Extracranial Internal Carotid Artery Stenting Research Articles

Antiplatelet Therapy During Emergent Extracranial Internal Carotid Artery Stenting: Comparison of Three Intravenous Antiplatelet Perioperative Strategies

IntroductionGuidelines for antiplatelet therapy administration, during emergent stenting for extra-cranial internal carotid artery (EC-ICA) occlusion in the setting of acute ischemic stroke (AIS) are lacking. Different antiplatelet regimen are used in association to endovascular therapy (EVT) for the treatment of EC-ICA lesions. We aimed to compare the clinical and radiological effects of three intravenous antiplatelet agents used during emergent EC-ICA stenting. Material and MethodsClinical data were collected from January 2015 to December 2019 in a monocentric prospective registry of AIS patients treated by EVT. All patients who underwent emergent EC-ICA stenting were sorted regarding the intravenous antiplatelet agent used during the procedure. ResultsAmong 218 patients treated by EVT for an EC-ICA occlusion of the anterior circulation during the study period, 70 underwent an emergent stenting of the EC-ICA. 60 were included in the present study, 9 received intravenous (IV) Cangrelor, 8 IV abciximab and 43 Aspirin. The rate of favorable neurological outcome, defined as modified Rankin Scale (mRS) ≤ 2 at three months were better in the Cangrelor and Aspirin groups (66,7% and 58,1%, respectively) than in the Abciximab group (37,5%), as well as, the rate of any intracranial ICH (22,2% and 37,2% vs 62,5%). The rate of acute stent reocclusion was similar between groups. ConclusionWhen used as a rescue treatment during emergent stenting of EC-ICA, Cangrelor and Aspirin present a better safety profile than Abciximab, with less intracranial hemorrhages and a higher rate of good clinical outcome. Additional studies are needed to confirm these findings.

Abstract WP57: Acute Carotid Stenting Following Intracranial Thrombectomy Has Comparable Safety and Efficacy in Early versus Late Time Window Stroke

Introduction: Endovascular thrombectomy (EVT) is beneficial in late time window stroke. However, patients with tandem extracranial carotid and intracranial occlusions are under-represented in previous trials. We analysed our acute anterior circulation strokes with tandem occlusions treated with EVT and extracranial internal carotid artery stenting. Methods: A prospectively maintained database of EVT patients treated in two Australian comprehensive stroke centres between January 2016 and May 2019 was screened for acute anterior circulation ischaemic stroke patients treated with EVT and extracranial internal carotid artery stenting. The cohort was divided into patients treated in early ( < 6 hours from symptom onset) and late (>6 hours from symptom onset) time windows. Results: Endovascular thrombectomy with acute carotid stenting was performed in 96 patients (mean age 71years, 78.3% male, mean time to reperfusion 13.5 +/- 10.1 hours, median NIHSS 15). Treatment >6hours after symptom onset occurred in 61 (63.5%) patients. No significant difference was seen between the two groups with respect to age, sex, presenting NIHSS, or mTICI score. At 90-day follow-up, good functional outcome (mRS 0-2) was similar for patients treated in the late versus early time windows, 19 (54.3%) vs 34 (55.7%), p=0.89 respectively. No difference was seen for symptomatic intracranial haemorrhage, 5 (7.2%) vs 3 (8.1%) p=0.87, or mortality at 90-day follow-up, 15 (24.6%) vs 6 (17.1%) p=0.40. Conclusion: Carotid stenting in late time window has comparable safety and efficacy to early time window stroke.

Abstract TP128: Determinants of Hemorrhagic Transformation After Emergent Extracranial Internal Carotid Artery Stenting for Tandem Occlusions

Background and Purpose: Extracranial internal carotid artery (ICA) lesion in the setting of tandem occlusions is a therapeutic challenge, and hemorrhagic transformation (HT) is one of the leading causes of poor clinical outcome. We aimed to determine determinants of HT for tandem occlusions undergoing emergent extracranial ICA stenting during endovascular treatment (EVT). Methods: We performed a prospective, observational cohort study of consecutive patients with non-cardioembolic ischemic stroke due to tandem occlusion who underwent EVT with extracranial ICA stent placement during the procedure from April 2013 to June 2019 in a single stroke center. We compared clinical (vascular risk factors, previous antiplatelet treatment, and IV rtPA), radiological (ASPECTS at admission and in-stent thrombosis at 24 hours) and serological (platelet count, fibrinogen, total cholesterol, HDL-cholesterol, and LDL-cholesterol) parameters according to the presence of HT in 24 hours CT-scan. Results: One-hundred and eight patients were included: 78.7% were men, mean age 68.5±14.3 years, median time from symptoms onset to treatment was 220 (150-337.5) minutes, median ASPECTS at admission was 9 (8-10). Eighty-six (79.6%) patients presented an extracranial ICA occlusion, and 22 (20.4%) a high-grade (>50%) stenosis. In 88 (81.5%) patients the etiology of extracranial ICA lesion was ateroma, and in 20 (18.5%) was a dissection. Intravenous rtPA was administered in 47 (43.5%) patients. Successful recanalization (mTICI ≥2b) was achieved in 83 (76.9%) patients, and extracranial ICA recanalization in 108 (100%) patients. Type 2 diabetes (OR 1.5, 95% CI 1.1-3.5), higher fibrinogen levels (OR 4.6, 95% CI 1.6-12.9), and ASPECTS <7 at admission (OR 2.1, 95% IC 1.1-5.1) were found as independent predictors of HT in multiple logistic regression analysis. Conclusions: Patients with a non-cardioembolic ischemic stroke due to tandem occlusion who present type 2 diabetes, higher fibrinogen levels, or ASPECTS <7 at admission are at high risk of HT. In these particular cases, it might be useful to stent with a stent that does not need double antiplatelet treatment immediately after the procedure.

Abstract WP15: Safety of Dual Antiplatelet Treatment in Emergent Large Vessel Occlusion (ELVO) Patients Treated With Mechanical Thrombectomy (MT) and Extracranial Internal Carotid Artery Stenting

Introduction: Extracranial Internal carotid artery (ExICA) stenting may be required during mechanical thrombectomy (MT) for anterior circulation large vessel occlusions (ACLVO) with coexisting ExICA steno-occlusive disease. We sought to evaluate the safety of acute dual antiplatelet therapy (DAP) in this high-risk MT subgroup. Methods: Consecutive ACLVO patients treated with MT were evaluated during a five-year period. All patients receiving ExICA stenting during MT were also acutely treated with DAP coupled with heparin or eptifibatide drips. Baseline stroke severity and early hypodensity on baseline CT were assessed using NIHSS-score and ASPECTS. Complete reperfusion (CR) was defined as modified Thrombolysis in Cerebral Infarction grades IIb/III) at the end of MT. Final infarct volume (FIV) on brain MRI was assessed at 24-48 hours using standardized methodology. Safety outcomes included symptomatic Intracranial Hemorrhage (sICH) documented by SITS-MOST criteria, infarct in new unaffected territory (INT) determined according to ESCAPE trial methodology and three-month mortality. We also assessed 3-month functional outcomes using modified Rankin Scale (mRS) scores. Results: Among 309 ACLVO patients treated with MT, 24 received additional ExICA stenting. Eptifibatide and heparin drips were administered in 15 (65% of stenting subgroup: 9 patients: aspirin + clopidogrel, 6 patients: aspirin + ticagrelor) and 8 (35% of stenting subgroup: 6 patients: aspirin + clopidogrel, 2 patients: aspirin + ticagrelor) cases respectively. Patients with and without ExICA stenting had similar (p>0.1) median baseline NIHSS-scores (15 vs. 16 points) and ASPECTS (10 vs. 10 points). The two groups did not differ (p>0.1) in terms of median FIV (20 vs. 15 cm 3 ) and median 3-month mRS-scores (2 vs. 2). Patients with ExICA stenting had similar (p>0.1) rates of sICH (5% vs. 8%), INT (0% vs. 9%), CR (74% vs. 70%) and 3-month mRS-scores of 0-2 (55% vs. 51%) compared to the rest. Conclusions: DAP coupled with eptifibatide or heparin drips does not appear to increase peri-procedural complications or to worsen clinical outcome of ELVO patients treated with MT and ExICA stenting.

Abstract TMP31: Hyperacute Extracranial Internal Carotid Artery Stenting vs Angioplasty: Which is the Best for Recanalization?

Background: Up to 20% of acute intracranial occlusions have an associated extracranial internal carotid artery (ICA) severe stenosis or occlusion, and they often need specific treatment. However, it remains unclear which is the best option for extracranial revascularization. We aimed to study differences in restenosis, complications, and stroke recurrences between patients treated with stenting and those who underwent angioplasty without stenting. Methods: Prospective study of consecutive patients with non-cardioembolic ischemic stroke and occlusion or severe stenosis of the extracranial ICA, who underwent hyperacute endovascular procedure from April 2013 to December 2015. We divided patients depending on the extracranial treatment they received. We compared the rate of stenosis >50% or occlusion of the ICA at 24 hours (evaluated by carotid ultrasound or CTA). Besides, we analyzed differences in complications and stroke recurrences within 1 year of follow-up. Results: From 97 patients who underwent hyperacute revascularization of the extracranial ICA, 63 fulfilled the inclusion criteria: mean age 65.6±13.6 years, median time from symptoms onset to treatment 249 [161-330] minutes. Thirty-one (49.2%) were treated with angioplasty and 32 (50.8%) with stent. Both groups were comparable in demographic data, vascular risk factors, previous treatment (including antiplatelets), and ASPECTS score. Thirty-seven (58.7%) received intravenous rtPA and 58 (92.1%) intracranial thrombectomy. Patients who underwent angioplasty presented stenosis >50% or occlusion at 24h more frequently than those who underwent stenting (67.7% vs 21.9% , p =0.002), regardless the degree of residual stenosis after the angioplasty. Thirteen (38.1%) of the angioplasties were permeable at 24 hours, nevertheless 39.1% needed a deferred stenting. There were no differences in complications, including intracranial hemorrhage, despite intravenous rtPA or early double antiplatelet therapy, as well as in stroke recurrences within 1 year ( p >0.05 for all comparisons). Conclusions: Hyperacute extracranial ICA stenting seems to have a lower risk of restenosis compared to angioplasty, without a significant increase of complications and stroke recurrences