Introduction: Carotid occlusions are responsible for 10-25% of large vessel acute ischemic strokes (AIS). While endovascular therapy (ET) is now standard of care for large vessel AIS, tandem lesions remain a therapeutic challenge. Outcomes of patients with tandem lesions undergoing ET with carotid revascularization remain unknown. We aimed to determine the prevalence, risk factors and outcomes of acute carotid stent closure (ACSC) in AIS patients with tandem lesions undergoing ET.
Methods: Retrospective review of endovascular database of AIS patients treated in a single tertiary care center from 2010-2016. Patients with tandem lesions identified. Baseline demographics, home medications, IV tPA use, procedural characteristics and outcomes collected. Patients grouped according to carotid stent patency. Data analyzed using SPSS. Factors with p < 0.20 included in multivariate model.
Results: Out of 280 AIS patients undergoing ET, a total of 32 patients with tandem lesions identified. ACSC seen in 25% of patients. Baseline demographics similar in two groups. IV tPA use associated with 3 times greater risk of ACSC (12.5% vs 37.5%; p = 0.10). Number of stents (No ACSC 1.13 ± 0.33 vs ACSC 1.75 ± 1.04; p = 0.013) significant in univariate analysis. Baseline mRS, IV tPA use, Number of Stents, Post Stent Angioplasty, Residual ICA stenosis and Poor TICI recanalization grade included in the multivariate model. Number of stents (p = 0.028) and Poor TICI recanalization grade (p = 0.031) reached significance on multivariate linear regression analysis. Patients with ACSC had significantly greater hospitalization days (7.08 ± 3.73 vs 13.5 ± 6.86; p = 0.002), worse discharge mRS (2.17 ± 2.09 vs 4.5 ± 0.75; p = 0.005), worse discharge NIHSS (4.33 ± 4.53 vs 14.71 ± 4.85; p = 0.001), unfavorable disposition (16.67% vs 62.5%; p = 0.023) and worse 90 days mRS (2.0 ± 2.25 vs 4.67 ± 0.82; p = 0.01).
Conclusions: ACSC seen in 25% of AIS with tandem lesions treated with ET. IV tPA use associated with 3 times greater risk of ACSC (37.5% vs 12.5%) presumably due to an inability for antiplatelet loading. Number of stents and poor TICI recanalization grade reached significance on multivariate analysis. ACSC associated with significantly worse outcomes. Larger studies are required to confirm these findings