Introduction Recanalization of tandem vascular occlusions involving the cervical carotid artery and an ipsilateral intracranial large vessel is a difficult treatment challenge. These lesions have been historically observed to be refractory to most conservative medical therapies. New endovascular options have been rapidly emerging over the last few years resulting in potentially higher revascularization rates. Recanalization of tandem lesions with different devices may be possible by opening the distal occlusion first, followed by treatment of the proximal lesion, or vice versa. However, safety and efficacy of these treatment modalities have not been well established. We report our early experience of a combined endovascular approach for the treatment of tandem occlusions in acute stroke patients using the Penumbra thrombectomy device.
Methods We included 20 patients from two high volume centers in this retrospective analysis. The patients presented with acute ischemic stroke symptoms within 8 h of symptoms onset. All patients were found to have occlusion of the middle cerebral artery and/or carotid terminus with associated occlusion or critical stenosis/functional occlusion of the ipsilateral cervical carotid segment. Intracranial hemorrhage was ruled out in all cases before the procedure. The patients underwent combined endovascular treatment with extracranial angioplasty/stenting and intracranial mechanical thrombectomy with the Penumbra device. Demographics, catheter selection, pre- and post-procedural neurologic status, recanalization rates and outcomes were recorded and compared to previously reported data.
Results 12 male (63.2%) and 8 female patients (42.8%) were included (mean age 65.7±13.1 years). Carotid dissection was reported to be responsible for the proximal vascular lesion in three patients (15%). Extracranial stenting was performed in 17 (85%) cases; in the remaining three patients stenting was technically not feasible. Different caliber catheters were utilized to treat the intracranial lesion: Penumbra 054 in 11 cases, 032 in 9, 041 in 8, and 026 in 2. Multiple Penumbra catheters were used in 10 patients (50%). Successful recanalization was achieved in 17 cases (85%). Mean NIHSS preprocedure was 17.6±6.7 in recanalized and 17.7±9.5 in nonrecanalized group; postprocedure NIHSS was 11.8±12.4 in recanalized and 21.0±6.0 in nonrecanalized (p=0.12;NS). Follow-up outcome at 30 days was available for 11/20 patients (55%): 8 recanalized and all 3 nonrecanalized patients. Favorable outcome (mRS≤2) was observed in 4/8 recanalized patients (50%) and none (0%) in the non-recanalized group. Two patients (10%) died; both in the non-recanalized group. One symptomatic (5%) and three asymptomatic (15%) ICHs were reported.
Conclusion The combined use of extracranial angioplasty/stenting and intracranial mechanical thrombectomy with the Penumbra device appears technically feasible and relatively safe with high recanalization rates. Our results are consistent with previous reports showing that recanalization is associated with better outcomes. These results are comparable and in line with prior neurointerventional trials and case series of tandem occlusions, but larger studies are warranted.
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