Emergent Carotid Artery Stenting Research Articles

Abstract 049: Predictors of Hemorrhagic Transformation Following Mechanical Thrombectomy with Emergent Carotid Artery Angioplasty and Stenting for Tandem Occlusions of the Anterior Circulation

Introduction Hemorrhagic transformation of the ischemic core following mechanical thrombectomy (MT) for acute ischemic strokes can negate the benefits of the procedure. Previous regressions have identified variables suggesting larger strokes and longer procedural times as significant predictors of hemorrhagic transformation. Tandem occlusions add another layer of complexity, as the proximal carotid occlusion and the emergent carotid artery angioplasty and stenting (eCAS) introduces additional factors that can influence hemorrhagic transformation by altering the dynamics of reperfusion. We investigated predictors of hemorrhagic transformations following MT+eCAS performed for anterior circulation tandem occlusion in patients with baseline mRS 0‐2.; Methods Retrospective analysis of institutional thrombectomy database for patient characteristics, thrombectomy details, in‐hospital course, and follow‐up outcomes to shortlist significant univariate predictors to conduct multivariate binomial logistic regression and assess for significant predictors of hemorrhagic transformations following MT+eCAS during in‐hospital stay.; Results Multivariate binomial backwards logistic regression identified hypertension (p=0.042) and use of balloon guide catheters as opposed to conventional guide catheters (p=0.035) to significantly increase the risk of hemorrhagic transformation. Middle cerebral artery occlusions as opposed to internal carotid terminus occlusions (p=0.025), conscious sedation as opposed to general anesthesia (p=0.002), primary aspiration passes as opposed to primary stent retriever passes (p=0.007), retrograde as opposed to anterograde eCAS (p=0.004), intracranial slow flow following MT+eCAS (p=0.049) and oral aspirin/ticagrelor as opposed to intravenous eptifibatide load prior to eCAS (p=0.021) suggested reduced risk of hemorrhagic transformation, symptomatic or not.; Conclusion The study identified procedural predictors of hemorrhagic transformation specific to tandem occlusions. Patients undergoing mechanical thrombectomy with carotid artery stenting (MT+eCAS) under general anesthesia, using primary stent retriever passes, anterograde eCAS, and receiving an intravenous eptifibatide load before eCAS were particularly vulnerable to hemorrhagic transformation. Gradual reperfusion, shown to be protective against hemorrhagic transformation, was supported by the significance of intracranial slow flow.

Abstract 375: Predictors of Good Clinical Outcomes After First Pass Effect in Anterior Circulation Tandem Occlusions

Introduction First pass effect (FPE) is an independent predictor of good clinical outcomes following mechanical thrombectomy (MT) in non‐tandem occlusions. A proximal tandem carotid steno‐occlusion introduces additional times and technical complexities which can influence recanalization and reperfusion dynamics and potentially, clinical outcomes in the long run. We evaluated the predictors of good clinical outcomes, specifically mRS0‐1 and mRS0‐2 at 90 days, in patients with anterior circulation tandem occlusions where recanalization was achieved through FPE from MT with emergent carotid artery angioplasty and stenting (eCAS), and had a baseline mRS0‐2.; Methods We perform a retrospective analysis of institutional thrombectomy database to identify univariate predictors. Significant predictors will be included in a multivariate logistic regression to determine significant predictors of mRS0‐1 and mRS0‐2 at 90 days post‐MT and eCAS.; Results We included 88 (66.2%) patients who achieved first pass effect among 133 anterior tandem occlusions undergoing MT with eCAS. Among patients with mRS0‐2 at 90 days, multivariate regression identified age (OR:0.857[0.772‐0.952],p=0.004), intravenous alteplase (OR:12.3[1.3‐114],p=0.027), use of a ballon guide catheter as opposed to conventional guides (OR:0.02[0.01‐0.63],p=0.027), time from arterial access to recanalization (OR:0.96[0.92‐0.999],p=0.043), pre‐eCAS oral aspirin/ticagrelor load as opposed to intravenous eptifibatide load (OR:0.017[0.001‐0.964],p=0.048) and symptomatic ICH (OR:0.025[0.001‐0.723],p=0.032) to be significant predictors. Significant predictors for mRS0‐1 at 90‐days were male sex (OR:41.33[1.45‐1179.31],p=0.03), hypertension (OR:0.03[0‐0.44],p=0.012), diabetes (OR:0.04[0‐0.63],p=0.023), use of a ballon guide catheter as opposed to conventional guides (OR:0.03[0‐0.66],p=0.027), distal embolization (OR:0.02[0‐1.71],p=0.082), time from arterial access to recanalization (OR:0.93[0.86‐0.99],p=0.026), residual carotid stenosis after eCAS (OR:0.003[0‐0.18],p=0.005), pre‐eCAS oral aspirin/ticagrelor load as opposed to intravenous eptifibatide load (OR:0.02[0‐0.25],p=0.016) and symptomatic ICH (OR:0.01[0‐0.38],p=0.012). Notably, heparin infusion post procedure predicted improved outcomes but was insignificant (OR: 55.54[0.59‐5226.65],p=0.083).; Conclusion The study highlights important considerations for eCAS, including the choice of antiplatelet loading agent, residual carotid stenosis and longer recanalization times which seem to impact good clinical outcomes.

The Dual-layer CGuard Stent Is Safe and Effective in Emergent Carotid Artery Stenting and in Tandem Occlusions: aMulti-centric Study.

Dual-layer stents have fallen into disrepute after several studies reported high rates of in-stent occlusions in acute stroke treatments. The CGuard stent is anew-generation hybrid dual-layer stent that has been designed to provide less thrombogenicity and to prevent peri- and postinterventional emboli. The aim of the study is to evaluate the safety and efficacy of the CGuard stent for the acute treatment of occlusion or high-grade stenosis of the extracranial internal carotid artery (ICA) in patients with acute ischemic stroke (AIS) with and without concomitant intracranial large vessel occlusion (LVO). All patients who underwent emergent carotid artery stenting (CAS) with the CGuard stent were identified and analyzed from the stroke registries from four tertiary German stroke centers. Clinical, procedural, and imaging data were evaluated. Stent patency within 72 h, intracranial hemorrhage, and modified Rankin score (mRS) at discharge were the safety and efficacy end points. Overall, ninety-six patients were included (mean age70.2 ± 11.8, 66males (68.8%), median NIHSS score at admission 11 (7-17), IVlysis: n = 44 (45.8%)). Stent placement was successful in all patients. Eighty-three (86.4%) patients had tandem occlusions. In-stent occlusion occurred in 5patients (5.2%) and 3patients developed early in-stent stenosis (3.1%). Median mRS at discharge was 2 (1-4). In this multicenter study, the use of the dual-layer CGuard stent for emergent CAS, particularly in tandem occlusions, was safe and resulted in low rates of in-stent occlusions.

Tirofiban versus aspirin to prevent in-stent thrombosis after emergent carotid artery stenting in acute ischemic stroke

BackgroundSeveral antithrombotic treatments during emergent carotid artery stenting (eCAS) have been proposed, but an appropriate protocol to balance risk–benefit is not well known.ObjectiveTo investigate the efficacy and safety of tirofiban...

Clinical and safety outcomes of acute stenting plus thrombectomy for carotid tandem lesions with large ischemic core

BackgroundWe evaluated the clinical and safety outcomes of emergent carotid artery stenting (eCAS) plus endovascular thrombectomy (EVT) among patients with anterior tandem lesion (TL) and large ischemic core (LIC).MethodsThis retrospective...

The efficacy and efficiency of percutaneous lidocaine injection for minimizing the carotid reflex in carotid artery stenting: A single-center retrospective study.

To assess whether local anesthetic infiltration could minimize the carotid baroreceptor reflex (CBR) which has an incidence after carotid artery stenting (CAS) that varies from 29% to 51%. This retrospective single-center study included 51 patients (mean age, 70.47 years) who underwent CAS for carotid stenosis. The groups included patients who underwent CAS for asymptomatic ischemic stroke (n=41) or symptomatic disease (n=10). Preprocedural percutaneous lidocaine injections (PPLIs) were administered to 70.6% and 5.9% of patients who underwent elective CAS and emergency CAS, respectively. Among patients who received PPLIs, the mean degree of stenosis was 80.5% (95% confidence interval [CI]: ±10.74, 51-98%). The mean distance from the common carotid artery bifurcation to the most stenotic lesion (CSD) was 8.3 mm (95% CI: ±0.97, 6.3-10.2 mm); the mean angle between the internal carotid artery and common carotid artery (CCA) trunk (IAG) was 65.6° (95% CI: ±2.39, 61-70°). Among patients who did not receive PPLIs, the mean degree of stenosis was 84.0% (95% CI: ±8.96, 70-99%). The mean CSD was 5.9 mm (95% CI: ±1.83, 1.9-9.9 mm); the mean IAG was 60.4° (95% CI: ±4.41, 51-70°). The procedure time was longer in the PPLI group than in the no PPLI group (28.19 [n=39] vs. 18.88 [n=12] days) (P=0.057); the length of intensive care unit stay was shorter in the PPLI group (20.01 [n=36] vs. 28.10 [n=5] days) (P=0.132). Targeted PPLI administration to the carotid bulb decreased aberrant heart rates and blood pressure changes induced by carotid stent deployment and balloon inflation. As CBR sensitivity increases with decreasing distance to the stenotic lesion from the CCA bifurcation, PPLIs may help stabilize patients during procedures for stenotic lesions closer to the CCA.

Predictors of Good Functional Outcome in Patients with Tandem Occlusion After Revascularization Treatment: Single-Center Experience with 12-Month Follow-Up

The optimal management and procedural strategy for tandem occlusion (TO) in acute ischemic stroke are still unclear, as is the long-term outcome of these patients. The aim of this study was to evaluate predictors of good functional outcome in patients with TO through the analysis of demographics, clinical, and radiological data with a 1-year follow-up. We collected data on 100 patients with TO who underwent revascularization treatments in our comprehensive stroke center. We divided patients into 2 groups: those with good functional outcome, defined as a modified Rankin Scale 0-2, and those with poor functional outcome, defined as a modified Rankin Scale 3-6 at 3, 6, and 12-month follow-up. Moreover, we investigated which variables were able to influence mortality. At multivariate analysis, endovascular treatment with mechanical thrombectomy combined with emergent cervical carotid artery stenting was an independent predictor of good functional outcome at 6 and 12months (adjusted odds ratio [aOR] 4.3, confidence interval [CI] 1.49-12.31, P= 0.007) (aOR 3.5, CI 1.25-9.61, P= 0.017) and was associated with a lower rate of mortality at 3 and 6months follow-up (aOR 0.14, CI 0.04-0.57, P= 0.006 and aOR 0.296, CI 0.97-0.902, P= 0.032, respectively). Furthermore, smoking habit was associated with a better outcome at 3-month follow-up (aOR 10.7, CI 2.2-51.6, P= 0.003) but not at 6- and 12-month. Our research, conducted in a small sample size of patients with acute ischemic stroke due to TO of anterior circulation, found that acute stent placement seems to be safe, improving clinical outcome, and it is associated with low rate of mortality at long-term follow-up.

Value of intravenous alteplase before thrombectomy among patients with tandem lesions and emergent carotid artery stenting: A subgroup analysis of the SWIFT DIRECT trial.

The value of intravenous thrombolysis (IVT) in eligible tandem lesion patients undergoing endovascular treatment (EVT) is unknown. We investigated treatment effect heterogeneity of EVT + IVT versus EVT-only in tandem lesion patients. Additional analyses were performed for patients undergoing emergent internal carotid artery (ICA) stenting. SWIFT DIRECT randomized IVT-eligible patients to either EVT + IVT or EVT-only. Primary outcome was 90-day functional independence (modified Rankin Scale score 0-2) after the index event. Secondary endpoints were reperfusion success, 24 h intracranial hemorrhage rate, and 90-day all-cause mortality. Interaction models were fitted for all predefined outcomes. Among 408 included patients, 63 (15.4%) had a tandem lesion and 33 (52.4%) received IVT. In patients with tandem lesions, 20 had undergone emergent ICA stenting (EVT + IVT: 9/33, 27.3%; EVT: 11/30, 36.7%). Tandem lesion did not show treatment effect modification of IVT on rates of functional independence (tandem lesion EVT + IVT vs. EVT: 63.6% vs. 46.7%, non-tandem lesion EVT + IVT vs. EVT: 65.6% vs. 58.2%; p for interaction = 0.77). IVT also did not increase the risk of intracranial hemorrhage among tandem lesion patients (tandem lesion EVT + IVT vs. EVT: 34.4% vs. 46.7%, non-tandem lesion EVT + IVT vs. EVT: 33.5% vs. 26.3%; p for interaction = 0.15). No heterogeneity was noted for other endpoints (p for interaction > 0.05). No treatment effect heterogeneity of EVT + IVT versus EVT-only was observed among tandem lesion patients. Administering IVT in patients with anticipated emergent ICA stenting seems safe, and the latter should not be a factor to consider when deciding to administer IVT before EVT.

Abstract WP208: Infarction Size Affects Clinical Outcomes in Emergent Carotid Artery Stenting With Mechanical Thrombectomy

Background: Management of large vessel occlusion with extensive ipsilateral internal carotid artery (ICA) occlusion is unknown. We evaluated patients who underwent emergent carotid artery stenting (CAS) of the ICA with mechanical thrombectomy (MT). Methods: We retrospectively collected baseline demographic, clinical, and radiographic data on 27 patients who presented as a stroke alert within 24 hours of symptoms and had extensive (from bifurcation to distal ICA) occlusion by computerized tomography angiography from 2019-2023 at our institution. All patients underwent CAS with MT and received dual antiplatelet therapy. We measured outcomes by: (1) development of symptomatic ICH at 24 hours, (2) mortality, (3) Modified Rankin Scale (mRS) at 90 days, and (4) change in NIHSS at 24 hours. Baseline characteristics were reported by descriptive statistics. Statistical analyses were completed using Fisher’s exact test, Wilcoxon rank sum test, and logistic regression. Differences were statistically significant at p < 0.05. Results: The mean age for our cohort was 64.5 ± 10.62 and nine patients were females (33.3%). Sixteen had M1 (59.3%) while 10 had M2 occlusion (37%), 14 patients received IV tPA (51.9%), and mean NIHSS at presentation was 15.6 ± 5.99. All patients achieved TICI 2b or TICI 3 recanalization. In our cohort, patients with lower ASPECT score 7.4 ± 1.8 compared to those with higher ASPECT score 9.0 ± 1.0 were more likely to have symptomatic ICH ( p = 0.032), and higher odds of mortality OR = 0.496, 95% CI (0.261-0.945). The development of symptomatic ICH at 24 hours following procedure was associated with severe disability (mRS 4-6) at 90 days ( p = 0.032). Administration of intravenous tPA was significantly associated with improvement of 4 or more points on NIHSS at 24 hours ( p = 0.032), but not with symptomatic ICH ( p = 0.419). Age, NIHSS at presentation, systolic blood pressure, and diabetes mellitus were not associated with mortality or symptomatic ICH. Conclusion: The area of infarction at the time of presentation (ASPECT score) is an essential factor in stratifying patient selection for emergent CAS during MT in extensive internal carotid artery occlusion. Further studies are needed to evaluate infarction size for safe interventions.

Elective carotid stenting fulfills quality standards defined in guidelines.

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. 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. 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). 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. · 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.. · Keil F, Stahn S, Reitz SC et al. Elective carotid stenting fulfills quality standards defined in guidelines. Fortschr Röntgenstr 2024; 196: 471 - 481.

Abstract 063: Emergent versus delayed carotid artery stenting in tandem occlusion strokes treated with thrombectomy

Introduction It is controversial when to pursue carotid artery stenting (CAS) after acute tandem occlusion (TO) strokes treated with endovascular thrombectomy (EVT). We conducted a retrospective observational study to evaluate the clinical and safety outcomes of emergent versus delayed CAS in the first week of EVT. Methods In this retrospective cohort study, using 2016‐19 Nationwide Readmissions Database, we identified patients with acute ischemic stroke who had EVT for anterior circulation large vessel occlusions (LVOs) and CAS up to 7 days of EVT. CAS performed on day ‐1, 0 or 1 day after admission was considered as emergent CAS. CAS performed 2‐7 days after EVT was defined as delayed CAS. The primary clinical outcomes were all‐cause mortality during same admission. Secondary safety outcomes included intracranial hemorrhage (ICH), seizures, gastric tube (G‐tube) insertion, &gt; 24‐hours mechanical ventilation, tracheostomy, length of stay (LOS), and discharge location (home vs. others). Multivariate logistic regression analysis was used to compare outcomes in emergent CAS group in comparison to delayed CAS group. Age, sex, hypertension, diabetes mellitus, hyperlipidemia, and use of thromobolytics were considered as covariates. Results We identified total of 1990 hospitalizations meeting the study inclusion criteria (mean age: 67 years ± standard deviation:12 years, female 612 (31%). Of these, 1745 (87%) had undergone emergent CAS with EVT and 245 (13%) had delayed CAS (2‐7 days) pos‐EVT. Baseline characteristics were similar between the two cohorts. Delayed CAS cohort had significantly less mortality rates [6 vs 13%; OR 0.43, 95% CI 0.24‐0.78], less ICH [20 vs 30%; OR 0.6, 95% CI 0.43‐0.82¬¬], less cerebral edema [16 vs 23%; OR 0.65, 95% CI 0.44‐0.96], and less mechanical ventilation for &gt;24‐hours [11 vs 18%; OR 0.54, 95% CI 0.34‐0.85]. There was no significant difference between the two treatment groups for tracheostomy, G‐tube placements, new‐onset seizure, and mean LOS. Conclusion Delaying CAS for 2‐7 days after EVT might be a safer approach for endovascular revascularization in anterior circulation LVO strokes secondary to tandem lesions.

Abstract 234: Antithrombotic use in Emergent Cervical Carotid Artery Stenting in Thrombectomy

Introduction Current literature suggests a benefit in functional outcomes and reperfusion rates when carotid artery stenting (CAS) and mechanical thrombectomy (MT) are performed emergently. However, rates of symptomatic intracranial hemorrhages have been inconclusive. Antithrombotic protocols used in CAS and MT tend to be heterogenous among physicians. There is no standardized data on antithrombotic therapy use during CAS and MT procedures with less associated rates of symptomatic hemorrhagic transformation. We aimed to compare the efficacy and safety of antithrombotic use in patients requiring CAS and MT. Additionally, we sought to analyze clinical and mortality outcomes in CAS and MT retrospectively at our institution. Methods We searched for patients who underwent emergency cervical ICA stent placement and intracranial thrombectomy with stent‐retriever and/or aspiration devices in our institution between 2019‐2023. Clinicoangiographic and antithrombotic data were analyzed. Good clinical outcomes were a &lt; 4 points of NIHSS at 24 hours, mRS (0‐3) at 90 days, and disposition to home or inpatient rehabilitation. Characteristics of hemorrhagic transformation (HT) according to the European Cooperative Acute Stroke Study (ECASS). Clinical, radiographic, and mortality outcomes were described. Results Twenty‐seven patients were treated. The mean age was 64 years, nine females: mean occlusion time 400 minutes, mean fluoro time 32 minutes. Fourteen patients received IV tissue‐type plasminogen (tPA) activator. The admission NIHSS score mean was 16. Stent placement was feasible in all cases. Thrombolysis in Cerebral Infarction score of 2B was achieved in 18 patients (66.7%); the rest had a TICI 3 score. Twelve patients had improved 4 NIHSS points between admission and 24 hours. Dual antiplatelet therapy with aspirin and clopidogrel was used in 15 patients before stenting. While six patients received aspirin and ticagrelor, and the rest received eptifibatide drip. Seven (26%) patients had symptomatic intracranial hemorrhages. Antithrombotic type of treatment had no significant association with bad outcomes (p‐value: 0.872), neither did IV tPA use (p‐value: 0.853). Fourteen patients had good clinical outcomes (mRS 0‐3) at discharge, while eight died. At 90 days follow‐up, the median mRS was 3. Conclusion Our analysis suggests no significant association between symptomatic hemorrhagic transformation with IV tPA or heterogenous antithrombotic use. Our retrospective study has several limitations, including sample size and heterogeneous pathology. Larger studies are needed to stratify symptomatic hemorrhages' high‐risk profile in CAS and MT.

Efficacy and Safety Outcomes for Acute Ischemic Stroke Patients Treated with Intravenous Infusion of Tirofiban After Emergent Carotid Artery Stenting

IntroductionEmergent stenting of the extracranial internal carotid artery (ICA) in stroke patients requires antiplatelet therapy to prevent in-stent thrombosis with a higher risk of intracranial haemorrhage.Aim of the StudyAssess the efficacy and safety of emergent carotid stenting with intravenous tirofiban in acute ischemic stroke patients.MethodsPrimary endpoint: symptomatic hemorrhage. Secondary endpoints: 90-day functional outcome and mortality.ResultsOf the 62 patients, 21 (34%) received tirofiban as a single antiplatelet, and 41 (66%) received combined therapy. Premedication with anticoagulants and antiplatelets was significantly more frequent in the tirofiban-only group. The rate of symptomatic haemorrhage was significantly lower in the tirofiban-only group than in the combined group (4.8% vs. 27%, p = 0.046). The patients with tirofiban alone had a significantly better functional outcome at day 90 than the combined group (52% vs. 24%, p = 0.028). Mortality was equal (24%) in both groups. Pre-interventional NIHSS score (p = 0.003), significant blood pressure fluctuations (p = 0.012), tandem occlusion (p = 0.023), and thrombolysis (p = 0.044) showed relevant influence on the rate of symptomatic hemorrhage in the entire patient cohort.ConclusionsA single antiplatelet therapy with tirofiban regardless of the premedication may improve the functional outcome in patients with stroke due to acute extracranial carotid lesion and emergent carotid stenting with lower rates of serious intracranial haemorrhage.For patients with high pre-interventional NIHSS score, tandem occlusion and after pre-interventional thrombolysis, caution is advised. Additionally, strict blood pressure monitoring should be conducted during the first 72 h after intervention.

Safety and efficacy of eptifibatide in acute ischemic stroke requiring extracranial carotid artery stenting.

The antiplatelet management in acute ischemic stroke requiring carotid artery stenting is heterogenous, with no clear guidelines to direct management. To evaluate the safety and efficacy of an intravenous eptifibatide protocol in the management of acute ischemic stroke requiring emergent carotid artery stenting. We performed a retrospective analysis of consecutive patients who underwent carotid artery stenting for acute ischemic stroke at a high-volume tertiary neuroscience center, who were managed with an intravenous eptifibatide protocol. The protocol consists of an intravenous loading eptifibatide bolus (180 mcg/kg) at the time of stenting, followed by a maintenance infusion of 1 mcg/kg/min, then oral or nasogastric loading of dual antiplatelet agents. 80 patients were included for analysis. Median presenting NIHSS was 17. Sixty-six patients (83%) had a tandem intracranial occlusion. Six (7.5%) patients developed symptomatic intracranial hemorrhage (sICH). Those who received intravenous thrombolysis were not more likely to develop sICH (10% vs 5%, p = 0.40). Those patients with a presenting ASPECTS <8 were significantly more likely to develop sICH than those with ASPECTS 8-10 (25% vs 3%, p = 0.004). Eptifibatide may have a role in the management of acute stroke requiring carotid stenting. Caution may be required in those with established infarct on presentation imaging.

Radiation Dose and Fluoroscopy Time of Extracranial Carotid Artery Stenting : Elective vs. Emergency Treatment Including Combined Mechanical Thrombectomy in Tandem Occlusion.

Fluoroscopically guided endovascular carotid artery stenting (CAS) of extracranial carotid stenosis (ECS) is areasonable alternative to carotid endarterectomy in selected patients. Diagnostic reference levels (DRL) for this common neurointervention have not yet been defined and respective literature data are sparse. We provide detailed dosimetrics for useful expansion of the DRL catalogue. Aretrospective single-center study of patients undergoing CAS between 2013 and 2021. We analyzed dose area product (DAP) and fluoroscopy time considering the following parameters: indications for CAS, semielective/elective versus emergency including additional mechanical thrombectomy (MT) in extracranial/intracranial tandem occlusion, etiology of ECS (atherosclerotic vs. radiation-induced), periprocedural features, e.g., number of applied stents, percutaneous transluminal angioplasty (PTA) and MT maneuvers, and dose protocol. Local DRL was defined as 75% percentile of the DAP distribution. A total of 102patients were included (semielective/elective CAS n = 75, emergency CAS n = 8, CAS + MT n = 19). Total median DAP was 78.2 Gycm2 (DRL 117 Gycm2). Lowest and highest median dosimetry values were documented for semielective/elective CAS and CAS + MT (DAP 49.1vs. 146.8 Gycm2, fluoroscopy time 27.1vs. 43.8 min; p < 0.005), respectively. Dosimetrics were significantly lower in patients undergoing 0-1 PTA maneuvers compared to ≥ 2maneuvers (p < 0.05). Etiology of ECS, number of stents and MT maneuvers had no significant impact on dosimetry values (p > 0.05). Alow-dose protocol yielded a33% reduction of DAP. This CAS study suggests novel local DRLs for both elective and emergency cases with or without intracranial MT. Adedicated low-dose protocol was suitable for substantial reduction of radiation dose.

Antithrombotic regimen in emergent carotid stenting for acute ischemic stroke due to tandem occlusion: a meta-analysis of aggregate data

BackgroundThe periprocedural antithrombotic regimen might affect the risk-benefit profile of emergent carotid artery stenting (eCAS) in patients with acute ischemic stroke (AIS) due to tandem lesions, especially after intravenous thrombolysis....

Abstract Number ‐ 148: Emergent Carotid Artery Stenting On Acute Stroke Patients With Carotid Occlusion: Benefit Or Harm?

Introduction Almost one out of four patients with acute middle cerebral artery occlusion also have ipsilateral internal carotid artery occlusion (ICAO). The interventions for acute stroke due to extracranial ICAO with or without intracranial occlusions are still a challenge. Case series reported early revascularization reduced stroke recurrence and improved outcomes. The benefits of this intervention on hyperacute ischemic strokes (within 6 hours) were much less known. We reported here two hyperacute stroke patients who emergent CAS on ICAO. Methods Electronic medical charts were reviewed, assessing intracranial hemorrhage (ICH) in two hyperacute stroke patients resulting from emergent carotid artery stenting (CAS) on the occluded internal carotid artery (ICA). Results Case description:The first patient was a 60‐year‐old male who had acute right hemiparesis, aphasia, and left gaze deviation with NIHSS12. The last known normal was five hours ago. Head and neck CT angiography (CTA) showed left anterior M2 branch artery occlusion and left ICAO. Head CT perfusion (CTP) showed a small core infarct with a large perfusion mismatch. Emergent CAS was performed without distal embolic protection (DEP) and followed by distal mechanical thrombectomy (MT). TICI 2B recanalization was achieved. After CAS, aspirin and clopidogrel were administrated. He had a large left MCA and PCA stroke from fetal PCA. A few days later, the patient developed large intraparenchymal hemorrhage (IPH) and intraventricular hemorrhage (IVH). He expired shortly. The second was a 52‐year‐old male had acute right facial droop, aphasia, dysarthria, and decreased consciousness (NIHSS 8). CTA showed left ICAO but patent intracranial arteries. CT perfusion showed a large mismatch without core infarction. He received intravenous tPA and had emergent CAS with a DEP. Aspirin 600 mg was administrated afterward. A few hours later, he had worsened weakness. Head CT showed left IPH, IVH, and subarachnoid hemorrhages with cerebral edema, and midline shift. He was medically managed for a prolonged stay and was discharged to a rehabilitation facility. Conclusions We presented two consecutive cases of emergent revascularization of ICAO in hyperacute stroke carried a high risk of ICH with poor outcome. Our online database search found that only a few case series of emergent CAS on ICAO were reported. Overall, emergent CAS carried about 20% risk of ICH and high mortality. Other series reported angioplasty on stenotic or occluded cervical ICA lesions with MT on distal occlusions had less hemorrhagic risk because there was no need fordual antiplatelet treatment. Most emergent CAS cases were performed on tandem occlusions for faster direct access and better efficacy of distal recanalization. A futurestudy comparing hemorrhagic risk betweenemergent CAS versus angioplasty of ICAO in patients with tandem occlusions can help to establish a standard MT protocol. For isolated ICAO with patent intracranial arteries from good collaterals, CTP may not be a good guidance tool for decision‐making of emergent CAS as it can falsely show mismatch from existing collaterals due to occlusion. A randomized clinical trial of comparison of medical management versus emergent CAS on those patients is warranted.

Abstract Number ‐ 90: Bailout Technique for Entangled Stentriever and Carotid Stent during Tandem Large Vessel Occlusion Endovascular Therapy

Introduction Tandem occlusions represent 10–20% of all acute ischemic stroke patients.1 Endovascular Thrombectomy (EVT) for this subset of patients is more challenging given the proximal underlying steno occlusive disease. Emergent carotid artery stenting could achieve a considerably high chance of reperfusion and functional independence.2 Methods This is a case report of a 73‐year‐old woman who presented with left MCA syndrome‐NIHSS 13 found to have left ICA/MCA tandem occlusions. EVT was pursued, initial angiographic run of the left common carotid artery demonstrated severe stenosis at the origin of left cervical ICA which harbors a mid‐cervical ICA loop and proximal left MCA occlusion. Following our retrograde revascularization approach, an intracranial pass using an embotrap 5mm x 37 mm stent retriever (SR) was attempted however given proximal cervical ICA tortuosity and underlying proximal stenosis, the stability of triaxial system prevented optimal placement of the SR and achieving intracranial reperfusion. An antegrade revascularization approach was then pursued with uneventful cervical ICA angioplasty followed by extracranial carotid closed cell Xact stent placement. A stable triaxial system was navigated through the stented cervical ICA. An ideal SR pass was performed. Upon retrieving the clot‐incorporated SR with the intention to fully retrieve the SR into the locally placed aspiration catheter (AC) in the supraclinoid ICA under continuous aspiration, the triaxial system collapsed into the distal CCA, likely due to the mid cervical ICA loop, leading to entanglement of the proximal end of SR and distal ICA stent (Figure1‐A). Large thrombus was recovered from the AC aspirate. Results Numerous attempts to disentangle the SR from the ICA stent including attempts to re‐sheath the SR with different size microcatheters and guide catheters were unsuccessful. The cervical ICA lumen remained patent without evidence of dissection or residual thrombus however, the presence of SR pusher‐wire would preclude safe termination of the procedure. Surgical bailout with emergent carotid endarterectomy and removal of the stent/SR metal mesh was considered.3,4 However, given the high surgical risk with recent intravenous load of antithrombotics for emergent stent placement, this option was deemed as a last resort. We decided to attempt safe separation of the SR from its pusher wire and leave behind the patent ICA stent/SR in place. A gradual pulling pressure was applied to the SR wire while maintaining adjacent microwire access and fully inflated Viatrac 5mm x 30 mm extracranial balloon over the entangled portion to ensure continuous vascular access (Figure1‐B). The SR wire was then separated from the SR and fully retracted outside the body (Figure1‐C). Delayed angiographic runs continued to demonstrate full patency of the ICA lumen (Figure1‐D). No residual dissection, spasm or thrombus noted. Patient was discharged home with NIHSS of 3. Conclusions Exposure to EVT technical complications and bailout techniques are of utmost importance.

Comparison of three antithrombotic strategies for emergent carotid stenting during stroke thrombectomy: a multicenter study

BackgroundPeriprocedural 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...

Abstract TP154: Outcomes Of Acute Carotid Stenting With Or Without Intravenous Thrombolysis Among Patients With Acute Tandem Occlusion: Insights From STAR

Introduction: Emergency carotid artery stenting during mechanical thrombectomy has emerged as an effective emergent treatment for tandem carotid occlusions. Nevertheless, scarce evidence is available about the safety of this procedure in patients who received intravenous tPA before thrombectomy. Herein, we investigate the safety of acute carotid stenting among patients who received intravenous tPA in a large international multicenter registry. Methods: Patients from the Stroke Thrombectomy and Aneurysm Registry between 2010 and 2022 were analyzed. Only patients with concomitant occlusions of cervical carotid and proximal ipsilateral intracranial segments of the internal carotid or middle cerebral artery were included in the final analyses. Patients were divided into two groups, depending on tPA administration. The primary outcome was 90-day good clinical outcome (mRS 0-2), and the primary safety outcome was symptomatic intracranial hemorrhage. Univariate and multivariate regressions were performed adjusting for variables of clinical importance. Results: Among 9812 with acute ischemic stroke in the registry, 132 patients had acute tandem occlusion and underwent carotid stenting; of those, 60 patients received IV tPA. Compared to non-intravenous thrombolytics, patients with IV tPA had a higher male prevalence (78.3% Vs 54.4%, P=0.005) and better ASPECT scores (9 Vs 8, P=0.022) with a shorter time from onset to puncture (241 Vs 672 minutes, P&lt;0.001). There was no difference in rates of successful revascularization (94% Vs 95.5%, P=NS), good clinical outcome (50.8% Vs 61.4%, P=NS), symptomatic intracranial hemorrhage (15.3% Vs 14.5%, P=NS) or procedural complications (15% Vs 11.6%, P=NS) between the tPA and non-tPA groups. Conclusion: The use of IV tPA did not affect the safety or efficacy of emergent carotid stenting in the setting of acute tandem occlusion.