Page 89 - AN-3-3

Advanced Neurology Rescue stenting in mechanical thrombectomy

MT. RS (n = 107) was associated with a favorable shift in the 3. Patient selection
overall mRS score distribution (adjusted odds ratio [aOR],
3.74 [95% confidence interval (CI), 2.16 – 6.57]; P < 0.001), Proper selection of patients for RS must balance the benefits
higher rates of functional independence at 90 days (34.6% of potential recanalization with the risks of additional
vessel manipulation and subsequent antithrombotic
vs. 6.5%; aOR, 10.91 [95% CI, 4.11 – 28.92]; P < 0.001), and therapy. Appropriate patients for rescue therapy are those
lower 90-day mortality (29.9% vs. 43%; aOR, 0.49 [95% CI, who failed to achieve successful recanalization with initial
0.25 – 0.94]; P = 0.03) with similar rates of sICH (7.5% vs. MT techniques without additional strong indications to
11.2%; aOR, 0.87 [95% CI, 0.31 – 2.42]; P = 0.79]). 28 halt recanalization attempts (e.g., vessel perforation).
The Society of Vascular and Interventional Neurology RS is utilized when successful reperfusion (TICI ≥2b) is
Registry evaluated patients with LVO faced with failed MT not achieved despite MT. In general, a minimum of three
(mTICI 0 – 2a) and who were medically managed (n = 551) passes of MT is attempted before RS. However, if after an
compared to patients who underwent rescue therapy initial successful thrombectomy pass, the artery is seen
with angioplasty or stenting (n = 407). There were more to reocclude, and the lesion is likely related to ICAS, then
favorable outcomes by 90-day mRS shift in RT compared earlier RS or angioplasty may be reasonable to maintain
to failed MT and medically managed patients (odds ratio vessel patency and decrease the risk of endothelial injury
[OR] 1.79, [95% CI 1.32 – 2.45], P < 0.001), as well as lower with additional passes. In patients who are suspected to
rates of sICH in the RT group (3.8% vs. 9.1%, P = 0.04) and have an underlying intracranial atherosclerotic disease and
mortality (33.4% vs. 45.5%, P = 0.009). 69 at risk for reocclusion, we suggest waiting for 10 – 20 min
2.4.2. Posterior circulation after successful MT to ensure that there would not be
reocclusion.
Vertebrobasilar angioplasty and stenting in observational
studies have been demonstrated to be effective RS may be indicated in patients with severe residual
interventions. 70-72 A retrospective study conducted by stenosis (≥70%) and lack of reperfusion (critical stenosis)
Lu et al. evaluating the safety and efficacy of RS in or distal reperfusion or anatomical characteristics
72
vertebrobasilar artery occlusion after refractory MT suggesting a high risk of reocclusion such as in soft plaques
showed a higher rate of 90-day mRS score 0 – 3 (46.6% with moderate stenosis (>50%). However, the prospective
vs. 20.7%; aOR 5.06, 95% CI 1.88 – 13.59, P = 0.001) ANGEL-ACT registry showed a benefit for RS in patients
and a lower rate of 90-day mortality (34.5% vs. 55.2%; with refractory MT but no benefit in patients with residual
74
aOR 0.42, 95% CI 0.23 – 0.90, P = 0.026) in the RS group severe stenosis but with substantial reperfusion.
compared to the non-RS group. The rates of sICH were not Recently, MT time-based selection criteria have been
significantly different between the RS and non-RS groups. replaced with tissue-based selection criteria. 48,75-78 Several
No differences were observed between the self-expanding observational studies have shown that recanalization rates
stent and the balloon-mounted stent (BMS). 72 in the anterior and posterior circulations were similar
regardless of the time to reperfusion (>24 h) from the
In an analysis of the ANGEL-ACT registry, Luo et al. onset of symptoms. 70,79 However, patients with chronic
reported that the RS group, compared to the non-RS occlusions and those with a lack of salvageable tissue are
group with basilar artery occlusion, had favorable clinical unlikely to benefit from RS.
outcomes (16.7% vs. 51.9%, P = 0.023) and a significantly
lower mortality rate (58.3% vs. 18.5%, P = 0.006). While advanced age is not restrictive for RS, it is
26
Furthermore, using a glycoprotein IIb/IIIa inhibitor important to examine the overall health condition of older
improved the recanalization rate without increasing sICH. patients and anticipate their response to the procedure,
especially those associated with a potentially higher risk
2.4.3. Meta-analysis of microbleed burden, higher risk of falls, and the use
A 2023 systematic review and meta-analysis of of anticoagulation for heart arrhythmias. Interestingly,
1595 patients examining RS in both the anterior and diabetes mellitus has been reported as an independent
posterior circulation suggested that RS was safe and predictor of refractory MT, probably contributing to
effective with a pooled recanalization rate of 82% (95% CI underlying ICAS. 20,29
77 – 87%), mRS (0 – 2) at 3 months OR 3.96 (95% CI 2.69 – Following the placement of an intracranial stent, initial
5.84, P < 0.001), and lower 90-day mortality OR 0.46 (95% dual antiplatelet therapy followed by long-term antiplatelet
CI 0.30 – 0.65) compared to no RS sICH was lower in the monotherapy is required. In patients at increased bleeding
RS group but was not statistically significant (OR 0.63, 95% risk or unable to tolerate antiplatelet therapy, RS may not
CI 0.39 – 1.04, P = 0.075). 73 be an appropriate option.

Volume 3 Issue 3 (2024) 4 doi: 10.36922/an.3950