Purpose The clinical benefit of endovascular thrombectomy (EVT) after intravenous recombinant tissue plasminogen activator (IV rt-PA) has been demonstrated in several studies. Near 10% of acute ischemic stroke (AIS) patients are accompanied with carotid artery atherosclerotic occlusion. The MR Clean study in the Netherlands reported that acute carotid artery stenting (CAS) was performed in 30 patients in the intervention group (12.9%). However, there is no evidence of the benefit for emergent CAS in AIS patients, and there are no clear guidelines for specific medications as an adjunctive therapy within 24 hours of IV rt-PA.
Methods We analyzed single-center registry data retrospectively for 2006 to 2018. Emergent CAS during EVT was performed in select patients according to the operator’s decision. Most patients for emergent CAS was not used to antithrombotic medications routinely within 24 hours of IV rt-PA. Only some complicated cases were used intra-arterial or oral antithrombotics within 24 hours of IV rt-PA. Recanalization results were assessed by TICI grade immediately after the procedure. The clinical outcome was evaluated using the 3 months modified Rankin Scale.
Results Among 177 consecutive patients with AIS treated with rt-PA and EVT from 2006 to 2018, twenty-three(12.9%) patients underwent CAS as an EVT. Eighteen patients (78.3%) were accompanied with tandem occlusion. Median age was 68. Median NIHSS was 13. During the emergent carotid artery stenting, pre-stent balloon angioplasty was performed in 20 patients. Carotid Wallstent (Boston Scientific, Natick, USA) was used in all patients who treated with emergency CAS. Successful installation of CAS was achieved in 22 patients (95.6%). One case of CAS was failed. Two patients were installed multiple carotid stent for carotid dissection. And embolic protection device was used in 13 patients.However, four cases of CAS experienced thromboembolic complications including in-stent thrombosis and distal migration of emboli. In those cases, IA glycoprotein IIb/IIIa infused as a rescue method, and early antiplatelet within 24 hours of rt-PA was administered in one patient.Final successful recanalization (mTICI 2b-3) was achieved in 16 patients (69.5%). Eleven patients (47.8%) had a good functional outcome (modified mRS 0–2). Intracranial hemorrhage was occurred in 4 cases. The mortality case was two. The accompanying tandem occlusion was 61%.
Conclusions In this analysis, successful rate of emergency CAS and intracranial EVT after IV rt-PA was high as 95.6% and 69.5%. The good functional outcomes (mRS 0–2) were 46.7% in patients treated with emergency CAS and the overall clinical outcome would be acceptable.
Disclosures J. Seo: None. E. Kim: None.
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