Rescue stenting for acute ischemic stroke with refractory emergent large vessel occlusion in the modern thrombectomy era

Ahmad Sweid; Kalyan C Sajja; Nikolaos Mouchtouris; Joshua H Weinberg; Kavya Shivashankar; Hassan Saad; Rawad Abbas; Kareem El Naamani; Sunidhi Ramesh; Joseph Schaefer; Fadi Al Saiegh; Pascal Jabbour; Nabeel A Herial; Hekmat Zarzour; Stavropoula Tjoumakaris; Victor Romo; Robert H Rosenwasser; M Reid Gooch

doi:10.1016/j.clineuro.2022.107183

Rescue stenting for acute ischemic stroke with refractory emergent large vessel occlusion in the modern thrombectomy era

Clin Neurol Neurosurg. 2022 Apr:215:107183. doi: 10.1016/j.clineuro.2022.107183. Epub 2022 Feb 22.

Authors

Ahmad Sweid¹, Kalyan C Sajja², Nikolaos Mouchtouris³, Joshua H Weinberg⁴, Kavya Shivashankar⁵, Hassan Saad⁶, Rawad Abbas⁷, Kareem El Naamani⁸, Sunidhi Ramesh⁹, Joseph Schaefer¹⁰, Fadi Al Saiegh¹¹, Pascal Jabbour¹², Nabeel A Herial¹³, Hekmat Zarzour¹⁴, Stavropoula Tjoumakaris¹⁵, Victor Romo¹⁶, Robert H Rosenwasser¹⁷, M Reid Gooch¹⁸

Affiliations

¹ Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA. Electronic address: ahmad.sweid@jefferson.edu.
² Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA. Electronic address: kalyan.sajja@jefferson.edu.
³ Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA; Department of Neurosurgery, Emory University, Atlanta, GA, USA; Department of Anesthesia, Thomas Jefferson University, Philadelphia, PA, USA. Electronic address: nikolaos.mouchtouris@jefferson.edu.
⁴ Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA. Electronic address: Joshua.Weinberg@jefferson.edu.
⁵ Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA. Electronic address: Kavya.Shivashankar@jefferson.edu.
⁶ Department of Neurosurgery, Emory University, Atlanta, GA, USA. Electronic address: hassan.saad@emory.edu.
⁷ Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA; Department of Neurosurgery, Emory University, Atlanta, GA, USA; Department of Anesthesia, Thomas Jefferson University, Philadelphia, PA, USA. Electronic address: rawad.abbas@jefferson.edu.
⁸ Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA. Electronic address: kareem.elnaamani@jefferson.edu.
⁹ Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA. Electronic address: sunidhi.ramesh@jefferson.edu.
¹⁰ Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA. Electronic address: joseph.schaefer@students.jefferson.edu.
¹¹ Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA. Electronic address: fadi.al-saiegh@jefferson.edu.
¹² Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA. Electronic address: Pascal.Jabbour@jefferson.edu.
¹³ Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA. Electronic address: nabeel.herial@jefferson.edu.
¹⁴ Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA. Electronic address: Hekmat.Zarzour@jefferson.edu.
¹⁵ Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA. Electronic address: stavropoula.tjoumakaris@jefferson.edu.
¹⁶ Department of Anesthesia, Thomas Jefferson University, Philadelphia, PA, USA. Electronic address: Victor.Romo@jefferson.edu.
¹⁷ Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA. Electronic address: robert.rosenwasser@jefferson.edu.
¹⁸ Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA. Electronic address: Michael.gooch@jefferson.edu.

PMID: 35259678
DOI: 10.1016/j.clineuro.2022.107183

Abstract

Background and purpose: Rescue stenting is used as a bailout technique during mechanical thrombectomy for stroke. We performed a retrospective study analyzing outcomes of patients that received a stent as a bailout measure and compared results to a control group.

Methods: We identified all patients who underwent a mechanical thrombectomy for a large vessel occlusion between January 2010 and October 2019. Subjects with mTICI 0-2 A after at least three passes were defined as failed MT and constituted the control group (NSG-controls). Patients that received a rescue stent (RSG) formed the study group.

Results: Comparative analysis of patient demographics between NSG-controls and SRG was performed. Baseline characteristics and comorbidities were not significantly different between both groups. NIHSS at admission and IV t-PA were not significantly different among both groups (16.5 vs. 14.2, p = 0.19) and (39.4% vs. 29.4%, p = 0.30), respectively. There was no significant difference in procedural and post-procedural complications between both the groups. In the RSG, 24 patients (82.4%) achieved favorable revascularization outcomes. NIHSS at discharge (p = 0.01) was higher in the NSG-controls, while favorable functional outcome at three months (12% vs. 39.2%, p = 0.01) was observed at a higher proportion in the RSG. There was also a significant mortality difference, with 15.2% mortality in the RSG compared to 35.1% mortality in the NSG-controls (p = 0.03). In multivariate analysis, stenting was an independent predictor of favorable outcome (OR: 10.0, p = 0.009).

Conclusion: Herein, we demonstrated that rescue stenting is a feasible, safe, and effective procedure to improve stroke outcomes and should be seriously considered if the primary mechanical thrombectomy is not successful.

Keywords: Angioplasty; Mechanical thrombectomy; Rescue stenting; Stroke.

MeSH terms

Brain Ischemia* / complications
Humans
Ischemic Stroke* / surgery
Retrospective Studies
Stents / adverse effects
Stroke* / etiology
Thrombectomy / methods
Treatment Outcome