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Ischemic stroke
Original research
Comparison of three antithrombotic strategies for emergent carotid stenting during stroke thrombectomy: a multicenter study
  1. Raoul Pop1,2,3,
  2. Julien Burel4,
  3. Stephanos Nikolaos Finitsis5,
  4. Chrysanthi Papagiannaki6,
  5. Francois Severac7,
  6. Pierre H Mangin3,
  7. Dan Mihoc1,
  8. Ian Leonard-Lorant1,
  9. Roxana Gheoca8,
  10. Valerie Wolff8,
  11. Salvatore Chibbaro9,
  12. Igor Sibon10,
  13. Sébastien Richard11,
  14. Remy Beaujeux1,
  15. Gaultier Marnat12,
  16. Benjamin Gory13,14,15
  1. 1 Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, France
  2. 2 Interventional Radiology, Institut de Chirurgie Guidée par l'Image, Strasbourg, France
  3. 3 INSERM, EFS Grand-Est, BPPS UMR-S1255, FMTS, F-67065, University of Strasbourg, Strasbourg, France
  4. 4 Radiology, University Hospital Centre Rouen, Rouen, France
  5. 5 Neuroradiology, Aristotle University of Thessaloniki, Thessaloniki, Greece
  6. 6 Interventional Neuroradiology, Centre Hospitalier Universitaire de Rouen, Rouen, France
  7. 7 Public Healthcare Department, University Hospitals Strasbourg, Strasbourg, France
  8. 8 Neurology, University Hospitals Strasbourg, Strasbourg, France
  9. 9 Neurosurgery, University Hospitals Strasbourg, Strasbourg, France
  10. 10 Neurology, University Hospital Center Bordeaux, Bordeaux, France
  11. 11 Neurology Stroke Unit, University Hospital Centre Nancy, Nancy, France
  12. 12 Interventional and Diagnostic Neuroradiology, University Hospital Centre Bordeaux, Bordeaux, France
  13. 13 Department of Diagnostic and Interventional Neuroradiology, Centre hospitalier regional universitaire de Nancy, Nancy, France
  14. 14 Université de Lorraine, Nancy, France
  15. 15 IADI, INSERM U1254, Nancy, France
  1. Correspondence to Dr Raoul Pop, Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, France; pop.raoul{at}gmail.com

Abstract

Background Periprocedural antithrombotic treatment is a key determinant for the risk–benefit balance of emergent carotid artery stenting (eCAS) during stroke thrombectomy. We aimed to assess the safety and efficacy of three types of antithrombotic treatment.

Methods Retrospective review of prospectively collected endovascular databases in four comprehensive stroke centers, including consecutive cases of eCAS for tandem lesion strokes between January 2019 and July 2021. During this period, each center prospectively applied one of three periprocedural protocols: (a) two centers administered aspirin (250 mg IV); (b) one center administered aspirin and heparin (bolus+24 hours infusion); and (c) one center applied an aggressive antiplatelet strategy consisting of aspirin and clopidogrel (loading doses), with added intravenous tirofiban if in-stent thrombosis was observed during thrombectomy. Dichotomized comparisons of outcomes were performed between aggressive versus non-aggressive strategy (aspirin±heparin) and aspirin+heparin versus aspirin-alone groups.

Results Among 161 included patients, 62 received aspirin monotherapy, 38 aspirin+heparin, and 61 an aggressive treatment. Aggressive antiplatelet treatment was associated with an increased rate of excellent (modified Thrombolysis in Cerebral Infarction (mTICI) 2c-3) recanalization and reduced carotid stent thrombosis at day 1 (3.5% vs 16.3%), compared with non-aggressive strategy. There were no significant differences in hemorrhagic transformation or 90-day mortality. There was a tendency towards better clinical outcome with aggressive treatment, without reaching statistical significance. Addition of heparin to aspirin was not associated with an increased rate of carotid stent patency.

Conclusions Aggressive antiplatelet treatment was associated with improved intracranial recanalization and carotid stent patency, without safety concerns. These findings have implications for randomized trials and may be of utility for clinicians when making antithrombotic treatment choices.

  • Cervical
  • Platelets
  • Stent
  • Stroke
  • Thrombectomy

Data availability statement

Data are available upon reasonable request. Data are available upon reasonable request to Raoul Pop (pop.raoul@gmail.com).

https://doi.org/10.1136/jnis-2022-019875

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    Data availability statement

    Data are available upon reasonable request. Data are available upon reasonable request to Raoul Pop (pop.raoul@gmail.com).

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    Footnotes

    • Twitter @RaoulPop25

    • Contributors RP, SNF, BG: conception and design of the work, analysis and interpretation of data, drafting the manuscript, final approval of the version to be published, agreement to be accountable for all aspects of the work. JB, CP, FS, PHM, DM, IL-L, RG, VW, SC, IS, SR, RB, GM: acquisition and interpretation of data, critical revision of the manuscript, final approval of the version to be published, agreement to be accountable for all aspects of the work. Guarantor for this work :RP.

    • 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 SNF: patents planned, issued or pending: US11166738B2. IS: consulting fees from Sanofi Synthé-Labo, Servier, Boheringer Ingelheim, Astra-Zeneca, Novonordisk, Medtronic. Payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Sanofi Synthé-Labo, Medtronic, Boheringer Ingelheim, Astra-Zeneca, BMS-Pfizer. GM: consulting fees from Stryker Neurovascular, Microvention Europe, Balt. Payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Medtronic, Johnson and Johnson.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.