, requiring treatment of both pathologies in the same session, though technical risks may be encountered. The purpose of this study was to evaluate the technical feasibility and safety of combined treatment by using stent retrievers for the thrombosis, together with angioplasty and stent placement for the underlying stenosis.

MATERIALS AND METHODS

This was a retrospective review of 13 patients with basilar occlusions treated with thrombectomy by the Solitaire stent retriever and angioplasty and intracranial stent placement for underlying severe vertebrobasilar stenosis in the same session. Reperfusion was assessed in terms of the TICI score. Perioperative complications were recorded. Clinical outcomes were assessed by the NIHSS at discharge and the mRS on follow-up at 90 days.

RESULTS

Of the 30 patients with acute basilar artery occlusions treated with stent retrievers during the study period, 18 had coexisting severe intracranial stenosis. Thirteen patients meeting the criteria for our study received combined mechanical thrombectomy and angioplasty with stent placement. The successful recanalization rate was 100%. Distal vessel embolizations occurred in 3 patients. There were 2 mortalities. On discharge, 10 patients (77%) had an improvement in NIHSS of ≥10 points. At 90 days, 6 patients (46%) had a good functional outcome with an mRS of ≤2.

CONCLUSIONS

The combined use of mechanical thrombectomy with angioplasty and stent placement for acute basilar occlusions with underlying severe intracranial atherosclerotic stenosis is technically feasible and safe.

Adjuvant Tirofiban Injection Through Deployed Solitaire Stent As a Rescue Technique After failed Mechanical Thrombectomy in Acute Stroke

Purpose

We present our experiences of intra-arterial tirofiban injection through a deployed Solitaire stent as a rescue therapy after failed mechanical thrombectomy in patients with acute ischemic stroke.

Materials and Methods

Data on 18 patients treated with adjunctive tirofiban injection through a temporarily deployed Solitaire stent after failed mechanical thrombectomy were retrospectively reviewed. Solitaire stent was used as a primary thrombectomy device in 16 of 18 patients. Two patients received manual aspiration thrombectomy initially. If initial mechanical thrombectomy failed, tirofiban was injected intra-arterially through the deployed Solitaire stent and then subsequent Solitaire thrombectomy was performed.

Results

Fourteen patients had occlusions in the middle cerebral artery, 2 in the distal internal carotid artery, and 2 in the basilar artery. Successful recanalization was achieved in 14 patients (77.7%) after intra-arterial injection of tirofiban and subsequent Solitaire thrombectomy. Three patients without successful recanalization after rescue method received angioplasty with stenting. Overall, successful recanalization (TICI grades 2b and 3) was achieved in 17 (94.4%) of 18 patients. Periprocedural complications occurred in 5 patients: distal migration of emboli in 5 patients and vessel perforation in 1. Three patients died. Good functional outcome (mRS ≤ 2) was achieved in 9 patients (50.0%) at 3 months.

Conclusion

Rescue intra-arterial injection of tirofiban through a temporarily deployed Solitaire stent may facilitate further recanalization in cases of failed mechanical thrombectomy in patients with acute ischemic stroke.