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Advanced Neurology Rescue stenting in mechanical thrombectomy

Balloon angioplasty alone has been proposed as an initial abciximab; however, their usage in the setting of acute
step for severe residual stenosis. 94-99 Chen et al. reported ischemic stroke is considered off-label. 111
successful recanalization in 45 patients with balloon Expert opinion suggests the initial use of dual antiplatelet
angioplasty alone, whereas an additional 16 patients therapy, typically a combination of aspirin and clopidogrel,
required RS. Ni et al. combined balloon angioplasty with for 90 days to minimize the risks of acute stent thrombosis
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tirofiban as a first-line rescue treatment, 87% (n = 41/47) and recurrent strokes. 112,113 However, the optimal duration
and achieved successful recanalization whereas six patients of antiplatelet therapy for RS may fluctuate based on
required stent placement. Nonetheless, some authors individual patient characteristics and clinical discretion.
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suggested that adjunctive balloon angioplasty without Some data suggest a link between subtherapeutic
stenting may cause further intimal injury and increase the antiplatelet assay responses and in-stent thrombosis,
risk of vessel recoiling. 91 and a subset of patients needs closer monitoring. 114-117
The double solitaire stent retriever technique has been It is important to acknowledge that the post-procedure
proposed as an effective strategy for refractory artery administration of antiplatelet therapy may have potential
occlusions that do not respond to initial thrombectomy risks, including intracranial hemorrhage or systemic
attempts. 29,100 The TWIN2WIN randomized trial was bleeding complications. The initiation and maintenance of
stopped early when at interim analysis, preliminary data antiplatelets should be balanced against the risk of recurrent
showed higher rates of first-pass TICI 2c/3 rates in the dual stroke, the risk of hemorrhagic transformation of the index
stent retriever group compared to single stent retriever stroke, and individual patient factors.
group (46.6% vs. 24%, P = 0.015). 101 Periprocedural adjunctive treatment with IV or IA
Furthermore, Y-stent rescue thrombectomy was glycoprotein IIb/IIIa inhibitors may be considered. The
described with two stent retrievers deployed in separate RESCUE BT randomized trial in China examined the use of
branches of the middle cerebral artery, basilar artery, adjunct IV tirofiban versus placebo before thrombectomy
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to improve gripping of the clot, and in one study of in patients with LVO. In the subgroup of patients with
28 patients, had an overall recanalization rate of 85.7% and ICAS (of whom 52% had undergone balloon angioplasty,
good functional outcomes. Maus et al. proposed the dual and 26% received stenting), higher rates of functional
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stent retriever-assisted vacuum-locked extraction (SAVE) independence at 90 days (aOR: 1.68; 95% CI: 1.11 – 2.56,
technique for LVO clot retrieval, which combines a distally P = 0.02) and lower number of passes (median [IQR]
placed stent retriever and a proximally placed aspiration 1 [1 – 2] vs. 1 [1 – 2], P = 0.004) were observed in the
catheter together acting as a unit when the thrombectomy tirofiban group. 99
pass is being conducted. The SAVE technique, with
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simultaneous use of a distal stent retriever and proximal 4. Potential risks and complications
aspiration catheter, has also been found, in a retrospective The potential complications of RS are similar to
study, to successfully retrieve clots in patients with LVOs in complications seen in MT and extracranial cervical
middle cerebral artery bifurcation. 103,104 stenting. sICH is a potential critical complication in RS,
especially in patients with coagulopathy or concomitant
3.4. Adjunct pharmacological therapy
use of anticoagulation. Identification of hemorrhage may
The ideal periprocedural antithrombotic regimen also be a challenge in the post-procedural period due to
remains a topic of ongoing research. 93,105-107 GPI in the frequent concomitant presence of contrast staining,
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conjunction with MT has shown promise in improving which may be further distinguished from hemorrhage
clinical outcomes; however, there is not enough evidence with dual-energy CT or magnetic resonance imaging
to support IA versus IV bolus of GPI, and the optimal techniques in cases of uncertainty. A retrospective
maintenance infusion duration is unknown. 90,91,98,99,108,109 analysis by Yang et al. of patients with ICAS undergoing
A recent meta-analysis examined IA and IV GPI as first- first-line angioplasty and stenting showed lower rates
line rescue treatment after refractory thrombectomy or of asymptomatic ICH (9.1% [3/23] vs. 30.5% [82/269];
in the setting of high-grade stenosis. The GPI group P = 0.01) compared to first-line MT, suggesting stenting
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(n = 535) had higher rates of mRS ≤2 at 90 days (58.5% may not increase bleeding risk. Three meta-analyses have
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vs. 38.9%, P = 0.002) and lower mortality rates (7.8% vs. demonstrated no increased risk of sICH in RS compared to
17.5%, P = 0.04) compared to the non-GPI (n = 228). non-RS. Cai et al. included 1595 patients and demonstrated
Rates of sICH were not significantly different between no increased risk of sICH in RS compared to non-RS (OR
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the groups. GPI medications that are approved for use 0.63, 95% CI 0.39 – 1.04). Maingard et al. found a lower
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in the United States include tirofiban, eptifibatide, and rate of symptomatic ICH in the RS group compared to the
Volume 3 Issue 3 (2024) 6 doi: 10.36922/an.3950