Mechanical Thrombectomy in Tandem Lesion: Effects of Extracranial Carotid Dissection Versus Atherosclerosis
Darko Quispe-Orozco1, Milagros Galecio-Castillo1, Mouhammad Jumaa2, Afshin Divani3, Marc Ribo4, Michael Abraham5, Nils Petersen6, Johanna Fifi7, Waldo Guerrero8, Amer Malik9, James Siegler10, Thanh Nguyen11, Sunil Sheth12, Albert Yoo13, Guillermo Linares14, Nazli Janjua15, Wondwossen Tekle16, Mohamad Abdalkader17, Jazba Soomro13, Juan Vivanco-Suarez1, Aaron Rodriguez-Calienes1, Maxim Mokin18, Dileep Yavagal9, Ameer Hassan16, Santiago Ortega Gutierrez1
1University of Iowa Hospitals and Clinics, 2ProMedica Stroke Network, 3University of New Mexico, 4Hospital vall d'Hebron, 5The University of Kansas Health System, 6Yale University, 7Mount Sinai Hospital, 8University of South Florida College of Medicine, 9University of Miami Miller School of Medicine, 10University of Chicago, 11Boston Medical Center, 12University of Texas At Houston, 13Texas Stroke Institute, 14Saint Louis University, 15Pomona Valley Hospital Medical Center, 16Valley Baptist Medical Center, 17Boston Medical Center Deptartment Of Radiology, 18University of South Florida
Objective:
To investigate the effect of the cervical internal carotid artery (cICA) lesion etiology on patients with acute large vessel occlusions due to tandem lesions (TL-LVO) who undergo endovascular treatment (EVT).
Background:
Tandem lesions account for 10-20% of acute LVOs, and are associated with worse prognosis. Current studies have shown contradictory results when comparing outcomes in patients with atherosclerotic versus dissection of the cICA.
Design/Methods:
In this multi-center retrospective study from 16 Comprehensive Stroke Centers, we included adult patients with acute LVO-TL and underwent EVT. TLs were defined as intracranial(petrous to proximal ACM-M2) occlusion plus cICA steno-occlusive lesions(>70%). The primary outcomes were 90-days mRS 0-2 and successful reperfusion post-procedure(mTICI 2b-3). Secondary outcomes were ordinal shift on 90-days mRS and mTICI, mTICI 2c-3, symptomatic intracranial hemorrhage, any intracranial hemorrhage, early neurological improvement [admission NIHSS - discharge NIHSS >4], distal embolisms during/at the end of the procedure, and in-hospital and 90-days mortality. We used descriptive statistics and Inverse Probability of Treatment Weighting to compare patients with dissection versus those with atherosclerosis of the cICA lesion.
Results:
We included 526 patients. The median[IQR] age was 68[59-76] years, and 31% were females. 59(11.2%) presented dissection and 467(88.8%) atherosclerosis. Patients with dissection were younger (52vs.69 years, p=<0.001), had lower rates of hypertension (52.5vs.74.5%, p=<0.001), hyperlipidemia (27.1%vs.49.2%; p=0.001), and DM (15.3vs.29.8%, p=0.019). Matched analysis showed that patients with dissection had significant lower rates of successful reperfusion (79.7 vs. 89.1%, aOR 0.39, 95%CI 0.16–0.93, p=0.34) compared to patients with atherosclerosis, and greater rates of new distal embolization during the procedure (17.5vs.7.7%, aOR 2.53, 95%CI 1.15-5.55, p=0.21). No differences were observed in other outcomes.
Conclusions:
We found that in patients with acute stroke due to TLs, the etiology of the cervical lesion matters. Patients with dissection had lower odds of successful reperfusion, most likely due to higher rates of new distal embolisms during EVT.