Elsevier

World Neurosurgery

Volume 113, May 2018, Pages e431-e438
World Neurosurgery

Original Article
Another Endovascular Therapy Strategy for Acute Tandem Occlusion: Protect-Expand-Aspiration-Revascularization-Stent (PEARS) Technique

https://doi.org/10.1016/j.wneu.2018.02.052Get rights and content

Highlights

  • The half anterograde approach is feasible and safe in treating tandem occlusion.

  • The PEARS (with use of an embolic protection device) technique is more time-saving.

  • The PEARS technique decreases the likelihood of embolic events.

Objective

Initial stenotic occlusion of the internal carotid artery with intracranial artery occlusion in acute ischemic stroke is associated with high morbidity and can benefit from endovascular therapy. However, the optimal endovascular strategy is unclear. This study aimed to evaluate the feasibility of the “half” anterograde approach and clinical outcome of treated patients. Revascularization validity of the 2 “half” anterograde approach with (Protect-Expand-Aspiration-Revascularization-Stent [PEARS] technique) or without (plain technique) using an embolic prevention device and aspiration was also compared.

Methods

Data on initial stenotic occlusion of the internal carotid artery with intracranial artery occlusion in our prospective stroke registry database between January 2015 and February 2017 were collected. Clinical and angiographic data were retrospectively analyzed. Clinical outcome was evaluated at 3 months, defined as a modified Rankin scale ≤2 as a good clinical outcome.

Results

Overall, 26 patients with tandem occlusion were included; 96.3% of patients had successful recanalization. The rate of a good clinical outcome was 61.8%, symptomatic parenchymal hemorrhage was 7.7%, and mortality was 15.4%. The PEARS technique took less time (56 ± 14 vs. 97 ± 31 minutes; P = 0.002) and had less embolic events (0 vs. 30.8%; P = 0.012) compared with the plain technique. Use of the PEARS technique was an independent predictor for shortening revascularization time (β = −0.651, P = 0.001).

Conclusions

The half anterograde approach technique is feasible and safe for treating tandem occlusion. Furthermore, the PEARS technique is associated with a shorter reperfusion time and less embolic events than the plain technique, and should be recommended in tandem occlusion.

Introduction

A quarter of patients with middle cerebral artery occlusion (MCA) have concomitant internal carotid artery (ICA) occlusion, and up to 50% of patients with ICA occlusion have a proximal MCA occlusion.1 Tandem occlusion lesions have a poor response to intravenous recombinant tissue plasminogen activator. A previous study1 showed that the early recanalization rate (9%) and early neurological improvement rate (25%) were lower in the tandem occlusion group than in the isolated MCAocclusion group.

Endovascular therapy is the standard therapy for acute ischemic stroke that is caused by occlusion of a large intracranial artery.2, 3, 4, 5, 6, 7 The rate of tandem occlusion (TO) ranges from 18.6% to 32.2%8 and can benefit from endovascular therapy,9 but the optimal endovascular strategy is unclear.

Two strategies are commonly adapted in TO. These strategies are the anterograde approach (ICA stenting before thrombectomy) and the retrograde approach (thrombectomy before ICA stenting). Compared with the retrograde approach technique, the clinical outcome with the anterograde approach group9 may take longer to recanalize the occluded intracranial artery. And with the anterograde approach technique, the access to distal occlusion was harder to establish. Therefore, our study present another strategy for TO, which was named the “half” anterograde approach (balloon dilatation followed by thrombectomy, and then ICA initial stenting). Furthermore, revascularization validity of the 2 “half” anterograde approach with (Expand-Aspiration-Revascularization-Stent [PEARS] technique) or without (plain technique) using an embolic prevention device and aspiration was also compared.

Section snippets

Patients

The study was approved by and conducted in accordance with the guideline of our institutional review board. Consecutive patients with acute ischemic stroke of the anterior circulation were identified from our prospective endovascular stroke registry (started in January 2015). Patients were selected based on the following criteria: 1) digital subtraction angiography documentation of stenotic occlusion of the ICA with occlusion of the intracranial artery; 2) National Institutes of Health Stroke

Results

A total of 26 patients with TO were identified among 232 patients from our prospective acute anterior circulation ischemic stroke database who received endovascular therapy. The onset-to-presentation time of 24 patients was within 8 hours, 2 patients surpassed 8 hours. The baseline characteristics were similar between the 2 groups (Table 1). A total of 88.5% patients were men and the mean age was 70 ± 7 years. A total of 69.2% of patients were smokers, 73.1% had hypertension, 4.15% had diabetes

Discussion

The main aim of our study was to present the technique of the half anterograde approach for TO. Previously reported common techniques are the anterograde approach12, 13, 14, 15, 16, 17, 18 and retrograde approach.9, 19 Our technique of the half anterograde approach involved clot retrieval after balloon dilatation of the ICA initial segment. The final step was stenting for the ICA initial, if necessary. There are some advantages to this technique. First, our half anterograde saved more time in

Conclusion

Our case-control series suggests that the half anterograde approach for treatment of TO is technically feasible and safe, and may be associated with an improved clinical outcome. The PEARS technique (using an EPD and aspiration action) is superior to the plain technique (without using an EPD and aspiration action) for decreasing the revascularization time and embolic events. This technique should be considered in cases of acute initial stenotic occlusion of the ICA. However, our findings should

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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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