Article Text
Abstract
Introduction The optimal treatment for tandem large vessel occlusions (TOs) is unclear. This study compared balloon angioplasty plus carotid artery stenting (CAS) versus balloon angioplasty (BA) alone for managing TOs.
Methods This retrospective study analyzed data from the Stroke Thrombectomy and Aneurysm Registry. The primary outcome was the 90-day functional outcome. Secondary outcomes included mortality and degree of revascularization. Safety outcomes included periprocedural complications. Inverse propensity scoring and regression adjustment (IPSWR) addressed non-random treatment selection. To correct for multiple hypothesis testing, especially with significant post-hoc changes, the Sidak (1967) correction to p-values will be utilized and the Sidak-adjusted p (ps) will be reported. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) were reported.
Results The study included 244 TO patients, with 132 undergoing CAS and 112 undergoing BA. The CAS group had higher rates of successful reperfusion (95% vs 83.9% ORTUGA, p<0.001) but similar rates of good functional outcome and mortality compared to the BA group. IPSWR found no significant difference between CAS and BA for good functional outcome (ATE -0.13, 95% CI -0.29 to 0.02, p=0.08, ps=0.29), mortality (ATE 0.05, 95% CI -0.06 to 0.15, p=0.37, ps=0.87), or symptomatic ICH (ATE 0.04, 95% CI -0.05 to 0.13, p=0.40, ps=0.85). On Weighted regression, older age (aOR: 0.95, 95% CI 0.91–0.99; p=0.01, ps=0.15) and higher admission NIHSS (aOR: 0.93, 95% CI 0.87–0.99; p=0.02, ps=0.32) were associated with lower odds of functional independence. Intravenous thrombolysis was independently associated with higher odds of symptomatic Intracranial hemorrhage (sICH) (aOR: 6.62 [95% CI, 1.44 - 30.5]; p=0.02, ps=0.22), but not on its interaction analysis with CAS (aOR: 0.23 [95% CI, 0.03 - 1.89]; p=0.17, ps=0.95). Alberta Stroke Program Early Computed Tomography scores between 8–10 were associated with lower odds of sICH compared to 0–7 (aOR: 0.22 [95% CI, 0.07 - 0.69]; p=0.01, ps=0.14).
Conclusion This study found CAS and BA to be comparably safe and effective when combined with mechanical thrombectomy for TOs, but CAS tied to higher sICH from lower ASPECTS and IVT use, leaving uncertainty over the best approach. A limitation of our study is the statistical analysis when accounting for comparisons, mitigated by employing the Sidak-class method, revealing nonsignificant differences and emphasizing comparable functional outcomes between CAS and BA procedures. Nevertheless, further randomized trials are warranted to definitively determine the optimal endovascular approach.
Disclosures M. Essibayi: None. E. Almallouhi: None. M. Anadani: None. R. Medeiros: None. S. Yaghi: 2; C; Nonfunded research collaboration with Medtronic. I. Maier: 6; C; Speakers honoraria from Pfizer and Bristol- Myers Squibb. P. Jabbour: None. J. Kim: None. J. Kim: None. S. Wolfe: None. A. Rai: None. R. Starke: 1; C; RMS research is supported by the NREF, Joe Niekro Foundation, Brain Aneurysm Foundation, Bee Foundation, Department of Health Biomedical Research Grant (21K02AWD-007000) and by National Institute of H. 2; C; Penumbra, Abbott, Medtronic, Balt, InNeuroCo, Cerenovus, Naglreiter, Tonbridge, Von Medical, and Optimize Vascular. M. Psychogios: 1; C; Grants from the Swiss National Science Foundation (SNF) for the DISTAL trial (33IC30_198783) and TECNO trial (32003B_204977), Grant from Bangerter-Rhyner Stiftung for the DISTAL trial. Unrestricted Gr. 3; C; Stryker Neurovascular Inc., Medtronic Inc., Penumbra Inc., Acandis GmbH, Phenox GmbH, Siemens Healthineers AG. A. Shaban: None. A. Arthur: 1; C; Balt, Medtronic, Microvention, Penumbra and Siemens. 2; C; Arsenal, Balt, Johnson and Johnson, Medtronic, Microvention, Penumbra, Perfuze, Scientia, Siemens, Stryker. S. Yoshimura: 2; C; Stryker, Medtronic, Johnson & Johnson, Kaneka Medics. B. Howard: None. A. Alawieh: None. I. Fragata: None. H. Cuellar: 2; C; Medtronic, Penumbra and Microvention. A. Polifka: 2; C; Depuy Synthes and Stryker. J. Mascitelli: None. J. Osbun: None. C. Matouk: 1; C; R21NS128641. 2; C; Stryker, Medtronic, Microvention, Penumbra, and Silk Road Medical. M. Park: 2; C; Medtronic. M. Levitt: 1; C; Unrestricted educational grants from Medtronic and Stryker. 2; C; consulting agreement with Medtronic, Aeaean Advisers and Metis Innovative; equity interest in Proprio, Cerebrotech, Apertur, Stereotaxis, Fluid Biomed, and Hyperion Surgical. T. Dumont: None. R. Williamson: 2; C; Medtronic, Stryker, and Synaptive Medical. D. Altschul: 1; C; Grant from Bee foundation. 2; C; Microvention. A. Spiotta: 1; C; Research support from Penumbra, Stryker, Medtronic, RapidAI, Avail. 2; C; Penumbra, Stryker, Terumo, and RapidAI. Equity Avail. S. Al Kasab: 1; C; Grant from Stryker for RESCUE-ICAS registry.