Background Endovascular treatment (EVT) is the standard of care for selected patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO).
Objective To systematically review the available data on: (1) incidence, predictors, and outcomes of patients with reocclusion after successful EVT for AIS and, (2) the characteristics, complications, and outcomes of patients with reocclusion treated with repeated EVT (rEVT) within 30 days of the first procedure.
Methods PubMed was searched (between January 2012 and April 2021) to identify studies reporting reocclusion following successful EVT (Thrombolysis in Cerebral Infarction ≥2b) in patients with AIS due to LVO. Pooled incidence of reocclusion per 100 patients with successful recanalization following EVT was calculated using a random-effects model with Freeman-Tukey double arcsine transformation. Extracted incidences of reocclusion according to etiology and use of intravenous thrombolysis were pooled using random-effects meta-analytic models.
Results A total of 840 studies was identified and seven studies qualified for the quantitative analysis, which described 91 same-vessel reocclusions occurring within the first 7 days after treatment among 2067 patients (4.9%; 95% CI 3% to 7%, I2=70.2%). Large vessel atherosclerosis was associated with an increased risk of reocclusion (OR=3.44, 95% CI 1.12 to 10.61, I2=50%). We identified 90 patients treated with rEVT for recurrent LVO, described in five studies. The rates of procedural complications, mortality, and unfavorable functional outcome at 3 months were 18.0%, 18.9%, and 60.3%, respectively.
Conclusion In cohorts of patients with AIS due to LVO, 5% of patients experienced reocclusion within 7 days after successful EVT. Repeated EVT can be a safe and effective treatment for selected patients with reocclusion.
Data availability statement
Data are available upon reasonable request.
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LLN and DAdS contributed equally.
Contributors Conception, design and guarantors: DAdS, LLN. Search, screening, and quality assessment of articles: RO, MAC, LLN, DAdS. Data acquisition: RO, MAC. Data analysis and interpretation: RO, LLN, DAdS. Drafting of the article: RO. Critical revision: All authors. Final approval: All authors.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests JPM reports consulting fees from Amicus Therapeutics and Boehringer Ingelheim, speaker fees from Boehringer Ingelheim, and support for travel from Boehringer Ingelheim, Bayer and Pfizer, outside of the submitted work. TNN reports research support from Medtronic and the Society of Vascular and Interventional Neurology (unrelated), DSMB participation for TATAM, Endolow, TESLA, CREST-2 and SELECT-2 trial, and being President-Elect of SVIN. RGN reports potential conflicts with Stryker Neurovascular (DAWN Trial principal investigator–no compensation, TREVO Registry Steering Committee–no compensation, Trevo-2 Trial principal investigator–modest; consultant–modest), Medtronic (SWIFT Trial Steering. Committee–modest; SWIFT-Prime Trial Steering Committee–no compensation; STAR Trial Angiographic Core Laboratury–significant), Penumbra (3D Separator Trial Executive Committee–no compensation), Cerenovus/ Neuravi (ENDOLOW Trial principal investigator, EXCELLENT Registry principal investigator, ARISE-2 trial Steering Committee–no compensation, Physician Advisory Board, modest), Phenox (Physician Advisory Board, modest), Anaconda (Physician Advisory Board-modest), Genentech (Physician Advisory Board–modest), Biogen (Physician Advisory Board–modest), Prolong Pharmaceuticals (Physician Advisory Board–modest), Allm Inc (Physician Advisory Board–no compensation), IschemaView (Speaker, modest), Brainomix (Research Software Use–no compensation), Sensome (Research Device Use–no compensation), Viz-AI (Physician Advisory Board, stock options), Philips (Research Software Use–no compensation, Speaker–modest), and Corindus Vascular Robotics (Physician Advisory Board, stock options). ABC reports being a Cerenovus consultant and receiving personal fees from Medtronic. DCH reports compensation from Stryker, Vesalio, and Cerenovus for consultant services; compensation from Jacobs institute for data and safety monitoring services; stock options in Viz AI. JTF reports consulting fees from Cerenovus, Stryker, Microvention, and Penumbra, being DSMB lead for MIVU medical, ownership interest from Imperative Care, and being member of the editorial board of JNIS and board member of SNIS. SO-G reports consulting fees for Medtronic, Stryker Neurovascular, and Microvention, receiving grants from Stryker, IschemiaView, Viz.ai, Methinks, and NIH, and being treasurer of SVIN. DRY reports being part of the steering committee for the TIGER clinical trial sponsored by Rapid Medical and steering committee of CALM-2 sponsored by Vascular Dynamics, consulting fees from Medtronic, Cerenovus, Poseydon, and Neurosave, Deck Therapeutics, GLG Consulting, Guidepoint Consulting, Mosaic Consulting, and Neuralanalytics. DAdS reports non-financial support from Boehringer Ingelheim, DSMB participation for the SECRET trial, advisory board participation for AstraZeneca, grants from Astrazeneca, speaker fees from Bayer and being member of the executive committee of the European Stroke Organisation. The other authors report no conflicts.
Provenance and peer review Not commissioned; externally peer reviewed.
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