With rescue, outcomes are better and there’s no increased risk of hemorrhage or mortality, a retrospective analysis shows.
Rescue stenting following failed mechanical thrombectomy for large-vessel-occlusion (LVO) strokes results in better outcomes, without an increased risk of hemorrhage or death, compared with no further treatment. The findings, from a retrospective analysis, were published online March 16, 2018, ahead of print in Stroke.
When mechanical thrombectomy fails, lead author Byung Moon Kim, MD, PhD (Yonsei University College of Medicine, Seoul, Korea), told Neurovascular Exchange, “we can choose rescue treatment depending on the most probable cause of LVO, based on clinical and imaging features.
“If intracranial atherosclerotic disease is likely the cause, we administer glycoprotein IIa/IIIb inhibitors. If the LVO does not respond, . . . we perform rescue stenting,” he continued. “If a hard clot is likely the cause, simultaneous use of a stent retriever and contact aspiration thrombectomy is used.” If this fails, rescue stenting again becomes an option, depending on the patient’s clinical condition and angiographic findings.
The investigators conducted a retrospective analysis of the 591 patients treated for internal carotid or middle cerebral artery M1 occlusion strokes using mechanical thrombectomy at 16 comprehensive stroke centers between September 2010 and December 2015. In 148 of these patients (25.0%), mechanical thrombectomy failed to recanalize the artery. Of those, 48 underwent rescue stenting and 100 were left without further treatment.
Recanalization was successful in 31 of the 48 patients (64.6%) who underwent rescue stenting. Compared with those who underwent no further treatment, patients treated with rescue stenting were more likely to have a good outcome, defined as an mRS score of 0-2 at 3 months, and there was no increased risk of symptomatic intracranial hemorrhage (ICH) or mortality.
Outcomes With and Without Rescue Stenting
|
|
With (n = 48) |
Without (n = 100) |
P Value |
|
mRS 0-2 at 3 Months |
39.6% |
22% |
0.031 |
|
Symptomatic ICH |
16.7% |
20.0% |
0.823 |
|
Mortality |
12.5% |
19.0% |
0.360 |
Among the 31 patients who had successful recanalization with stenting, 54.8% had a good outcome, which is comparable to the 55.4% rate of good outcome seen in patients whose mechanical thrombectomy was successful.
Rescue stenting was an independent predictor of good outcome after adjusting for other factors (OR 3.39; 95% CI, 1.19-9.66, P = 0.022).
Follow-up vascular imaging was available for 23 of the 31 patients (74.2%) with recanalization success using rescue stenting. In these patients, the stent was patent in 20 (87.0%). Glycoprotein IIb/IIIa inhibitor use was significantly associated with stent patency but not with symptomatic ICH.
“Many clinicians are reluctant to use an intracranial stent because of the potential risk, . . . such as ICH associated with antithrombotic use,” said Kim. “But in our study, recue stenting and use of antiplatelets did not raise the risk of hemorrhagic transformation and was effective. It is worth trying when there are no other modalities [available] for thrombectomy failure cases.”
He cautioned, however, that further studies are needed to clarify the best timing and optimal patient selection for rescue stenting as well as optimal use of antithrombotic therapy following failed thrombectomy. It is also important to determine, he added, whether rescue stenting is beneficial when treating occlusions in other cerebral arteries.
In an accompanying editorial, Jens Fiehler, MD, PhD (University Medical Center Hamburg-Eppendorf, Hamburg, Germany), writes that, after failed mechanical thrombectomy, rescue stenting “seems to be a valid option” for selected acute stroke patients with suspected intracranial atherosclerotic disease.
“This method could be applied in 5% to 30% of [mechanical therapy cases] dependent on ethnicity and geographical location,” Fiehler says, calling for prospective single-arm studies. If their findings are favorable, he added, “then a randomized trial is the next logical step.”
Sources:
- Chang Y, Kim BM, Bang OY, et al. Rescue stenting for failed mechanical thrombectomy in acute ischemic stroke: A multicenter experience. Stroke. 2018;Epub ahead of print.
- Fiehler J. Failed thrombectomy in acute ischemic stroke: return of the stent? Stroke. 2018;Epub ahead of print.
Disclosures:
- Kim reports no relevant conflicts of interest.
- Fiehler reports receiving related research support from the German Ministry of Economy and Innovation and acting as a consultant for Acandis. He also receives unrelated research support from Medtronic, MicroVention, Philips, and Stryker and acts as an unrelated consultant for Acandis, Boehringer Ingelheim, Cerenovus, Covidien, Medtronic, MicroVention, Penumbra, Route92, and Stryker.
