Emergent Carotid Artery Stenting Research Articles

Safety and efficacy of symptomatic carotid artery stenting performed in an emergency setting.

Carotid artery stenting (CAS) has increasingly emerged as an alternative strategy to carotid endarterectomy in the treatment of patients with symptomatic carotid stenosis. Optimal timing for CAS after symptoms onset remains unclear. We aimed to evaluate the safety and efficacy of CAS when performed in an emergency setting. We performed a retrospective analysis of CAS patients admitted to our CSC with symptomatic extracranial carotid occlusion or significant stenosis from January 2014-September 2019. Emergency CAS was defined as CAS performed during the same hospitalization from TIA/stroke onset, whereas elective CAS as CAS performed on a subsequent admission. The primary outcome was defined as the occurrence of any stroke, myocardial infarction, or death related to the procedure at 3 months of follow-up. Secondary outcomes included periprocedural complications and the rate of restenosis/occlusion at follow-up. Logistic regression and survival analyses were used to compare outcomes and restenosis at follow-up. We identified 75 emergency and 104 elective CAS patients. Emergency CAS patients had significantly higher rates of ipsilateral carotid occlusion (17% vs. 2%, p < 0.001) and use of general anesthesia (19% vs. 4%, p = 0.001) than elective CAS. There were no significant differences between emergency and elective CAS in the primary (5.7% vs. 1%, p = 0.161) and secondary (9% vs. 4.8%, p = 0.232) outcomes. We did not find differences in the rate of restenosis/occlusion (7% vs. 11.6%; log-rank test p = 0.3) at a median of 13 months follow-up. In our study, emergency CAS in symptomatic patients might have a similar safety and efficacy profile to elective CAS at 3 months and long-term follow-up.

Safety and Outcome of Carotid Dissection Stenting During the Treatment of Tandem Occlusions: A Pooled Analysis of TITAN and ETIS.

The efficacy of endovascular therapy in patients with acute ischemic stroke due to tandem occlusion is comparable to that for isolated intracranial occlusion in the anterior circulation. However, the optimal management of acute cervical internal carotid artery lesions is unknown, especially in the setting of carotid dissection, but emergency carotid artery stenting (CAS) is frequently considered. We investigated the safety and efficacy of emergency CAS for carotid dissection in patients with acute stroke with tandem occlusion in current clinical practice. We retrospectively analyzed a prospectively maintained database composed of 2 merged multicenter international observational real-world registries (Endovascular Treatment in Ischemic Stroke and Thrombectomy in Tandem Lesion). Data from endovascular therapy performed in the treatment of tandem occlusions related to acute cervical carotid dissection between January 2012 and January 2019 at 24 comprehensive stroke centers were analyzed. The study assessed 136 patients with tandem occlusion due to dissection, including 65 (47.8%) treated with emergency CAS and 71 (52.2%) without. The overall rates of favorable outcome (90-day modified Rankin Scale score, 0-2) and successful reperfusion (modified Thrombolysis in Cerebral Infarction, 2b-3) were 58.0% (n=76 [95% CI, 49.6%-66.5%]) and 77.9% (n=106 [95% CI, 71.0%-85.0%]), respectively. In subgroup analyses, the rate of successful reperfusion (89.2% versus 67.6%; adjusted odds ratio, 2.24 [95% CI, 1.33-3.77]) was higher after CAS, whereas the 90-day favorable outcome (54.3% versus 61.4%; adjusted odds ratio, 0.84 [95% CI, 0.58-1.22]), symptomatic intracerebral hemorrhage (sICH; 10.8% versus 5.6%; adjusted odds ratio, 1.59 [95% CI, 0.79-3.17]), and 90-day mortality (8.0% versus 5.8%; adjusted odds ratio, 1.00 [95% CI, 0.48-2.09]) did not differ. In sensitivity analyses of patients with successful intracranial reperfusion, CAS was not associated with an improved clinical outcome. Emergency stenting of the dissected cervical carotid artery during endovascular therapy for tandem occlusions seems safe, whatever the quality of the intracranial reperfusion.

Emergency Carotid Endarterectomy Instead of Carotid Artery Stenting Reduces Delayed Hemorrhage in Thrombectomy Stroke Patients

PurposeData in the literature suggest that thrombectomy with emergency carotid artery stenting (CAS) in acute stroke is associated with an increased hemorrhage rate. As we perform thrombectomy with the patient under general anesthesia, we avoid emergency CAS and perform emergency carotid endarterectomy (CEA) as an alternative to CAS in the same anesthesia session in our angiography suite whenever needed and possible.MethodsWe compared 27 thrombectomy patients with emergency CEA and 62 thrombectomy patients with emergency CAS and glycoprotein (Gp) IIb/IIIa inhibitors and/or dual antiplatelet therapy (DAPT) in the same time span.ResultsThe symptomatic hemorrhage rate was 0% (0/27) in the CEA group and 8% (5/62) in the CAS group (p = 0.317). The parenchymal hemorrhage rate (PH2) was 7% (2/27) in the CEA group and 16% (10/62) in the CAS group (p = 0.333). Both cases of PH2 in the CEA group occurred during the intervention and were diagnosed on immediate postinterventional imaging, whereas in the CAS group only 2/10 cases of PH2 occurred during the intervention and the remaining 8 PH2 occurred within 3 days after the intervention (p = 0.048). Clinical outcome at 90 days was comparable with 39% of CEA and 51% of CAS patients achieving good clinical outcome (modified Rankin scale, mRS 0–2, p = 0.452).ConclusionThe use of CEA is a feasible alternative to CAS in acute stroke and has the advantage that DAPT/GpIIb/IIIa inhibitors are not needed. All PH2 in CEA patients occurred during the intervention, implying that hemorrhage in this group is likely to be caused by reperfusion injury, whereas delayed hemorrhage is likely to be caused by DAPT/GpIIb/IIIa inhibitors.

Achievable aspiration flow rates with large balloon guide catheters during carotid artery stenting

BackgroundEmergency carotid artery stenting (CAS) is a frequent endovascular procedure, especially in combination with intracranial thrombectomy. Balloon guide catheters are frequently used in these procedures. Our aim was to determine if mechanical aspiration through the working lumen of a balloon occlusion catheter during the steps of a carotid stenting procedure achieve flow rates that may lead to internal carotid artery (ICA) flow reversal which consecutively may prevent distal embolism.MethodsAspiration experiments were conducted using a commercially available aspiration pump. Aspiration flow rates/min with 6 different types of carotid stents inserted into a balloon guide catheter were measured. Measurements were repeated three times with increasing pressure in the phantom. To determine if the achieved aspiration flow rates were similar to physiologic values, flow rates in the ICA and external carotid artery (ECA) in 10 healthy volunteers were measured using 4D-flow MRI.ResultsAspiration flow rates ranged from 25 to 82 mL/min depending on the stent model. The pressure in the phantom had a significant influence on the aspiration volume. Mean blood flow volumes in volunteers were 210 mL/min in the ICA and 101 mL/min in the ECA.ConclusionsBased on the results of this study, flow reversal in the ICA during common carotid artery occlusion is most likely achieved with the smallest diameter stent sheath and the stent model with the shortest outer stent sheath maximum diameter. This implies that embolic protection during emergency CAS through aspiration is most effective with these models.

Use of Continuous Infusions of Eptifibatide and Cangrelor in Large Vessel Occlusion Acute Ischemic Stroke After Emergent Carotid Artery Stenting

Placement of carotid stents in the setting of large vessel occlusion (LVO) is sometimes necessary in patients with steno-occlusive disease of the extracranial internal carotid artery (ICA) or ICA dissection. Use of antiplatelet agents is required to prevent in-stent thrombosis; however, after an LVO, a decompressive hemicraniectomy may be necessary. After placement of a carotid stent, a fine balance must be obtained between preventing stent-related thromboembolic complications while also maintaining the possibility of quickly and safely performing a decompressive hemicraniectomy, if indicated. In this case, we discuss the novel use of continuous eptifibatide and cangrelor infusions after carotid stent placement to maintain stent patency, while preserving the option of emergent hemicraniectomy. A 55-year-old man presented with left hemispheric ischemic symptoms due to flow failure from a left ICA dissection. He underwent emergent angiography with angioplasty and stenting of the petrous and ascending cervical segments of the left ICA. The procedure was complicated by an embolization of thrombus to a left middle cerebral artery (MCA) M2 division branch, resulting in an occlusion, which could not be opened. The patient was placed on short acting intravenous antiplatelet agents (eptifibatide infusion for 60 h and cangrelor infusion for 24 h) for prevention of in-stent thrombosis while under close observation for potential neurologic decline and need for decompressive hemicraniectomy. After 84 h of observation, the patient did not experience a decline and the antiplatelet infusions were discontinued after he received aspirin and a loading dose of clopidogrel. Intravenous eptifibatide or cangrelor infusions are short-acting antiplatelet options that can be used in patients with acute ischemic stroke from LVO in the setting of ICA stent placement when there exists a potential for decompressive hemicraniectomy. J Neurol Res. 2020;10(3):99-103 doi: https://doi.org/10.14740/jnr591

Impact of Antiplatelet Therapy During Endovascular Therapy for Tandem Occlusions: A Collaborative Pooled Analysis.

Background and Purpose- Antiplatelet agents could be used in the setting of endovascular therapy for tandem occlusions to reduce the risk of de novo intracranial embolic migration, reocclusion of the extracranial internal carotid artery lesion, or in-stent thrombosis in case of carotid stent placement but have to be balanced with the intracerebral hemorrhagic transformation risk. In this study, we aim to investigate the impact of acute antiplatelet therapy administration on outcomes during endovascular therapy for anterior circulation tandem occlusions. Methods- This is a retrospective analysis of a collaborative pooled analysis of 11 prospective databases from the multicenter observational TITAN registry (Thrombectomy in Tandem Lesions). Patients were divided into groups based on the number of antiplatelet administered during endovascular therapy. The primary outcome was favorable outcome, defined as a modified Rankin Scale score of 0 to 2 at 90 days. Results- This study included a total of 369 patients; 145 (39.3%) did not receive any antiplatelet agent and 224 (60.7%) received at least 1 antiplatelet agent during the procedure. Rate of favorable outcome was nonsignificantly higher in patients treated with antiplatelet therapy (58.3%) compared with those treated without antiplatelet (46.0%; adjusted odds ratio, 1.38 [95% CI, 0.78-2.43]; P=0.26). Rate of 90-day mortality was significantly lower in patients treated with antiplatelet therapy (11.2% versus 18.7%; adjusted odds ratio, 0.47 [95% CI, 0.22-0.98]; P=0.042), without increasing the risk of any intracerebral hemorrhage. Successful reperfusion (modified Thrombolysis in Cerebral Ischemia score 2b-3) rate was significantly better in the antiplatelet therapy group (83.9% versus 71.0%; adjusted odds ratio, 1.89 [95% CI, 1.01-3.64]; P=0.045). Conclusions- Administration of antiplatelet therapy during endovascular therapy for anterior circulation tandem occlusions was safe and was associated with a lower 90-day mortality. Optimal antiplatelet therapy remains to be assessed, especially when emergent carotid artery stenting is performed. Further randomized controlled trials are needed.

Emergency carotid artery revascularization using Casper-RX stent: A single-center experience.

Casper-RX (MicroVention, Aliso Viejo, California, USA) is a dual-layer closed cell stent recently introduced as a carotid artery revascularization device. Although its effectiveness and safety has been proved in elective cases, there are contradictive results regarding its patency in emergency settings. The purpose of the study is to present our single-center experience with the Casper-RX stent in the emergency interventions. Consecutive patients who underwent emergency carotid artery stenting using Casper-RX system with or without additional intracranial thrombectomy between August 2016 and June 2019 at our institution were included. Primary end point was the short-term patency of the carotid stents evaluated before hospital discharge by use of Doppler ultrasonography. Twenty-nine procedures performed on 28 patients were included in the study. All stents were patent on final angiograms. Acute stent occlusion was observed only in one case (3.4%) with a spontaneous cervical internal carotid artery dissection the day after the procedure. In 26 (89.6%) cases, an additional intracranial thrombectomy was performed with a successful recanalization rate of 96.1%. Seven adverse events occurred peri-/post-procedural: two cases (6.9%) with iatrogenic dissection of distal cervical internal carotid artery during intracranial thrombectomy, two parenchymal hematoma type 2 (6.8%), and three patients (10.3%) developed massive infarction. This study supports the safety and efficacy of the Casper-RX stent in emergency endovascular carotid artery revascularization procedures.

Emergent carotid artery stenting in patients with acute ischemic stroke due to cervical internal carotid artery steno-occlusive lesion: Comparison of tandem intracranial occlusion and isolated cervical internal carotid artery occlusion

Acute ischemic strokes caused by steno-occlusive lesion of the cervical internal carotid artery are associated with poor clinical outcome. We evaluated the clinical efficacy of emergent carotid artery stenting for the management of these lesions. We compared the clinical outcomes regarding the intracranial lesion, namely tandem occlusions versus isolated cervical internal carotid artery occlusion. We retrospectively reviewed patients with acute ischemic stroke who underwent carotid artery stenting for cervical internal carotid artery steno-occlusive lesion between 2011 and 2018. After dividing the patients into two groups according to the presence or absence of intracranial lesions (tandem group and isolated cervical group), we analyzed demographic data, angiographic findings, and clinical outcomes. A modified Rankin Scale score ≤2 was defined as a favorable clinical outcome. Of 75 patients, 46 patients (61.3%) had tandem lesions, and the remaining 29 had only cervical internal carotid artery steno-occlusive lesion. Successful stenting was performed in all patients with favorable clinical outcomes (64.0%). Successful reperfusion score (thrombolysis in cerebral infarction ≥2 b) was 84.0%; tandem group (76.1%) versus isolated cervical group (96.6%) of cases. Mean modified Rankin Scale score at 90-days was 2.09. The rate of favorable clinical outcome showed no statistically significant difference between the two groups (p = 0.454). Endovascular treatment in patients with acute ischemic stroke due to cervical internal carotid artery steno-occlusive lesion is a technically feasible and clinically effective intervention regardless of intracranial occlusion. Therefore, we recommend endovascular treatment regardless of the presence of concomitant intracranial artery occlusion for patients with acute ischemic stroke caused by cervical internal carotid artery steno-occlusive lesion.

Predictors of a Favorable Outcome after Emergent Carotid Artery Stenting in Acute Anterior Circulation Stroke Patients.

PurposeThis study aimed to identify independent predictors of favorable outcomes associated with emergent carotid artery stenting (CAS) in patients with acute anterior circulation stroke.Materials and MethodsThis study included 93 patients with acute stroke who underwent emergent CAS to treat stenoocclusive lesions in the cervical internal carotid artery (ICA) within 6 hours of the onset of the associated symptoms. Data were compared between patients with and without favorable outcomes. The independent predictors of a favorable outcome were determined via logistic regression analysis (modified Rankin Scale 0–2 at 90 days).ResultsIntracranial tandem occlusion was noted in 81.7% of patients (76/93) among which (76/93), 55 of whom underwent intracranial recanalization therapy. Intracranial reperfusion was successful in 74.2% (69/93) and favorable outcomes were noted in 51.6% of patients (48/93). The mortality rate was 6.5% (6/93). In logistic regression analysis, diffusion-weighted imaging-Alberta Stroke Program Early CT Score [odds ratio (OR), 1.487; 95% confidence interval (CI), 1.018–2.173, p = 0.04], successful reperfusion (OR, 5.199; 95% CI, 1.566–17.265, p = 0.007), and parenchymal hemorrhage (OR, 0.042; 95% CI, 0.003–0.522, p = 0.014) were independently associated with a favorable outcome.ConclusionBaseline infarct size, reperfusion status, and parenchymal hemorrhage were independent predictors of favorable outcomes after emergent CAS to treat stenoocclusive lesions in the cervical ICA in patients with acute anterior circulation stroke.

Use of Continuous Infusions of Eptifibatide and Cangrelor in Large Vessel Occlusion Acute Ischemic Stroke After Emergent Carotid Artery Stenting

Placement of carotid stents in the setting of large vessel occlusion (LVO) is sometimes necessary in patients with steno-occlusive disease of the extracranial internal carotid artery (ICA) or ICA dissection. Use of antiplatelet agents is required to prevent in-stent thrombosis; however, after an LVO, a decompressive hemicraniectomy may be necessary. After placement of a carotid stent, a fine balance must be obtained between preventing stent-related thromboembolic complications while also maintaining the possibility of quickly and safely performing a decompressive hemicraniectomy, if indicated. In this case, we discuss the novel use of continuous eptifibatide and cangrelor infusions after carotid stent placement to maintain stent patency, while preserving the option of emergent hemicraniectomy. A 55-year-old man presented with left hemispheric ischemic symptoms due to flow failure from a left ICA dissection. He underwent emergent angiography with angioplasty and stenting of the petrous and ascending cervical segments of the left ICA. The procedure was complicated by an embolization of thrombus to a left middle cerebral artery (MCA) M2 division branch, resulting in an occlusion, which could not be opened. The patient was placed on short acting intravenous antiplatelet agents (eptifibatide infusion for 60 h and cangrelor infusion for 24 h) for prevention of in-stent thrombosis while under close observation for potential neurologic decline and need for decompressive hemicraniectomy. After 84 h of observation, the patient did not experience a decline and the antiplatelet infusions were discontinued after he received aspirin and a loading dose of clopidogrel. Intravenous eptifibatide or cangrelor infusions are short-acting antiplatelet options that can be used in patients with acute ischemic stroke from LVO in the setting of ICA stent placement when there exists a potential for decompressive hemicraniectomy. J Neurol Res. 2020;10(3):99-103 doi: https://doi.org/10.14740/jnr591

Carotid Artery Stenting Using a Double-layer Micromesh Stent.

Carotid artery stenting (CAS) has recently emerged as a potential alternative to carotid endarterectomy (CEA) in Japan. However, one of its disadvantages is the higher incidence of ischemic complications than CEA, such as distal embolism during or after the procedure. Plaque protrusion (PP) through the stent strut after deployment of the stent has been suggested as one of the major causes of distal embolism, especially in patients with unstable plaques. The need for increased plaque coverage to reduce the risk of PP through the stent struts has led to the development of a double-layer micromesh stent (micromesh stent) system. This stent system has already been used clinically in European countries with good short- to medium-term follow-up results. Also clinical trials evaluating micromesh stents have been completed in Japan. Hence, usefulness of the micromesh stent for CAS is expected. According to the results of several clinical studies, CAS with the double-layer micromesh stent has the potential to minimize distal embolism during or after the procedure even in patients with unstable plaques. However, it may not be suitable for emergency CAS at this point. Also, since results of only short- to medium-term follow-up have been reported, longer-term follow-up will be required in the near future.

Treatment Strategy for Progressive Cervical Internal Carotid Artery Stenosis Under Restriction of the Use of Antiplatelet Drugs

Acute ischemic stroke caused by cervical internal carotid artery stenosis (ICS) with altered consciousness and progressive paralysis leads to a poor neurologic prognosis. When such a patient is brought to the hospital in the hyperacute phase, intravenous tissue plasminogen activator is first administered. However, when an indwelling carotid artery stent is required after administration, physicians often hesitate to use antithrombotic drugs. In this report, we propose performing staged angioplasty (SAP) for such cases. Four patients were retrospectively investigated. In all 4 patients, we immediately performed only percutaneous transluminal angioplasty (PTA) without antiplatelet drugs. If both cerebral perfusion on angiography and neurologic findings improved, no additional treatment was provided; otherwise, emergency carotid artery stenting (eCAS) was performed. In PTA-successful cases, eCAS or carotid endarterectomy (CEA) was performed with single or dual antiplatelet drugs at a later date. The success rate of PTA was 50% (2 of 4), and the overall treatment success rate was 100% (4 of 4). Three patients had favorable outcomes (modified Rankin Scale [mRS] score 0-2), but unfortunately, 1 patient had severe disability (mRS score >3) on discharge. The PTA-successful patients had no perioperative complications. On the other hand, 1 of the 2 patients who underwent eCAS experienced embolic complications, including distal embolization. In this investigation, both eCAS and SAP could be performed safety. However, performing SAP first without antiplatelet drugs to avoid hemorrhagic complications and cerebral hyperperfusion syndrome appears to have considerable validity.

Emergent Carotid Stenting Plus Thrombectomy After Thrombolysis in Tandem Strokes: Analysis of the TITAN Registry.

Emergent carotid artery stenting plus mechanical thrombectomy is an effective treatment for acute ischemic stroke patients with tandem occlusion of the anterior circulation. However, there is limited data supporting the safety of this approach in patients treated with prior intravenous thrombolysis (IVT). We aimed to investigate the safety of emergent carotid artery stenting-mechanical thrombectomy approach in stroke patient population treated with prior IVT —We assessed patients with acute ischemic stroke because of atherosclerotic tandem occlusion that were treated with emergent carotid artery stenting-mechanical thrombectomy approach from the multicenter observational Thrombectomy in Tandem Lesions registry. Patients were divided into 2 groups based on pretreatment IVT (IVT versus no-IVT). Intracerebral hemorrhages were classified according to the European Cooperative Acute Stroke Study II criteria. Among 205 patients included in the present study, 125 (60%) received prior IVT. Time from symptoms onsetto-groin puncture was shorter (234±100 versus 256±234 minutes; P=0.002), and heparin use was less in the IVT group (14% versus 35%; P<0.001); otherwise, there was no difference in the baseline characteristics. There was no significant difference between the IVT and no-IVT groups in the rate of symptomatic intracerebral hemorrhage (5% versus 8%; P=0.544), parenchymal hematoma type 1 to 2 (15% versus 18%; P=0.647), successful reperfusion (modified Thrombolysis in Cerebral Ischemia 2b–3), or 90-day favorable outcome (modified Rankin Scale score of 0–2 at 90 days). The 90-day all-cause mortality rate was significantly lower in the IVT group (8% versus 20%; P=0.017). After adjusting for covariates, IVT was not associated with symptomatic intracerebral hemorrhage or 90-day mortality Emergent carotid artery stenting-mechanical thrombectomy approach was not associated with an increased risk of hemorrhagic complications in tandem occlusion patients who received IVT before the intervention.

Short-Term Double Layer Mesh Stent Patency for Emergent or Elective Carotid Artery Stenting.

Background and Purpose- Novel double layer micromesh stents have recently been introduced for treatment of patients with significant carotid stenosis. Strict evaluation of safety and patency of such novel devices is required both in elective and in emergency interventions. We report a single center experience with double layer mesh stents for carotid artery revascularization. Methods- Consecutive patients who underwent carotid artery stenting with a double layer mesh stent between June 2015 and September 2018 in our tertiary vascular referral center were included. Treatment indications were emergent carotid artery stenting for intracranial or extracranial carotid stenosis in patients undergoing intraarterial thrombectomy for acute ischemic stroke in the anterior circulation, or elective carotid artery stenting for significant symptomatic or asymptomatic stenosis. End points were postprocedural thrombotic stent occlusion and procedural stroke or death. Results- Fifty-four patients were included; 27 were treated for acute stroke with intracranial and extracranial (tandem) lesions and 27 for elective stenting. Follow-up imaging was available for 9/27 (33%) patients with acute stroke, and 19/27 (70%) electively treated patients. Five stent occlusions occurred, of which 2 were symptomatic with clinical deterioration within one day. Another patient deteriorated on postprocedural day one, but imaging of the carotids was not performed, and the stent turned out occluded on the 30-day duplex. All stent occlusions occurred in patients treated for acute stroke. Conclusions- This study suggests that occlusion of novel double layer mesh stents occurs in a considerable proportion of carotid artery stenting procedures performed in the emergency setting for acute stroke, with occlusion-related symptoms in half the cases. Future prospective studies should clarify the role of double layer mesh stents in this high-risk patient population.

Carotid Artery Stenting in Acute Stroke Using a Microporous Stent Device: A Single-Center Experience

Carotid artery stenting (CAS) is an established treatment for carotid artery stenosis, typically in a semielective or elective setting. The growth of mechanical thrombectomy for acute stroke has led to an increased use of emergent carotid artery stenting (eCAS). This single-center retrospective case series evaluates the safety and efficacy of eCAS using a dual-layer micromesh nitinol stent to treat carotid artery stenosis in the acute stroke setting. Ethics approval was granted by the institutional review board. Clinical data of all patients who underwent CAS using the Casper dual-layer micromesh nitinol stent system (MicroVention, Terumo, Tustin, California, USA) at a tertiary level 24-hour endovascular thrombectomy service over a 2-year period (June 2016-June 2018) were retrospectively obtained and reviewed. Twenty eCAS procedures were performed in 19 patients over the study period. Most patients had tandem lesions (12/20; 60%). Median National Institute of Health Stroke Scale score on admission was 17 (interquartile range 9-22). Stent deployment was technically successful in all patients. Recanalization rate was 95%. Symptomatic intracranial hemorrhage occurred in 2 patients (10%), both resulting in death. No other procedure-related deaths occurred. Stent thrombosis occurred in 2 patients. One delayed embolic stroke occurred. No other stent-related complications occurred. Median National Institute of Health Stroke Scale score at 24 hours postprocedure was 3 (interquartile range 1-12). Six patients had a good clinical outcome (modified Rankin Scale score between 0 and 2) at 3- to 6-month follow-up (38%). eCAS using the Casper stenting system is effective and technically feasible in the acute stroke setting, although the ideal antiplatelet and anticoagulation regime is not clearly established.

Endovascular Recanalization of Acute Tandem Cervical Carotid and Intracranial Occlusions: Efficacy of Cervical Balloon Angioplasty Alone Then Intracranial Target Recanalization Strategy

Tandem cervical carotid and intracranial occlusions are a well-known cause of complicated endovascular thrombectomy (EVT) in acute ischemic stroke. We aimed to evaluate safety and efficacy of an anterograde approach, which involved carotid balloon angioplasty (BA) alone without carotid artery stenting (CAS) followed by intracranial target recanalization (TR). Between April 2009 and March 2017, 62 patients with tandem lesions confirmed in the cervical carotid and simultaneously in the intracranial arteries had EVT performed to target these lesions. Clinical, imaging, and angiographic outcomes for these patients were analyzed and compared. Overall, successful reperfusion was achieved in 80.6% (50/62) and a favorable outcome in 61.3% (38/62) of patients. BA alone was enough to maintain access for TR in 85.5% (group A and B; 53/62), although more than one half (31/53; group B) required rescue CAS at the end of EVT due to elastic recoil. In contrast, emergent CAS was additionally required for the remaining 9 patients to maintain distal access (group C). In a subgroup comparison, procedure time (PT) to target recanalization was significantly shorter in group A and B than group C (P= 0.002). A multivariate regression model revealed age, parenchymal hematoma, and PT to target recanalization as independent predictors of favorable outcome. EVT for tandem cervical carotid and intracranial occlusions showed optimistic results in terms of clinical and angiographic outcome. The anterograde EVT strategy of cervical BA alone then intracranial TR was effective in 85.5% of patients, which was likely to reduce PT to target recanalization.

Cholesterol Crystals in Embolic Debris are Associated with Postoperative Cerebral Embolism after Carotid Artery Stenting

Object: We investigated possible associations among the presence of cholesterol crystals in embolic debris, the proportions of debris components, and postoperative cerebral embolism in patients undergoing carotid artery stenting (CAS). Methods: Sixty-seven consecutive procedures were performed for internal carotid artery stenosis with CAS at our hospital between November 2015 and February 2018. Procedures for emergency CAS for stroke in evolution or crescendo transient ischemic attack were excluded (n = 12). The embolic debris from remaining procedures (n = 55) was stained with hematoxylin-eosin and the red blood cells, white blood cells, and fibrin were quantified by color-based segmentation. Cholesterol crystals and calcification were examined histopathologically. Diffusion-weighted imaging (DWI) was performed 1–3 days after CAS, and the images were used to classify procedures according to the presence of new lesions. Results: Of the 55 CAS procedures, new DWI lesions were identified after 32. One patient had symptomatic cerebral embolism. Higher proportions of patients with cholesterol crystals in embolic debris (17 vs. 78%, p < 0.001) and higher proportion of white blood cells (mean 2.3 [0–9.9] vs. 4.2% [0–29.9%], p < 0.01) were observed in the embolic debris of procedures with and without new DWI lesions. Conclusions: Cholesterol crystals were common in the embolic debris from patients with postoperative ischemic lesions after CAS. These results suggest that inflammatory destabilization of the intraplaque lipid component is related to postprocedural DWI lesions.

Emergency Carotid Artery Stenting for an Internal Carotid Artery Occlusion with Contralateral Stenosis

Emergency Carotid Artery Stenting for an Internal Carotid Artery Occlusion with Contralateral Stenosis

Acute administration of tirofiban versus aspirin in emergent carotid artery stenting.

Carotid artery stenting requires antiplatelet therapy for prevention of in-stent thrombosis. Patients suffering from acute ischemic stroke undergoing intravenous thrombolysis and emergent carotid artery stenting (eCAS) are at high risk for intracranial bleeding. We assessed efficacy and safety of acute administration of intravenous tirofiban versus aspirin in these patients. A retrospective, single center, cohort study was carried out of 32 patients who underwent eCAS (18 received tirofiban, 14 received aspirin) at our comprehensive stroke center (2008-2016). Of our 32 consecutive eCAS patients, favorable clinical outcomes (modified Rankin scale ≤ 2) were achieved in eight (47%) tirofiban patients and six (46%) aspirin patients ( p = 0.96). Overall rates were similar for symptomatic intracranial bleeding (tirofiban 22%, aspirin 29%, p = 0.68) and mortality (tirofiban 18%, aspirin 23%, p = 0.71). Tirofiban and aspirin demonstrated similar efficacy and safety in thrombolyzed stroke patients who underwent eCAS in our cohort. Intravenous tirofiban with its short half-life might represent an alternative to aspirin in select patients.

Emergent Carotid Artery Stenting in Atherosclerotic Disease of the Internal Carotid Artery With Tandem Intracranial Occlusion

Emergent Carotid Artery Stenting in Atherosclerotic Disease of the Internal Carotid Artery With Tandem Intracranial Occlusion