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1
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DiLosa K, Wolinsky R, Harding J, Patibandla A, Maximus S, MacCallum K, Siada S, Kwong M. A Multicenter Evaluation of Clopidogrel Resistance and Its Role in Predicting Stent Thrombosis in Transcarotid Artery Revascularization. Ann Vasc Surg 2025; 110:226-232. [PMID: 39341559 DOI: 10.1016/j.avsg.2024.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 08/02/2024] [Accepted: 09/15/2024] [Indexed: 10/01/2024]
Abstract
BACKGROUND Clopidogrel resistance testing is not routine prior to transcarotid artery revascularization (TCAR) and resistance rates are not well described in this setting despite frequent use of periprocedural clopidogrel. We compared 2 resistance testing modalities to determine the relationship between resistance and stent outcomes. METHODS Consecutive patients undergoing TCAR at 3 institutions were retrospectively identified. Clopidogrel-resistance testing results and outcomes were described. RESULTS A total of 210 patients underwent TCAR from 2018-2022. One hundred fifty four (73%) were on dual antiplatelet therapy (DAPT) for at least 7 days prior to TCAR. Twenty-nine patients were not on DAPT due to therapeutic anticoagulation and most (38/56, 68%) received a loading dose of a second antiplatelet the day of surgery. Twenty-five patients (11.9%) experienced stent thrombosis within 30 days. Patients not on DAPT for at least 7 days prior to surgery were more prone to stent thrombosis (16.7% vs. 10.4%, P = 0.164). More than half (133/210, 63%) of patients underwent resistance testing, 25 with thromboelastography with platelet mapping (TEG-PM), 103 with VerifyNow P2Y12 platelet reactivity assay, and 5 with both. Prevalence of Clopidogrel resistance among tested patients was 41%. In patients tested using both TEG-PM and VerifyNow, agreement was poor (Cohen's Kappa -0.05). Among patients with resistance, 12 (22%) experienced stent thrombosis. Comparatively, 8 (10%) patients without resistance developed thrombosis (P = 0.021). VerifyNow P2Y12 platelet reactivity assay correctly predicted Clopidogrel resistance more accurately than TEG-PM (70% vs. 40%, P = 0.025) and had sensitivity of 56% and specificity of 73% for stent thrombosis. CONCLUSIONS Our multi-institutional cohort confirms a high rate of Clopidogrel resistance in patients undergoing TCAR, with higher acute stent thrombosis rates noted in patients with resistance. VerifyNow P2Y12 platelet reactivity assays more reliably predict Clopidogrel resistance than TEG-PM.
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Affiliation(s)
- Kathryn DiLosa
- Department of Surgery, University of California, Davis Health, Sacramento, CA.
| | | | - Joel Harding
- Department of Surgery, University of California, Davis Health, Sacramento, CA
| | - Anjani Patibandla
- Department of Surgery, University of California, Davis Health, Sacramento, CA
| | - Steven Maximus
- Department of Surgery, University of California, Davis Health, Sacramento, CA
| | - Katherine MacCallum
- Division of Vascular & Endovascular Surgery, Brown University, Providence, RI
| | - Sammy Siada
- UCSF Fresno, Division of Vascular Surgery, Fresno, CA
| | - Mimmie Kwong
- Department of Surgery, University of California, Davis Health, Sacramento, CA
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2
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Liu T, Chen L, Deng S, He J, Li D, Chen Y. Subacute in-stent thrombosis after carotid artery stenting in a patient with gene polymorphisms associated with aspirin and clopidogrel resistance: a case report. Thromb J 2024; 22:86. [PMID: 39363335 PMCID: PMC11451114 DOI: 10.1186/s12959-024-00660-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Accepted: 09/29/2024] [Indexed: 10/05/2024] Open
Abstract
BACKGROUND Carotid artery stenting (CAS) is a key treatment option for moderate to severe carotid artery stenosis. Carotid stent thrombosis (CST), a rare complication of CAS, has gained significant attention because of its catastrophic nature. More evidences are needed to guide the diagnosis and treatment of CST. CASE PRESENTATION This study reports a rare case of sub-acute CST following CAS in a 50-year-old male patient who had experienced repeated cerebrovascular events on the premise of taking antiplatelet drugs. He also suffered an occlusion of the left middle cerebral artery (MCA) in the M2 segment, likely caused by an embolus detached from the stent thrombus. The cause of CST in this patient was presumed to be dual antiplatelet resistance (AR), as indicated by genetic testing. After treated with guide catheter-directed thrombolysis, thrombus aspiration, and a second round of thrombolysis, his in-stent thrombus was basically cleared. His M2 occlusion was resolved by mechanical thrombectomy using the Solitaire FR/Stent with Intermediate Catheter Assisting technique. The patient recovered well after replacement of antiplatelet drugs, and no new thromboembolic event occurred during the 13-month follow-up period. CONCLUSIONS The occurrence rate of AR-related CST may be underestimated as the cause of majority CST cases remains unclear. Implementation of genetic test for aspirin and clopidogrel resistance may be helpful to find the possible cause of CST and to avoid future repeated cerebrovascular events by replacement of antiplatelet drugs.
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Affiliation(s)
- Tianzhu Liu
- Neurological Disease Center, Zigong Fourth People's Hospital, Zigong, 643000, Sichuan, China.
- Department of neurology, Traditional Chinese Medicine Hospital of Gaoxian, Yibin, 645154, Sichuan, China.
- , 19 Tanmulin street, Ziliujing district, Zigong, Sichuan, China.
| | - Li Chen
- Department of neurology, Affiliated Hospital of Traditional Chinese Medicine of Southwest Medical University, Luzhou, 646000, Sichuan, China
| | - Shiyu Deng
- Department of neurology, Affiliated Hospital of Traditional Chinese Medicine of Southwest Medical University, Luzhou, 646000, Sichuan, China
| | - Jie He
- Department of neurology, Traditional Chinese Medicine Hospital of Gaoxian, Yibin, 645154, Sichuan, China
| | - Dekang Li
- Department of neurology, Traditional Chinese Medicine Hospital of Gaoxian, Yibin, 645154, Sichuan, China
| | - Yunbo Chen
- Neurological Disease Center, Zigong Fourth People's Hospital, Zigong, 643000, Sichuan, China
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3
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Fan YM, Liu HY, Xue YY. Mechanical thrombectomy for symptomatic stent thrombosis after carotid artery stenting. Front Neurol 2023; 14:1277366. [PMID: 38020615 PMCID: PMC10663350 DOI: 10.3389/fneur.2023.1277366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023] Open
Abstract
Background As there is still no consensus on the treatment of carotid stent thrombosis (CST), we would like to describe our experience with the revascularization of CST by mechanical thrombectomy. Methods We retrospectively studied patients who underwent mechanical thrombectomy after CST at Xuzhou Municipal First People's Hospital and Xuzhou Central Hospital between January 2020 and November 2022. The results of the procedures, complications, and clinical and imaging follow-up were recorded. Results A total of six patients were included in this study. The stenosis grade before stent implantation was ≥85% in all patients, and the stenosis length ranged from 7 to 20 mm. Patients experienced CST within 6 days to 45 months after carotid artery stenting (CAS); the median admission on the National Institutes of Health Stroke Scale (NIHSS) at CST was 12 (range 8-25). Mechanical thrombectomy was successfully performed in all patients. There was no periprocedural death, and the modified Rankin Scale (mRS) at the 3-month follow-up was 0-2. All patients showed recovery from their neurological deficits. Conclusion The treatment of symptomatic CST with mechanical thrombectomy resulted in satisfactory clinical outcomes. This regimen could be effective and safe, and future prospective and randomized studies are warranted.
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Affiliation(s)
- You-Min Fan
- Department of Neurology, Xuzhou Municipal First People’s Hospital, Xuzhou, China
| | - Han-Yang Liu
- Department of Interventional Radiology, Xuzhou Central Hospital, Xuzhou, China
| | - Yu-Yang Xue
- Department of Interventional Radiology, Xuzhou Municipal First People’s Hospital, Xuzhou, China
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4
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Wang H, Xu L, Qin Y, Xiao G. Revascularization of acute stent thrombosis caused by diarrhea after carotid artery stenting in an intermediate clopidogrel metabolizer. BMC Neurol 2023; 23:260. [PMID: 37415135 DOI: 10.1186/s12883-023-03293-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 06/19/2023] [Indexed: 07/08/2023] Open
Abstract
Carotid artery stenting (CAS) is an alternative treatment to carotid endarterectomy for carotid artery stenosis. Acute stent thrombosis (ACST) is an extremely rare complication but can have devastating consequences. Although many cases have been reported, the best treatment is still uncertain. In this study, we report the treatment of ACST caused by diarrhea in an intermediate clopidogrel metabolizer. We also review the literature and discuss appropriate treatment strategies for this rare event.
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Affiliation(s)
- Huaishun Wang
- Second Affiliated Hospital of Soochow University, Suzhou, 215004, China
| | - Longdong Xu
- fifth People's Hospital of Changshu, Suzhou, 215004, China
| | - Yan Qin
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, Second Affiliated Hospital of Soochow University, No. 1055 Sanxiang Road, Suzhou, 215004, China.
| | - Guodong Xiao
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, Second Affiliated Hospital of Soochow University, No. 1055 Sanxiang Road, Suzhou, 215004, China.
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5
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Zhang JB, Fan XQ, Chen J, Liu P, Ye ZD. Acute carotid stent thrombosis: A case report and literature review. World J Clin Cases 2022; 10:9310-9317. [PMID: 36159434 PMCID: PMC9477654 DOI: 10.12998/wjcc.v10.i26.9310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 11/10/2021] [Accepted: 08/05/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Acute carotid stent thrombosis (ACST) is a rare but devastating complication in the carotid artery stenting (CAS) procedure. The aim of this article is to report a case and review cases of ACST reported in the literature, and investigate risk factors and management strategies for ACST.
CASE SUMMARY We reviewed the treatment process of a patient with ACST after CAS. Then multiple databases were systematically searched to identify studies reporting ACST from 2005 to 2020. The demographic data, risk factors, treatment strategies, and prognosis were extracted and analyzed.
CONCLUSION The reason for ACST is multifactorial. Proper patient selection, normative anti-platelet treatment, and perfect technical detail may decrease the incidence of ACST. Several treatment strategies such as thrombolysis, mechanical thrombectomy, and open surgery may be options for the treatment of ACST. Limited data have shown that carotid endarterectomy is effective with favorable results.
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Affiliation(s)
- Jian-Bin Zhang
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Xue-Qiang Fan
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Jie Chen
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Peng Liu
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Zhi-Dong Ye
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing 100029, China
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6
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Wei W, Wang Y, Wang P, Li Z. Revascularization of acute stent thrombosis after carotid artery stenting in a CYP2C19*2 heterozygote patient. J Int Med Res 2021; 49:3000605211001191. [PMID: 33745326 PMCID: PMC7989125 DOI: 10.1177/03000605211001191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Carotid artery stenting (CAS) is an alternative strategy to carotid endarterectomy for the prevention of ischemic stroke. Acute carotid stent thrombosis (ACST) is an extremely rare but devastating complication of CAS. Although cases of successful recanalization have been reported, there is still a lack of experience regarding the choice of ACST treatment methods and the timing of such treatments, especially when patients are confirmed CYP2C19*2 heterozygotes. Here, we report a case of successful revascularization after ACST in a patient with CYP2C19*2 heterozygosity. We also review the literature and discuss appropriate treatment strategies for this devastating and rare event.
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Affiliation(s)
- Wei Wei
- Department of Emergency, Chengdu Second People's Hospital, Chengdu, China
| | - Yan Wang
- Department of Neurology, Chengdu Fifth People's Hospital, Chengdu, China
| | - Pian Wang
- Department of Neurology, Chengdu Fifth People's Hospital, Chengdu, China
| | - Zheng Li
- Department of Neurology, Chengdu Fifth People's Hospital, Chengdu, China
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7
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Murray NM, Wolman DN, Marks M, Dodd R, Do HM, Lee JT, Heit JJ. Endovascular Treatment of Acute Carotid Stent Occlusion: Aspiration Thrombectomy and Angioplasty. Cureus 2020; 12:e7997. [PMID: 32523851 PMCID: PMC7274505 DOI: 10.7759/cureus.7997] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Introduction Acute carotid stent occlusion (CSO) is a rare complication of endovascular carotid stent placement that requires emergent intervention. We describe angioplasty or combined angioplasty and aspiration thrombectomy as a new endovascular technique for CSO treatment. The technique is compared to others previously described in the literature. Methods We performed a retrospective cohort study of all patients who underwent endovascular treatment (ET) of acute symptomatic CSO from January 2008 to March 2018 at our neurovascular referral center. Patient demographics, endovascular treatment details, and outcome data were determined from the electronic medical record. Primary outcome was successful stent recanalization and cerebral reperfusion (modified thrombolysis in cerebral infarction (mTICI) score IIB-III). Secondary outcomes were National Institutes of Health Stroke Scale (NIHSS) shift from presentation to discharge, mortality, and modified Rankin Scale (mRS) score at 3 months. Additionally, a literature review (years 2008-2019) was performed to characterize other techniques for ET of CSO. Results Four patients who underwent ET of acute CSO were identified. ET treatment by angioplasty (n = 1) or combined aspiration thrombectomy and angioplasty (n = 3) resulted in carotid stent recanalization in all patients. Tandem intracranial occlusions were present in three patients (75%), and successful cerebral reperfusion was achieved in all patients. Patient symptoms improved (mean NIHSS shift -5.3 ± 7.2 at discharge). One patient died of a symptomatic reperfusion hemorrhage and another died of cardiac complications by 3-month follow-up. The mRS scores of the surviving patients were 1 and 3. Previously described studies (n = 14) using different and varied techniques had moderate recanalization rates and outcomes. Conclusion Combined aspiration thrombectomy and angioplasty for the neurointerventional treatment of acute CSO leads to high rates of stent recanalization and cerebral reperfusion. The recanalization rate here is improved compared to previously reported techniques. Further multicenter studies are required to risk-stratify patients for specific ET interventions.
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Affiliation(s)
| | | | | | - Robert Dodd
- Neurosurgery/ Cerebrovascular and Skull Base Surgery, Stanford University Medical Center, Palo Alto, USA
| | - Huy M Do
- Radiology, Stanford University School of Medicine, Stanford, USA
| | - Jason T Lee
- Vascular Surgery, Stanford University, Stanford, USA
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8
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Coelho AP, Lobo M, Nogueira C, Gouveia R, Campos J, Augusto R, Coelho N, Semião AC, Canedo A. Overview of evidence on risk factors and early management of acute carotid stent thrombosis during the last two decades. J Vasc Surg 2019; 69:952-964. [PMID: 30798846 DOI: 10.1016/j.jvs.2018.09.053] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 09/20/2018] [Indexed: 10/27/2022]
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9
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Moulakakis KG, Kakisis J, Tsivgoulis G, Zymvragoudakis V, Spiliopoulos S, Lazaris A, Sfyroeras GS, Mylonas SN, Vasdekis SN, Geroulakos G, Brountzos EN. Acute Early Carotid Stent Thrombosis: A Case Series. Ann Vasc Surg 2017; 45:69-78. [PMID: 28483628 DOI: 10.1016/j.avsg.2017.04.039] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 04/06/2017] [Accepted: 04/07/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Acute early carotid stent thrombosis (AcuteCST) is a rare complication after carotid artery stenting (CAS). The purpose of this retrospective study was to investigate the incidence, causes, and optimal management of AcuteCST. METHODS Medical records of all patients undergoing CAS between 2008 and 2016 were retrospectively reviewed. The time of thrombosis, grade of stenosis, lesion side, preprocedural and postprocedural anticoagulants, causes, symptoms, treatment, recanalization, and outcome were reviewed. RESULTS Overall, 674 patients were treated with CAS. Four cases of AcuteCST were identified (0.59%). In the first patient, the stent thrombosis was attributed to dissection caused by filter deployment within a distal internal carotid artery with 360° coiling. Notably, in 3 of the 4 cases of thrombosis a second overlapping stent had been deployed. In total, 41 patients of the cohort under investigation underwent overlapping stent deployment. The use of a second overlapping stent as a bail-out procedure due to dissection or malposition or due to long lesions was correlated with increased rate of thrombosis (3/41 [7.3%] vs. 1/633 [0.002%]). In 2 patients, carotid stents were thrombosed within 2 hr of the procedure. Endovascular thrombus aspiration and subsequent eversion carotid endarterectomy with stent explantation in the first patient and intrathrombus urokinase administration with thromboaspiration and additional stent placement in the second patient were followed. In the other 2 patients having their carotid stents thrombosed 3 and 4 days after the procedure, treatment with low weight molecular heparin and antiplatelet regimens was followed. CONCLUSIONS The use of overlapping stents in the carotid artery is a predisposing factor for AcuteCST. Prognostic factors of this potentially devastating complication are the initial clinical presentation expressing the grade of ischemic brain damage, the accurate and timely recognition of the thrombosis, and the prompt restoration of oxygenated blood flow into the viable tissue at risk of infarction.
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Affiliation(s)
- Konstantinos G Moulakakis
- Department of Vascular Surgery, School of Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece.
| | - John Kakisis
- Department of Vascular Surgery, School of Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Georgios Tsivgoulis
- Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Vasilis Zymvragoudakis
- Department of Vascular Surgery, School of Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Stavros Spiliopoulos
- Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Andreas Lazaris
- Department of Vascular Surgery, School of Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Giorgos S Sfyroeras
- Department of Vascular Surgery, School of Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Spyridon N Mylonas
- Department of Vascular Surgery, School of Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Spyridon N Vasdekis
- Department of Vascular Surgery, School of Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - George Geroulakos
- Department of Vascular Surgery, School of Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Elias N Brountzos
- Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
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10
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Moulakakis KG, Mylonas SN, Lazaris A, Tsivgoulis G, Kakisis J, Sfyroeras GS, Antonopoulos CN, Brountzos EN, Vasdekis SN. Acute Carotid Stent Thrombosis. Vasc Endovascular Surg 2016; 50:511-521. [DOI: 10.1177/1538574416665986] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Acute carotid stent thrombosis (ACST) is a rare complication that can lead to dramatic and catastrophic consequences. A rapid diagnosis and prompt recanalization of the internal carotid artery are needed to minimize the ischemic insult and the reperfusion injury. We reviewed the current literature on this devastating complication of CAS with the intention of investigating the potential causative factors and to define the appropriate management. According to our study discontinuation of antiplatelet therapy, resistance to antiplatelet agents and inherent or acquired thrombotic disorders are the main causes of thrombosis. Technical intraprocedural parameters such as dissection, atheroma prolapse, kinking of the distal part of internal carotid artery and embolic protection device occlusion can also result in early carotid stent thrombosis. Rapid reperfusion ensures an improved neurological outcome and a better prognosis in the short and long term. Thrombolysis, mechanical thrombectomy or thromboaspiration in combination with drug or thrombolytic therapy, surgical therapy and re-angioplasty are treatment options that have been used with encouraging results. In conclusion, optimal perioperative antiplatelet treatment as well as technical considerations regarding the carotid artery stenting plays a determinant role.
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Affiliation(s)
- Konstantinos G. Moulakakis
- Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece
| | - Spyridon N. Mylonas
- Vascular Unit, 2nd Clinic of Surgery, Aretaieion Hospital, Medical School, University of Athens, Athens, Greece
| | - Andreas Lazaris
- Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece
| | - Georgios Tsivgoulis
- Department of Neurology, Athens University Medical School, Attikon University Hospital, Athens, Greece
| | - John Kakisis
- Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece
| | - Giorgos S. Sfyroeras
- Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece
| | - Constantine N. Antonopoulos
- Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece
| | - Elias N. Brountzos
- Department of Radiology, Athens University Medical School, Attikon University Hospital, Athens, Greece
| | - Spyridon N. Vasdekis
- Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece
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Eom YI, Hwang YH, Hong JM, Choi JW, Lim YC, Kang DH, Kim YW, Kim YS, Kim SY, Lee JS. Forced arterial suction thrombectomy with the penumbra reperfusion catheter in acute basilar artery occlusion: a retrospective comparison study in 2 Korean university hospitals. AJNR Am J Neuroradiol 2014; 35:2354-9. [PMID: 25034774 DOI: 10.3174/ajnr.a4045] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE A performance of forced arterial suction thrombectomy was not reported for the treatment of acute basilar artery occlusion. This study compared revascularization performance between intra-arterial fibrinolytic treatment and forced arterial suction thrombectomy with a Penumbra reperfusion catheter in patients with acute basilar artery occlusion. MATERIALS AND METHODS Fifty-seven patients with acute basilar artery occlusion were treated with intra-arterial fibrinolysis (n = 25) or forced arterial suction thrombectomy (n = 32). Baseline characteristics, successful revascularization rate, and clinical outcomes were compared between the groups. RESULTS Baseline characteristics, the frequency of patients receiving intravenous recombinant tissue plasminogen activator, and mean time interval between symptom onset and femoral puncture did not differ between groups. The forced arterial suction thrombectomy group had a shorter procedure duration (75.5 minutes versus 113.3 minutes, P = .016) and higher successful revascularization rate (88% versus 60%, P = .017) than the fibrinolysis group. Fair outcome, indicated by a modified Rankin Scale 0-3, at 3 months was achieved in 34% of patients undergoing forced arterial suction thrombectomy and 8% of patients undergoing fibrinolysis (P = .019), and the mortality rate was significantly higher in the fibrinolysis group (25% versus 68%, P = .001). Multiple logistic regression analysis identified the forced arterial suction thrombectomy method as an independent predictor of fair outcome with adjustment for age, sex, initial NIHSS score, and the use of intravenous recombinant tissue plasminogen activator (odds ratio, 7.768; 95% CI, 1.246-48.416; P = .028). CONCLUSIONS In acute basilar artery occlusion, forced arterial suction thrombectomy demonstrated a higher revascularization rate and improved clinical outcome compared with traditional intra-arterial fibrinolysis. Further clinical trials with the newer Penumbra catheter are warranted.
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Affiliation(s)
- Y-I Eom
- From the Departments of Neurology (Y.-I.E., J.M.H., J.S.L.)
| | - Y-H Hwang
- Departments of Neurology (Y.-H.H., Y.-W.K.)
| | - J M Hong
- From the Departments of Neurology (Y.-I.E., J.M.H., J.S.L.)
| | - J W Choi
- Radiology (J.W.C., S.Y.K.), Ajou University Medical Center, Suwon, South Korea
| | - Y C Lim
- Department of Neurosurgery (Y.C.L.), Ajou University Hospital, Daegu, South Korea
| | - D-H Kang
- Neurosurgery (D.-H.K.) Radiology (D.-H.K., Y.-W.K., Y.-S.K.), Kyungpook National University Hospital, Daegu, South Korea
| | - Y-W Kim
- Departments of Neurology (Y.-H.H., Y.-W.K.) Radiology (D.-H.K., Y.-W.K., Y.-S.K.), Kyungpook National University Hospital, Daegu, South Korea
| | - Y-S Kim
- Radiology (D.-H.K., Y.-W.K., Y.-S.K.), Kyungpook National University Hospital, Daegu, South Korea
| | - S Y Kim
- Radiology (J.W.C., S.Y.K.), Ajou University Medical Center, Suwon, South Korea
| | - J S Lee
- From the Departments of Neurology (Y.-I.E., J.M.H., J.S.L.)
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12
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Morr S, Lin N, Siddiqui AH. Carotid artery stenting: current and emerging options. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2014; 7:343-55. [PMID: 25349483 PMCID: PMC4208632 DOI: 10.2147/mder.s46044] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Carotid artery stenting technologies are rapidly evolving. Options for endovascular surgeons and interventionists who treat occlusive carotid disease continue to expand. We here present an update and overview of carotid stenting devices. Evidence supporting carotid stenting includes randomized controlled trials that compare endovascular stenting to open surgical endarterectomy. Carotid technologies addressed include the carotid stents themselves as well as adjunct neuroprotective devices. Aspects of stent technology include bare-metal versus covered stents, stent tapering, and free-cell area. Drug-eluting and cutting balloon indications are described. Embolization protection options and new direct carotid access strategies are reviewed. Adjunct technologies, such as intravascular ultrasound imaging and risk stratification algorithms, are discussed. Bare-metal and covered stents provide unique advantages and disadvantages. Stent tapering may allow for a more fitted contour to the caliber decrement between the common carotid and internal carotid arteries but also introduces new technical challenges. Studies regarding free-cell area are conflicting with respect to benefits and associated risk; clinical relevance of associated adverse effects associated with either type is unclear. Embolization protection strategies include distal filter protection and flow reversal. Though flow reversal was initially met with some skepticism, it has gained wider acceptance and may provide the advantage of not crossing the carotid lesion before protection is established. New direct carotid access techniques address difficult anatomy and incorporate sophisticated flow-reversal embolization protection techniques. Carotid stenting is a new and exciting field with rapidly advancing technologies. Embolization protection, low-risk deployment, and lesion assessment and stratification are active areas of research. Ample room remains for further innovations and developments.
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Affiliation(s)
- Simon Morr
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, Buffalo, NY, USA ; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA
| | - Ning Lin
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, Buffalo, NY, USA ; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, Buffalo, NY, USA ; Department of Radiology, School of Medicine and Biomedical Sciences, Buffalo, NY, USA ; Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, NY, USA ; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA ; Jacobs Institute, Buffalo, NY, USA
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