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Abstract
Background The periprocedural antithrombotic regimen might affect the risk-benefit profile of emergent carotid artery stenting (eCAS) in patients with acute ischemic stroke (AIS) due to tandem lesions, especially after intravenous thrombolysis. We conducted a systematic review and meta-analysis to evaluate the safety and efficacy of antithrombotics following eCAS.
Methods We followed PRISMA guidelines and searched MEDLINE, Embase, and Scopus from January 1, 2004 to November 30, 2022 for studies evaluating eCAS in tandem occlusion. The primary endpoint was 90-day good functional outcome. Secondary outcomes were symptomatic intracerebral hemorrhage, in-stent thrombosis, delayed stent thrombosis, and successful recanalization. Meta-analysis of proportions and meta-analysis of odds ratios were implemented.
Results 34 studies with 1658 patients were included. We found that the use of no antiplatelets (noAPT), single antiplatelet (SAPT), dual antiplatelets (DAPT), or glycoprotein IIb/IIIa inhibitors (GPI) yielded similar rates of good functional outcomes, with a marginal benefit of GPI over SAPT (OR 1.88, 95% CI 1.05 to 3.35, Pheterogeneity=0.31). Sensitivity analysis and meta-regression excluded a significant impact of intravenous thrombolysis and Alberta Stroke Program Early CT Score (ASPECTS). We observed no increase in symptomatic intracerebral hemorrhage (sICH) with DAPT or GPI compared with noAPT or SAPT. We also found similar rates of delayed stent thrombosis across groups, with acute in-stent thrombosis showing marginal, non-significant benefits from GPI and DAPT over SAPT and noAPT.
Conclusions In AIS due to tandem occlusion, the periprocedural antithrombotic regimen of eCAS seems to have a marginal effect on good functional outcome. Overall, high intensity antithrombotic therapy may provide a marginal benefit on good functional outcome and carotid stent patency without a significant increase in risk of sICH.
- stroke
- stent
- thrombectomy
- thrombolysis
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
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Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
Footnotes
TNN and MR are joint senior authors.
Twitter @fdianamd, @AbdalkaderMD, @RaoulPop25, @yangha73, @V_DaRos, @ggcirillo, @ArKatsanos, @CheesemakerMD, @FishingNeurons, @Diana_A_Sousa, @S_Pesch, @ZiniAndrea, @atomasell, @marcriboj, @NguyenThanhMD, @micheleromoli
Collaborators APT-eCAS collaborators: Maximilian Thormann, MD, Liu Yang, MD, Ansgar Berlis, MD, Rémy Beaujeux, MD, Dong-Hun Kang, MD, Guillaume Saliou, MD, Daniele G Romano, MD, Gianfranco Vornetti, MD, Roberto Floris, MD, Benjamin Gory, MD, Manuel Requena, MD. Matteo Zanoni, MD, Lucio D’Anna, MD, Umberto Pensato, MD, Keisuke Imai, MD, Tudor G. Jovin, MD, Rainer Dabitz, MD, Anastasios Mpotsaris, MD, Serdar Tütüncü, MD, Stephanie Lescher, MD, José E Cohen, MD, Hannah Lockau, MD, Alejandro M Spiotta, MD, Jae Young Choi, MD, Sibylle Stampfl, MD, Donald V Heck, MD, Woong Yoon, MD, Daniel Giansante Abud, MD, Seungnam Son, MD, Mikayel Grigoryan, MD, Robert Fahed, MD, Leonardo Rangel-Castilla, MD, Fawaz Al-Mufti, MD, Omer Faruk Eker, MD, Marta Wallocha, MD, Tomas Klail, MD, Doo Hyuk Kwon, MD, Shunsuke Yamashita, MD.
Contributors Conception and design of the work: FD, MiR and TNN. Data acquisition: FD and MiR. Data analysis and interpretation: FD, MiR, TNN. Drafting the work: FD, MiR, TNN, MA. Critical revision: all authors. Final approval: all authors. Guarantor: FD.
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 None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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