Rescue Stenting for Failed Mechanical Thrombectomy in Acute Ischemic Stroke

A Multicenter Experience

Yoonkyung Chang, MD; Byung Moon Kim, MD; Oh Young Bang, MD; Jang-Hyun Baek, MD; Ji Hoe Heo, MD; Hyo Suk Nam, MD; Young Dae Kim, MD; Joonsang Yoo, MD; Dong Joon Kim, MD; Pyoung Jeon, MD; Seung Kug Baik, MD; Sang Hyun Suh, MD; Kyung-Yul Lee, MD; Hyo Sung Kwak, MD; Hong Gee Roh, MD; Young-Jun Lee, MD; Sang Heum Kim, MD; Chang-Woo Ryu, MD; Yon-Kwon Ihn, MD; Byungjun Kim, MD; Hong Jun Jeon, MD; Jin Woo Kim, MD; Jun Soo Byun, MD; Sangil Suh, MD; Jeong Jin Park, MD; Woong Jae Lee, MD, PhD; Jieun Roh, MD; Byoung-Soo Shin, MD; Jeong-Min Kim, MD

Disclosures

Stroke. 2018;49(4):958-964. 

In This Article

Abstract and Introduction

Abstract

Background and Purpose: Effective rescue treatment has not yet been suggested in patients with mechanical thrombectomy (MT) failure. This study aimed to test whether rescue stenting (RS) improved clinical outcomes in MT-failed patients.

Methods: This is a retrospective analysis of the cohorts of the 16 comprehensive stroke centers between September 2010 and December 2015. We identified the patients who underwent MT but failed to recanalize intracranial internal carotid artery or middle cerebral artery M1 occlusion. Patients were dichotomized into 2 groups: patients with RS and without RS after MT failure. Clinical and laboratory findings and outcomes were compared between the 2 groups. It was tested whether RS is associated with functional outcome.

Results: MT failed in 148 (25.0%) of the 591 patients with internal carotid artery or middle cerebral artery M1 occlusion. Of these 148 patients, 48 received RS (RS group) and 100 were left without further treatment (no stenting group). Recanalization was successful in 64.6% (31 of 48 patients) of RS group. Compared with no stenting group, RS group showed a significantly higher rate of good outcome (modified Rankin Scale score, 0–2; 39.6% versus 22.0%; P=0.031) without increasing symptomatic intracranial hemorrhage (16.7% versus 20.0%; P=0.823) or mortality (12.5% versus 19.0%; P=0.360). Of the RS group, patients who had recanalization success had 54.8% of good outcome, which is comparable to that (55.4%) of recanalization success group with MT. RS remained independently associated with good outcome after adjustment of other factors (odds ratio, 3.393; 95% confidence interval, 1.192–9.655; P=0.022). Follow-up vascular imaging was available in the 23 (74.2%) of 31 patients with recanalization success with RS. The stent was patent in 20 (87.0%) of the 23 patients. Glycoprotein IIb/IIIa inhibitor was significantly associated with stent patency but not with symptomatic intracranial hemorrhage.

Conclusions: RS was independently associated with good outcomes without increasing symptomatic intracranial hemorrhage or mortality. RS seemed considered in MT-failed internal carotid artery or middle cerebral artery M1 occlusion.

Introduction

After the success of 5 randomized clinical trials, most guidelines recommend mechanical thrombectomy (MT) for acute stroke because of anterior circulation large vessel occlusion (LVO).[1–7] Nevertheless, in a meta-analysis of the 5 pivotal randomized controlled trials of MT, the rate of recanalization failure was up to 29%.[8] Because recanalization success is one of the most powerful factors for good outcome after acute stroke,[1–9] many studies have been focused on improving MT efficacy.[10,11] Yet, few studies have addressed on the rescue treatment strategies for recanalization failure with the currently available MT tools. Permanent placement of a self-expanding stent has been suggested as a primary or rescue modality for intracranial LVO.[12–17] After MT failed in patients with acute stroke because of anterior circulation LVO, however, there has only been one small single-center case series comparing rescue permanent stenting (RS) and nonstenting groups without further treatment.[18]

We hypothesized that patients with RS (RS group [RSG]) would have better outcomes than those without RS who were left nonrecanalized (no stenting group [NSG]) after MT failed. To test the hypothesis, we compared functional outcome at 3 months, symptomatic intracranial hemorrhage (sICH), and mortality between RSG and NSG in a cohort of patients in whom MT had failed to recanalize intracranial internal carotid artery (ICA) or middle cerebral artery (MCA) M1 occlusion.

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