Abstract P477: A Meta-Analysis of Carotid Stenting and Angioplasty for Treatment of Tandem Occlusion Stroke

Abstract

Introduction: Acute ischemic stroke (AIS) in the setting of tandem extracranial carotid disease and intracranial large vessel occlusion (TO) is associated with poor functional outcome. It remains unclear whether the extracranial lesion requires acute stenting or angioplasty alone. Meta-analyses to date have included predominantly retrospective non-comparative series. Our meta-analysis aimed to investigate if emergent carotid stenting plus endovascular thrombectomy (EVT) is more effective than angioplasty alone plus EVT at reducing incomplete recanalization (TICI <2b/3), symptomatic ICH (sICH) rate, or poor functional outcome (mRS>2 90 days). Methods: Systematic review identifying TO studies comparing those undergoing carotid angioplasties alone to stenting. Results were pooled using inverse variance random effects meta-analyses. Conclusions accounted for the magnitude of effect, precision and risk of bias in the studies using the modified GRADE process of the American Academy of Neurology. Results: Ten non-blinded, observational studies totaling 1006 TO patients met inclusion criteria. Baseline patient characteristics were without significant confounders. Mean initial NIHSS was 15.3 and 15.0 and symptom onset-to-recanalization time was 332 and 337 minutes in the stenting and angioplasty groups, respectively. Overall, poor functional outcome at 90 days occurred in 44.6% of patients and death occurred in 13.0% of patients. There was a significant decrease in the rate of mRS>2 (OR=0.55, CI 95% 0.40 –0.76) and death (OR=0.47, CI 95% 0.24–0.94) in patients treated with stenting vs angioplasty. TICI <2b/3 occurred in 21.5% of patients overall with no statistical difference in patients treated with stenting vs angioplasty (OR=0.67, CI 95% 0.42—1.07). sICH occurred in 5.7% of patients overall and there was no statistical difference in patients treated with stenting vs angioplasty (OR=1.19, CI 95% 0.53—2.67). Conclusion: Emergent stenting possibly decreases the risk of mRS>2 and mortality at 90 days. There is insufficient evidence to conclude whether stenting increases the risk of TICI <2b/3 and sICH. Confidence in the evidence is low, anchored by observational study designs and absence of blinding. A randomized controlled study is warranted.