Stentriever Thrombectomy Failure: A Challenge in Stroke Management

doi:10.1016/j.wneu.2017.03.070

World Neurosurgery

Volume 103, July 2017, Pages 57-64

https://doi.org/10.1016/j.wneu.2017.03.070 Get rights and content

Background and Objective

Stentriever thrombectomy failure in patients with acute ischemic stroke caused by anterior circulation large artery occlusion is not a rare event. The purpose of this study was to investigate whether other procedures (tirofiban, permanent stenting) are able to recanalize the occluded vessel and determine a better outcome without increasing mortality and intracranial hemorrhage rates.

Methods

Among 513 patients consecutively admitted with anterior circulation stroke, 109 underwent stentriever thrombectomy. Modified Thrombolysis in Cerebral Ischemia (mTICI) 2b-3 recanalization was achieved in 60 patients (55.0%, group 1). Only 3 of 19 patients (group 2) obtained additional recanalization with intra-arterial infusion of tirofiban. The remaining 46 either underwent permanent stenting (n = 23, group 3) or were left nonrecanalized (n = 23, group 4). The rate of mTICI 2b-3 and clinical outcomes were analyzed in the different groups.

Results

A successful recanalization (mTICI 2b-3) was achieved in 17 patients of group 3 (73.9%). A significantly better outcome was observed in group 3 (modified Rankin Scale [mRS] score, 0–2) than in group 4 at 3 months (56.5% vs. 17.4%). Symptomatic intracranial hemorrhage rates were not different between group 3 and group 4 (4.3% vs. 4.3%), whereas there was a significantly higher mortality in group 4 than in group 3 (39.1% vs. 4.3%). On multivariate analysis, permanent stenting was the only factor independently associated with favorable outcome and mortality.

Conclusions

Permanent stenting might be a feasible solution in patients with acute large artery occlusion after stentriever thrombectomy failure.

Introduction

Endovascular mechanical thrombectomy combined with intravenous thrombolysis has recently been shown to be superior to thrombolysis alone in the treatment of patients with acute ischemic stroke with large artery occlusion (LAO) of the anterior circulation.¹ In particular, stentriever thrombectomy has been recommended as a first-line method for intra-arterial recanalization, although other thrombectomy or aspiration devices approved by local health authorities may be used at the discretion of the neurointerventionist if rapid, complete, and safe revascularization of the target vessel can be achieved.² Stentriever thrombectomy does not guarantee a successful recanalization (modified Thrombolysis in Cerebral Ischemia [mTICI], 2b-3) in all patients as already reported.³ In these cases, additional treatment with glycoprotein IIb/IIIa antagonists such as tirofiban and/or permanent stenting might represent a possible solution to achieve a better prognosis, because recanalization is known to be a strong predictor of good outcome in cerebral ischemia secondary to LAO.⁴ Glycoprotein IIb/IIIa inhibitors have been associated with increased risk of fatal intracerebral hemorrhage (ICH) and poor outcome,⁵ but not in all studies,⁶ and it has been shown that mechanical thrombectomy with stentrievers does not cause relevant endothelial damage.⁷ Permanent stenting has been suggested as another primary approach or as a rescue tool for recanalization of acute intracranial LAO,8, 9, 10 even though safety is an important issue here as well, because these procedures might increase the rates of symptomatic ICH and death. For this reason, we decided to conduct an observational study in patients with acute stroke caused by an anterior circulation LAO with the aim of investigating whether tirofiban and/or permanent stenting after mechanical thrombectomy failure are able to recanalize the occluded vessel and determine a better outcome without increasing mortality and ICH rates.

Section snippets

General Study Protocol

Patients consecutively admitted to the Stroke Unit of the University Hospital of Padua (Italy) from January 2014 to July 2016 for their first-ever acute ischemic stroke caused by anterior circulation LAO (defined as occlusion of the intracranial internal carotid artery [ICA] and/or middle cerebral artery [M1 segment and/or proximal M2 segment]) were prospectively assessed according to standardized diagnostic and therapeutic procedures as recommended by the European Stroke Organization,¹¹

Results

During the study period, a total of 513 patients were hospitalized for their first-ever acute anterior circulation ischemic stroke, comprising 315 men (61.4%) and 198 women (38.6%), with a mean age of 71.5 ± 11.4 years. Among those with an anterior circulation LAO, 109 underwent stentriever thrombectomy either alone or in combination with intravenous thrombolysis, and a successful recanalization was achieved in 60 patients (55.0%). An intra-arterial infusion of tirofiban was administered after

Discussion

The main result of our study is that in patients with acute stroke with anterior circulation LAO refractory to stentriever thrombectomy, permanent stenting determined mTICI 2b-3 recanalization in 73.9% of cases with a better clinical outcome and a reduced mortality compared with the nonstent group, without an increase in symptomatic ICH.

Many (45%) of the patients in this study with acute ischemic stroke caused by anterior circulation LAO did not recanalize after stentriever thrombectomy either

Conclusions

According to our study, in patients with acute ischemic stroke caused by anterior circulation LAO and refractory to stentriever thrombectomy, permanent stenting seems to lead to a better clinical outcome and reduced mortality without an increase in ICH rate. Moreover, our results suggest that permanent stenting as a rescue treatment might be a therapeutic option also for elderly patients, given the positive impact of vessel recanalization in all age groups. In conclusion, permanent stenting

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Cited by (27)

Underlying intracranial atherosclerotic disease is associated with worse outcomes in acute large vessel occlusion undergoing endovascular thrombectomy
2023, Journal of Stroke and Cerebrovascular Diseases
Data on large vessel occlusion (LVO) management due to intracranial atherosclerotic disease (ICAD) are scarce.
To compare clinical outcomes between patients with ICAD and those without ICAD following mechanical thrombectomy (MT).
We performed a retrospective analysis of consecutive patients who underwent MT for LVO in a large academic comprehensive stroke center, and compared in-hospital mortality, 90-day mortality, favorable functional outcome at 90 days, and symptomatic intracranial hemorrhage (ICH) using chi-squared tests and multivariate logistic regression analyses. We defined ICAD as observable plaque at occlusion site post-thrombectomy.
Among 215 patients (mean age 67.1 ± 16.0 years; 60.5% female; 83.6% Black, median NIHSS score 16), ICAD was present in 38 patients (17.7%). Diabetes and dyslipidemia were more common in those with ICAD (57.9% vs. 38.4%, p = 0.027 and 29.0% vs. 14.7%, p = 0.035, respectively). Substantial reperfusion (TICI ≥2b) was achieved less often (84.2% vs. 94.4%, p = 0.031) but symptomatic ICH was also less common in ICAD patients (0% vs. 9.0%, p = 0.081). In-hospital and 90-day mortality were more common (36.8% vs. 15.8%, p = 0.003 and 52.6% vs. 26.6%, p = 0.002, respectively) and favorable functional outcome (mRS 0-2) at 90 days was less common (7.9% vs. 33.9%, p = 0.001) in ICAD patients. After adjusting for prognostic variables, ICAD was independently associated with in-hospital mortality (OR=4.1, 95% CI 1.7-9.7), 90-day mortality (OR=3.7, 95% CI 1.6-8.6), and poor functional outcome at 90 days (OR=5.5, 95% CI 1.6-19.4).
Symptomatic ICAD in a predominantly African American cohort is associated with increased odds of mortality and poor functional outcome at 90 days in patients with LVO undergoing MT.
Balloon Angioplasty Combined with Tirofiban as a First-Line Rescue Treatment After Failed Mechanical Thrombectomy for Middle Cerebral Artery Occlusion with Underlying Atherosclerosis
2022, World Neurosurgery
The standard rescue modality for patients with intracranial atherosclerotic stenosis after failed mechanical thrombectomy (MT) is not well established. We evaluated the safety and efficacy of balloon dilation in combination with tirofiban as the first-line salvage therapy when MT failed in these patients.
We retrospectively analyzed the records of 47 patients admitted between January 2018 and June 2021, with middle cerebral artery atherosclerotic occlusion, who underwent balloon angioplasty in combination with tirofiban as the first-line salvage therapy after the failure of MT. The recanalization outcome, procedure-related complications, symptomatic intracranial hemorrhage, and functional outcome at 90 days were reviewed.
Recanalization with a modified Thrombolysis in Cerebral Infarction grade of 2b-3 was achieved in 41 (87.2%) of the 47 patients. Acute stents were deployed in another 6 patients who did not achieve successful re-perfusion after balloon angioplasty. Successful recanalization was achieved in 3 of them. One patient (2.1%, 1/47) experienced re-occlusion several days later due to the withdrawal of antiplatelet therapy for parenchymal hematoma. Seven patients (14.9%, 7/47) underwent stent angioplasty in the stable stage (range: 1–2 months) because severe residual stenosis was detected on follow-up imaging. There was only one event of periprocedural complication, namely ectopic migration of emboli. The good functional outcome rate was 55.3% (26/47), without the events of symptomatic intracranial hemorrhage and mortality.
Balloon angioplasty in combination with tirofiban is safe and effective for middle cerebral artery atherosclerotic occlusion after the failure of MT.
Efficacy and safety of tirofiban injection with intracranial stenting in early reocclusion due to intracranial atherosclerosis
2022, Interdisciplinary Neurosurgery: Advanced Techniques and Case Management
We aimed to develop an optimal protocol for failed mechanical thrombectomy (MT) in cases of emergent large vessel occlusion (ELVO) with intracranial atherosclerosis (ICAS).
A total of 117 patients without underlying heart disease who were not taking antiplatelet drugs had early reocclusion during MT for ELVO due to ICAS. They were divided into the following 3 groups according to rescue treatment methods: 1) Combined intravenous (IV) + intra-arterial (IA) tirofiban group (n = 48), emergent percutaneous transluminal angioplasty (PTA) and intracranial stenting (ICS) followed by IA injection of tirofiban and a continuous IV tirofiban infusion for 8 h; 2) IA tirofiban group (n = 33), only IA 0.5–1.0 mg tirofiban infusion for 5 min regardless of PTA or ICS; and 3) no tirofiban group (n = 36), no tirofiban injection regardless of PTA or ICS.
ICS was more frequently performed in the combined IV + IA tirofiban group than in the IA tirofiban group (100% vs 46%, p < 0.05). The proportion of m-TICI grades 2b and 3 (93.8% vs. 63.6%, p < 0.05), especially the proportion of m-TICI grade 3 (81.3% vs. 36.4%, p < 0.05), was higher in the combined IV + IA tirofiban group than in the IA tirofiban group. The rate of postoperative intracranial hemorrhage was not significantly different among the three groups. The rate of modified Rankin scale scores of 0–2 at 3 months after MT was highest in the combined IV + IA tirofiban group (63%), followed by the IA tirofiban (46%) and no tirofiban groups (8%, p < 0.05).
ICS with IA and continuous IV tirofiban injections for 8 h is an effective and safe protocol for failed MT in patients with ELVO with ICAS.
Efficacy and safety of rescue angioplasty and/or stenting for acute large artery occlusion with underlying intracranial atherosclerosis: A systematic review and meta-analysis
2021, Clinical Neurology and Neurosurgery
Intracranial angioplasty and/or stenting implantation is an important rescue treatment for the management of intracranial atherosclerosis-related occlusion (ICAS-O) after mechanical thrombectomy failure, but its safety and efficacy remain unclear. We investigated the safety and efficacy of rescue intracranial angioplasty and/or stenting for emergent large artery occlusion (LAO) with underlying ICAS.
We searched for relevant full-text articles in EMBASE, PubMed and the Cochrane Central Register of Controlled Trials from inception to March 1, 2020. We calculated the odds ratios (ORs) using random-effects models for symptomatic intracranial hemorrhage (sICH), mortality, recanalization rate and favorable clinical outcome at 90 days between ICAS-O group treated by rescue therapy and Non ICAS-O group. RStudio software 1.3.959 was used to perform this meta-analysis.
Ten studies were included with a total of 1639 patients, of which 450 (27.5 %) were in the ICAS-O group treated with intracranial angioplasty and/or stenting, and 1189 (72.5 %) were in the Non ICAS-O group. Overall, intracranial angioplasty and/or stenting did not improve the recanalization rate (OR, 0.67 [0.26–1.76]; p = 0.419) or favorable functional outcome (OR, 1.01 [0.64–1.58]; p = 0.97) in patients with underlying ICAS-O, and the risk of sICH (OR, 0.99 [0.59–1.68]; p = 0.983) and mortality (OR, 1.26 [0.87–1.83]; p = 0.225) did not significantly differ between ICAS-O and Non ICAS-O.
From these observational study results, rescue intracranial angioplasty and/or stenting seems safe in patients with emergent LAO after attempted thrombectomy, but further rigorous studies are warranted to confirm its efficacy.
Stenting of Mobile Calcified Emboli After Failed Thrombectomy in Acute Ischemic Stroke: Case Report and Literature Review
2020, World Neurosurgery
Mobile calcified emboli are a rare cause of large vessel occlusion and acute ischemic stroke and pose unique challenges to standard mechanical thrombectomy techniques. Intracranial stenting has been reported as a rescue maneuver in cases of failed mechanical thrombectomy owing to dissection or calcified atherosclerotic plaques, but its use for calcified emboli is not well described.
We present 2 cases of acute ischemic stroke caused by mobile calcified emboli. Standard mechanical thrombectomy techniques using aspiration catheters and stent-retrievers failed to remove these emboli, so intracranial stenting was successfully performed in each case, albeit after overcoming unique challenges associated with the stenting of calcified emboli. We also review the literature on intracranial stenting as a salvage therapy for failed mechanical thrombectomy.
Mobile calcified emboli are rare causes of acute ischemic stroke. Intracranial stenting can be used to successfully treat calcified emboli when mechanical thrombectomy has failed.
Rescue Intracranial Stenting After Failed Mechanical Thrombectomy for Acute Ischemic Stroke: A Systematic Review and Meta-Analysis
2019, World Neurosurgery
Citation Excerpt :
Cornelissen et al.27 had no predetermined number of failed MT attempts, whereas Yoon et al.20 and Kim et al.24 required intra-arterial vasodilator delivery with persistent stenosis at 3–5 minutes prior to stenting. Interestingly, Baracchini et al.26 considered lesions appropriate for stenting when they were associated with calcified plaque or where lesions were deemed too distal for safe attempts at multiple MT passes because of a high risk of endothelial damage, dissection, or perforation. Overall, patients were older adults with a mean age of 66.6 years.
Up to 20% of patients fail to achieve reperfusion with modified Thrombolysis in Cerebral Infarction (mTICI) scores of 0–1 after mechanical thrombectomy (MT). Furthermore, underlying intracranial atherosclerotic disease, particularly when associated with >70% residual or flow limiting stenosis, is associated with higher rates of failed MT and high failure risk MT. The aim of this study was to systematically review the procedural and clinical outcomes in patients with failed MT and high failure risk MT. We also explored differences between patients receiving acute rescue stenting compared with medical management alone.
A systematic literature search was conducted in Ovid MEDLINE, PubMed, Embase, and Cochrane online scientific publication databases for English language publications from their date of inception until October 2018. Studies including adult patients with acute ischemic stroke because of emergent large vessel occlusion with failed (mTICI score 0–1) or high failure risk MT within the anterior circulation who underwent rescue stenting were included. A systematic review and meta-analysis of proportions was performed.
Rescue intracranial stenting after failed MT or high failure risk MT results in improved clinical outcomes compared with patients without stenting (48.5% vs. 19.7%, respectively; P < 0.001), without an increase in the rate of symptomatic intracranial hemorrhage, despite additional use of antiplatelet agents (9.7% vs. 14.1%, respectively; P = 0.04).
In patients who fail initial attempts at MT or are high risk for acute reocclusion, rescue intracranial stenting could be considered with the aim to improve functional outcomes. Antiplatelet agents do not increase the risk of hemorrhage in these patients.

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: Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Original ArticleStentriever Thrombectomy Failure: A Challenge in Stroke Management

Background and Objective

Methods

Results

Conclusions

Introduction

Section snippets

General Study Protocol

Results

Discussion

Conclusions

J Am Coll Cardiol

Lancet

Lancet

Clin Neurol Neurosurg

Mechanical thrombectomy in acute ischemic stroke: Consensus statement by ESO-Karolinska Stroke Update 2014/2015, supported by ESO, ESMINT, ESNR and EAN

Int J Stroke

Safety and efficacy of Solitaire stent thrombectomy: individual patient data metaanalysis of randomized trials

Stroke

Predictors of good clinical outcomes, mortality, and successful revascularization in patients with acute ischemic stroke undergoing thrombectomy: pooled analysis of the Mechanical Embolus Removal in Cerebral Ischemia (MERCI) and Multi MERCI

Trials Stroke

Endovascular stroke therapy: tirofiban is associated with risk of fatal intracerebral hemorrhage and poor outcome

Stroke

Letter by Schlachetzki et al regarding article, “endovascular stroke therapy: tirofiban is associated with risk of fatal intracerebral hemorrhage and poor outcome”

Stroke

Immunohistochemical analysis of thrombi retrieved during treatment of acute ischemic stroke: does stent-retriever cause intimal damage?

Stroke

Self-expandable stents in the treatment of acute ischemic stroke refractory to current thrombectomy devices

Stroke

Primary stenting for acute ischemic stroke using the Enterprise intracranial stent: 2-year results of a phase-1 trial

J Vasc Interv Neurol

Original Article
Stentriever Thrombectomy Failure: A Challenge in Stroke Management