Outcomes of early carotid stenting and angioplasty in large-vessel anterior circulation strokes treated with mechanical thrombectomy and intravenous thrombolytics

Abstract

Introduction

Proximal cervical internal carotid artery stenosis greater than 50% merits revascularization to mitigate the risk of stroke recurrence among large-vessel anterior circulation strokes undergoing mechanical thrombectomy. Carotid artery stenting necessitates the use of antiplatelets, and there is a theoretical increased risk of hemorrhagic transformation given that such patients may already have received intravenous thrombolytics and have a significant infarct burden. We investigate the outcomes of large-vessel anterior circulation stroke patients treated with intravenous thrombolytics receiving same-day carotid stenting or selective angioplasty compared to no carotid intervention.

Materials and methods

The study cohort was obtained from the National (Nationwide) Inpatient Sample database between 2006 and 2014, using International Statistical Classification of Diseases, ninth revision discharge diagnosis and procedure codes. A total of 11,825 patients with large-vessel anterior circulation stroke treated with intravenous thrombolytic and mechanical thrombectomy on the same day were identified. The study population was subdivided into three subgroups: no carotid intervention, same-day carotid angioplasty without carotid stenting, and same-day carotid stenting. Outcomes were assessed with respect to mortality, significant disability at discharge, hemorrhagic transformation, and requirement of percutaneous endoscopic gastronomy tube placement, prolonged mechanical ventilation, or craniotomy.

Results

This study found no statistically significant difference in patient outcomes in those treated with concurrent carotid stenting compared to no carotid intervention in terms of morbidity or mortality.

Conclusions

If indicated, it is reasonable to consider concurrent carotid stenting and/or angioplasty for large-vessel anterior circulation stroke patients treated with mechanical thrombectomy who also receive intravenous thrombolytics.

Keywords

Stroke carotid stenting endovascular thrombectomy

Get full access to this article

View all access options for this article.

References

Lovett

Coull

Rothwell

. Early risk of recurrence by subtype of ischemic stroke in population-based incidence studies. Neurology 2004; 62: 569–573.

Barnett

Gunton

Eliasziw

et al.

Causes and severity of ischemic stroke in patients with internal carotid artery stenosis. JAMA 2000; 283: 1429–1436.

Barnett

Taylor

Eliasziw

et al.

Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 1998; 339: 1415–1425.

Mantese

Timaran

Chiu

et al.

The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST): Stenting versus carotid endarterectomy for carotid disease. Stroke 2010; 41(10 Suppl): S31–S34.

Bhatt

Kapadia

Bajzer

et al.

Dual antiplatelet therapy with clopidogrel and aspirin after carotid artery stenting. J Invasive Cardiol 2001; 13: 767–771.

Brott

Halperin

Abbara

et al.

2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. Stroke 2011; 42: e464–e540.

Cucchiara

Kasner

Tanne

et al.

Factors associated with intracerebral hemorrhage after thrombolytic therapy for ischemic stroke: Pooled analysis of placebo data from the Stroke-Acute Ischemic NXY Treatment (SAINT) I and SAINT II Trials. Stroke 2009; 40: 3067–3072.

Deyo

Cherkin

Ciol

. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 1992; 45: 613–619.

Powers

Derdeyn

Biller

et al.

2015 American Heart Association/American Stroke Association focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2015; 46: 3020–3035.

10.

Berkhemer

Fransen

Beumer

et al.

A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 2015; 372: 11–20.

11.

Jovin

Chamorro

Cobo

et al.

Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 2015; 372: 2296–2306.

12.

Behme

Mpotsaris

Zeyen

et al.

Emergency stenting of the extracranial internal carotid artery in combination with anterior circulation thrombectomy in acute ischemic stroke: A retrospective multicenter study. AJNR Am J Neuroradiol 2015; 36: 2340–2345.

13.

Male

Nickele

Elijovich

. Critical care of brain reperfusion. Curr Neurol Neurosci Rep 2016; 16: 23.

14.

Nogueira

Jadhav

Haussen

et al.

Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med 2018; 378: 11–21.

15.

Schievink

. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med 2001; 344: 898–906.

16.

Lee

Koh

Choi

. Emergency carotid artery stent insertion for acute ICA occlusion. J Korean Neurosurg Soc 2010; 47: 428–432.

17.

Battocchio

Fantozzi

Rizzo

et al.

Urgent carotid surgery: Is it still out of debate?

Int J Vasc Med 2012; 2012: 536392.

18.

Setacci

de Donato

Chisci

et al.

Carotid artery stenting in recently symptomatic patients: A single center experience. Ann Vasc Surg 2010; 24: 474–479.

19.

Sivan-Hoffmann

Gory

Armoiry

et al.

Stent-retriever thrombectomy for acute anterior ischemic stroke with tandem occlusion: A systematic review and meta-analysis. Eur Radiol 2017; 27: 247–254.