Factors Associated with Procedural Thromboembolisms after Mechanical Thrombectomy for Acute Ischemic Stroke

Comparative effectiveness of intra-arterial thrombolysis vs. mechanical thrombectomy: a literature review

Background

Acute ischemic stroke (AIS) remains one of the leading causes of morbidity and mortality worldwide. Time is the single most critical factor in the management of patients presenting with AIS, where re-opening of occluded blood vessels is paramount. Intra-arterial thrombolysis (IAT) and mechanical thrombectomy (MT) are two such therapies employed to reestablish cerebrovascular blood flow in patients with AIS. This review compares both IAT and MT according to their efficacy, safety profiles, recanalization rates, clinical outcomes, and adverse procedural events.

Methods

Study abstraction from electronic search databases comprising PubMed/MEDLINE, ResearchGate, and the National Library of Medicine was used. Screening and selection of relevant articles were comprehensively conducted for this review. Direct comparisons between IAT and MT in terms of variables including recanalization rates, clinical outcomes, and adverse procedural events were warranted for study inclusion. Research determined to exhibit insufficient data or without comparable groups were subsequently excluded.

Results

MT was prompter when executing procedures than IAT, achieving greater rates of recanalization. Both interventions displayed similar results regarding rates of symptomatic intracranial hemorrhage (sICH) and mortality. Despite current available data indicating MT to demonstrate more efficiency as a procedure, further research is needed to examine IAT in light of specific patient demographics, clinical presentation, and circumstances.

Conclusion

This review elucidated that MT often takes less time peri-procedurally, achieving greater success in revascularization compared with that of IAT. Regarding mortality and sICH rates, IAT and MT comparison showed equivocal results. Thus, while making therapeutic decisions, it is important to consider the unique clinical features of each patient as well as the timing of interventions in order to maximize treatment outcomes.

Association of Aortic Arch Calcification on Chest X-ray with Procedural Thromboembolism after Mechanical Thrombectomy for Acute Ischemic Stroke

Background and Objective: Procedural thromboembolism after a mechanical thrombectomy (MT) for an acute ischemic stroke (AIS) has rarely been studied. It may occur from the artery-to-artery embolization of atherosclerotic plaque in the aortic arch. We investigated the relationship between aortic arch calcification (AoAC) on a chest X-ray and procedural thromboembolism on diffusion-weighted imaging (DWI) after an MT. Materials and Methods: From January 2017 to December 2020, 131 patients underwent DWI within two days following an MT for an AIS. Procedural thromboembolism was defined as new DWI-positive lesions in other territories from the occluded artery on DWI within two days after MT. Results: Procedural thromboembolism was observed in 30 (22.9%) patients. Procedural thromboembolism was associated with old age (72.3 ± 9.44 vs. 65.7 ± 12.8 years, p = 0.003), a longer procedural time (77.6 ± 37.6 vs. 60.1 ± 29.7 min, p = 0.024), and AoAC (calcification (73.3%) vs. no calcification (29.7%), p < 0.001). Multivariable logistic regression analysis showed that procedural thromboembolism was independently associated with AoAC (adjusted odds ratio (OR): 6.107, adjusted 95% confidence interval (CI): 2.374–15.705, p < 0.001) and a longer procedural time (adjusted OR: 1.015, adjusted 95% CI: 1.001–1.030, p = 0.031). Conclusions: Procedural thromboembolism after an MT for an AIS was related to AoAC on a chest X-ray and a longer procedural time. Our results suggest that although rapid recanalization is the most crucial goal of an MT for an AIS, the importance of the careful advance of the guiding catheter through the aortic arch should not be underestimated to reduce the risk of procedural thromboembolism, especially in patients with AoAC on a chest X-ray.