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

Discussion

The major findings of this study are as follows: (1) RS resulted in successful recanalization in 64.6% of patients with recanalization failure with MT, and RSG had a significantly higher rate of good outcome without increasing sICH and mortality compared with NSG, (2) RS remained independently associated with good outcome after adjustment, and (3) the patients who had recanalization success with RS showed good outcome rate comparable to that of successful MT group. In contrast, of the patients who had recanalization failure even if RS was done, only 11.8% (2/17) had good outcome (Figure 2). Those findings highlight once again that recanalization success is one of the most important factors regardless of recanalization tools.

In the meta-analysis of 5 randomized trials (the HERMES investigation), recanalization failed in [almost equal to]29% of the patients who underwent MT.[8] There are several causes that underlies MT failure. One of the major causes is ICAS in situ thromboocclusion especially in Asian populations.[16,17] In ICAS LVO, even after successful recanalization was achieved with MT, repeat reocclusion occurred up to 77%, resulting in MT failure.[16] In this study, repeat reocclusion was significantly higher in the RSG than in the NSG. For MT-failed LVO especially because of repeat reocclusions, glycoprotein IIb/IIIa antagonist, balloon angioplasty, RS, or any combination of those have been suggested.[11] Placement of a self-expanding stent has been suggested as one of the effective endovascular tools before the MT era.[12–15] The results of this study suggest that RS can be revisited as a rescue option in cases with MT failure because of ICAS LVO.[11,16,18] Taking it into consideration that [almost equal to]1 of 5 LVO might be attributable to ICAS in the survey among all participating centers, the results are of important clinical implications.

RS may require glycoprotein IIb/IIIa antagonist or oral antiplatelet medication to prevent in-stent thrombosis. There has been a major concern that glycoprotein IIb/IIIa antagonist administration or oral antiplatelet medication in acute stroke setting may potentially increase sICH. However, the use of a glycoprotein IIb/IIIa inhibitor did not increase sICH rate but did the likelihood of stent patency significantly. Although not significant, in fact, the rate of sICH was lower in patients with glycoprotein IIb/IIIa inhibitor than those without. In addition, post-RS oral antiplatelet medication was also not associated with increasing sICH rate. Those results corresponded with the previous studies, indicating that glycoprotein IIb/IIIa inhibitor use with or without stenting in an acute stage may be safe.[18–21]

This study has several limitations inherent to its retrospective nature. The results of this study should be interpreted with caution because selection bias might have an influence on the results. However, the study population was recruited from the prospectively maintained registries of participating centers and showed balanced distribution of clinical variables, including stroke risk factors between the 2 groups. Therefore, selection bias less likely affected the major findings of the analysis. A prospective clinical trial is essential for confirming the results of this analysis. Nevertheless, the results of this study are important for contributing to baseline data for designing prospective studies and may be helpful in solving intracranial ICA or MCA-M1 occlusion refractory to MT.

In conclusion, RS was independently associated with good outcomes without increasing sICH or mortality in the study population. RS can be considered in MT-failed ICA or MCA-M1 occlusion despite of repetitive MT. Further studies are needed to define the optimal time of RS and the use of adjuvant antithrombotics in patients with failed MT.

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