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

Results

Five hundred ninety-one patients fulfilled enrollment criteria (Figure 1). Recanalization was successful in 443 patients (75.0%). Good outcome rate of recanalization success with MT was 55.4% (Figure 2). Of the 443 patients with recanalization success, the final method for achieving recanalization was stent retriever in 74.5% (n=330), Penumbra system in 19.4% (n=86), stent retriever plus Penumbra system in 3.4% (n=15), glycoprotein IIb/IIIa inhibitor in 1.9% (n=8), balloon angioplasty in 0.5% (n=2), and urokinase in 0.5% (n=2). Finally, MT failed in 148 patients (25.0%; mean age, 66.6±13.7 years; male:female=73:75). The mean number of MT attempt was significantly smaller in recanalization success (n=443; 2.4±1.7) than in recanalization failure (n=148; 3.6±2.1; P<0.01). Of the patients with recanalization failure with MT, 48 received RS while 100 were left without RS (Figure 1). In the survey of the 9 centers where RS was done, the indications for RS were (1) ICAS was highly suspected as a cause of LVO; (2) repeat reocclusion shortly after recanalization with MT; (3) clinical-infarct core mismatch (NIHSS [greater than over equal to]8 and Alberta Stroke Program Early CT Score 9 or 10); (4) good antegrade flow (modified Tissue Thrombolysis in Cerebral Ischemia 2b or 3) with stent retriever placement was persistent at least 10 minutes, but instant occlusion occurred after retrieval of stent; or (5) aggravating flow compromise because of residual stenosis after MT. In the survey among the all 16 participating centers, ICAS was suspected as a cause of large artery occlusions in 110 (18.7%) of the study population.

Figure 1.

Flow chart of patient inclusion steps and findings analyzed at each step. CTA indicates computed tomographic angiogram; EVT, endovascular therapy; GP, glycoprotein; IA, intra-arterial; ICA, internal carotid artery; ICH, intracranial hemorrhage; MCA, middle cerebral artery; mRS, modified Rankin Scale; MT, mechanical thrombectomy; NIHSS, National Institutes of Health Stroke Scale; NSG, no stenting group; RSG, rescue stenting group; sICH, symptomatic intracranial hemorrhage; and UK, urokinase.

Figure 2.

Distributions of the 3-month modified Rankin Scale score (mRS) of patients with recanalization success by mechanical thrombectomy alone and patients with rescue stenting and without rescue stenting after mechanical. MT indicates mechanical thrombectomy; NSG, no stenting group; recanalization success, modified Tissue Thrombolysis in Cerebral Ischemia, 2b–3; RS, rescue stenting; and RSG, rescue stenting group.

There were no differences in clinical and laboratory findings except for reocclusion rate (58.3% before RS in RSG versus 28% in NSG), the use of a glycoprotein IIb/IIIa inhibitor (70.8% in RSG versus 14.0% in NSG), and balloon angioplasty (31.3% in RSG versus 4.0% in NSG). The types of stents for RS were Solitaire AB/FR in 37 (77.1%), Wingspan in 8 (16.7%), Enterprise in 2 (4.2%), and a balloon-expandable stent in 1 (2.1%). Recanalization was successful in 31 patients (64.5%) of the RSG group. There was no RS procedure-related complication during the procedure. There was no difference in recanalization rate among stent type: 67.6% (25 of 37) with Solitaire AB/FR, 50% (4 of 8) with Wingspan, 50% with Enterprise (1 of 2), and 100% (1 of 1) with coronary stent (P=0.654). There were no differences between RS with and without balloon angioplasty in recanalization rate (81.3% versus 53.1%; P=0.068) and 3-month good outcome rate (40.0% versus 39.4%; P=0.99). The mean of puncture-to-recanalization time was significantly longer in patients with recanalization success with RS (n=31; 113±53 minutes) than in those with recanalization success with MT (n=443; 62±39 minutes; P<0.001). The RSG had a significantly higher rate of good outcome (mRS, 0–2 at 3 months; 39.6% in RSG versus 22.0% in NSG; P=0.031) with no difference in sICH (16.7% in RSG versus 20.0% in NSG; P=0.823) or mortality (12.5% in SG versus 19.0% in NSG; P=0.36; Table 1) Of the patients who had recanalization success with RS, 54.8% (17 of 31) had good outcome, which is comparable to that (55.4%) of recanalization success group with MT. Furthermore, of the patients who had recanalization success with RS, the distribution of mRS at 3 months was similar to that of patients with recanalization success with MT. In contrast, of the patients who had recanalization failure even if RS was done, only 11.8% (2 of 17) had good outcome (Figure 2). In multivariate binary logistic regression analysis, RS (odds ratio, 3.393; 95% confidence interval, 1.192–9.655; P=0.022) remained independently associated with good outcome, along with the initial National Institutes of Health Stroke Scale (odds ratio, 0.864; 95% confidence interval, 0.775–0.963; P=0.008) and good collateral on CTA (odds ratio, 13.893; 95% confidence interval, 1.515–127.393; P=0.02; Table 2). 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. The patients with patent stent had 87% of good outcome, whereas none of the 3 patients with stent occlusion had good outcome (P=0.011; Figure 2).

The antiplatelet strategy were determined by consensus between the operator and the responsible stroke neurologist based on the patients' clinical status and each center's protocol. Those were classified as follows: (1) glycoprotein IIb/IIIa inhibitor just before or after RS (loading of Tirofiban, 0.3–1.0 mg or Reopro 5–10 mg, followed by intravenous maintenance dose of the same drug for a 6–12 hours and then changed to dual antiplatelet medication), (2) oral dual antiplatelet medication just before or after RS (aspirin, 100–500 mg and plavix, 300 mg), (3) oral antiplatelet monotherapy just after RS (Plavix, 75–300 mg), and (4) no antiaggregation therapy was done until follow-up nonenhanced CT or MR was obtained next day.

Stent patency was associated with the use of glycoprotein IIb/IIIa inhibitor during or after the procedure but not with antiplatelet medication (aspirin, clopidogrel, or both) during the periprocedural period. Neither glycoprotein IIb/IIIa inhibitor nor antiplatelet medication increased the rate of sICH (Table 3).

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