Mechanical Thrombectomy Versus Combined Thrombectomy and Intravenous Thrombolysis in Tandem Lesions
Aaron Rodriguez-Calienes1, Milagros Galecio-Castillo1, Mudassir Farooqui1, Sunil Sheth3, Albert Yoo4, Afshin Divani5, Nils Petersen6, Michael Abraham7, Johanna Fifi8, Waldo Guerrero9, Amer Malik10, James Siegler11, Thanh Nguyen12, Guillermo Linares13, Nazli Janjua14, Darko Quispe Orozco15, Syed Zaidi16, Jessica Kobsa6, Ayush Prasad17, Asad Ikram18, Cynthia Zevallos1, Manuel Requena19, Marta Olive Gadea20, Abid Qureshi21, Tiffany Barkley22, Stavros Matsuokas23, Mohamad Abdalkader24, Sergio Salazar Marioni24, Jazba Soomro4, Juan Vivanco-Suarez1, Randall Edgell13, Maxim Mokin25, Dileep Yavagal10, Mouhammad Jumaa16, Ameer Hassan26, Santiago Ortega Gutierrez2
1Department of Neurology, 2Department of Neurology, Neurosurgery & Radiology, University of Iowa Hospitals and Clinics, 3University of Texas At Houston, 4Texas Stroke Institute, 5University of New Mexico, 6Yale University, 7The University of Kansas Health System, 8Mount Sinai Hospital, 9University of South Florida College of Medicine, 10University of Miami Miller School of Medicine, 11Cooper University Hospital, 12Boston Medical Center, 13Saint Louis University, 14Pomona Valley Hospital Medical Center, 15TTUHSC-SOM, Lubbock; Neurology Dept., 16ProMedica Stroke Network, 17Yale School of Medicine & Yale - New Haven Hospital, 18Harvard Medical School/ Beth Israel Deaconess Medical Center, 19Hospital Vall d Hebron, 20Vall D'Hebron Hospital, 21University of Kansas Medical Center, 22University of Kansas, 23Icahn School of Medicine at Mount Sinai, 24UT Health McGovern Medical School, 25University of South Florida, 26Valley Baptist Medical Center
Objective:
To describe the safety and efficacy of mechanical thrombectomy (MT) with or without intravenous thrombolysis (IVT) for patients with tandem lesions (TL). In addition, we assessed if the use of intraprocedural antiplatelets (APTs) influenced the safety of MT with IVT treatment.
Background:
MT has demonstrated a safe and effective profile for treating TL. However, alternative endovascular approaches to optimize outcomes are currently under investigation. The role of IVT preceding MT is not fully defined.
Design/Methods:
We performed a sub-analysis of an international registry of 16 centers. Patients were divided into MT only versus IVT+MT groups. Primary outcomes were sICH, parenchymal hematoma type 2 (PH2), and hemorrhagic transformation. Additional outcomes were successful (mTICI2b-3) and complete reperfusion (mTICI3), 90-day mRS 0-2, 90-day mRS 0-1, in-hospital and 90-day mortality. Multivariable logistic and nominal regressions were used to assess the association between both groups.
Results:
Of 691 patients, 599 were included (255 underwent IVT+MT and 344 MT only). After adjusting for confounders there was no difference in the risk of sICH (aOR=1.43;95%CI 0.72–2.87;p=0.308), PH2 (aOR=1.14;95%CI 0.57–2.28;p=0.705), and hemorrhagic transformation (aOR=0.92;95%CI 0.54–1.57;p=0.751) between groups. There was an IVT-by-intraprocedural APTs interaction (pinteraction=0.031). IVT increased the risk of sICH in patients with IV-APT therapy (aOR=3.58;95%CI 1.17–10.89;p=0.025). The IVT+MT group had higher odds of 90-day mRS 0-2 in patients within the 6 hours window (aOR=1.83;95%CI 1.02–3.27;p=0.042). The odds of successful reperfusion, complete reperfusion, 90-days mRS 0-1, in-hospital mortality, or 90-days mortality were not different between groups.
Conclusions:
Our study showed that the combination of IVT+MT for TL did not increase the risk of sICH, PH2, nor hemorrhagic transformation in comparison with MT only. Treatment with IVT with MT was associated with a higher rate of favorable functional outcome at 90 days within the 6-hour window. The use of IVT before MT increased the risk of sICH in patients who received intraprocedural IV-APTs.