Association of Acute Carotid Stenting with Functional Outcome Mediated by Successful Reperfusion in Tandem Lesions: Mediation Analysis of a Multicenter Registry
Aaron Rodriguez-Calienes1, Milagros Galecio-Castillo2, Ameer Hassan3, Mouhammad Jumaa4, Afshin Divani5, Marc Ribo6, Michael Abraham7, Nils Petersen8, Johanna Fifi9, Waldo Guerrero10, Amer Malik12, James Siegler13, Thanh Nguyen14, Sunil Sheth15, Albert Yoo16, Guillermo Linares17, Nazli Janjua18, Darko Quispe-Orozco2, Yujing Lu2, Juan Vivanco-Suarez2, Mahmoud Dibas2, Maxim Mokin11, Dileep Yavagal12, Santiago Ortega-Gutierrez2
1Department of Neurology, University of Iowa Hospitals and Clinics, 2Department of Neurology, University of Iowa Hopitals and Clinics, 3Department of Neurology, Valley Baptist Medical Center, 4Department of Neurology, ProMedica Stroke Network, 5University of New Mexico, 6Department of Neurology, Hospital vall d'Hebron, 7Department of Neurology, The University of Kansas Health System, 8Department of Neurology, Yale University, 9Department of Neurology, Mount Sinai Hospital, 10Department of Neurology and Brain Repair, 11Department of Neurology, University of South Florida, 12Department of Neurology, University of Miami Miller School of Medicine, 13Cooper Neurological Institute, Cooper University Hospital, 14Department of Neurology, Boston Medical Center, 15Department of Neurology, University of Texas At Houston, 16Department of Neurology, Texas Stroke Institute, 17Department of Neurology, Saint Louis University, 18Pomona Valley Hospital Medical Center
Objective:
We aimed to determine whether, and to what degree, successful reperfusion (mTICI 2b-3) mediates the relationship between acute CAS and functional outcome in patients with TLs.
Background:
Current evidence suggests that acute carotid artery stenting (CAS) for cervical lesions is associated with better functional outcomes in patients with acute stroke with tandem lesions (TLs) treated with endovascular treatment (EVT). However, a gap in understanding persists regarding the underlying causal pathophysiological mechanism of this relationship when compared to angioplasty alone.
Design/Methods:
This sub-analysis stems from a multicenter cohort study of patients with anterior circulation TLs who underwent EVT across 16 stroke centers spanning from January 2015 to December 2020. Mediation analysis was conducted to examine the potential causal pathway in which the relationship between acute CAS and favorable functional outcome (90-day mRS 0-2) is mediated by successful reperfusion.
Results:
A total of 570 patients were included, out of whom 354 (62.1%) underwent acute CAS, and 244 (47.4%) had a favorable functional outcome. Successful reperfusion was a predictor of favorable functional outcome (adjusted OR [aOR]: 7.38; 95% CI 3.55 – 17.02; p < 0.001). Successful reperfusion partially mediated the relationship between acute CAS and functional outcome, as acute CAS was still significantly associated with functional outcome after adjustment for successful reperfusion (aOR: 1.52; 95% CI 1.02 – 2.27; p = 0.042). Successful reperfusion explained 75% (95% CI 36-98%) of the relationship between acute CAS and functional outcome.
Conclusions:
In TL patients undergoing EVT, successful reperfusion predicted favorable functional outcome when CAS was performed as compared to angioplasty alone. A significant proportion (75%) of the treatment effect of acute CAS on functional outcome was found to be mediated through the improvement of successful reperfusion rates.