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THE JOURNAL OF CARDIOVASCULAR SURGERY

Rivista di Chirurgia Cardiaca, Vascolare e Toracica


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The Journal of Cardiovascular Surgery 2018 Jan 23

DOI: 10.23736/S0021-9509.18.10312-0

Copyright © 2018 EDIZIONI MINERVA MEDICA

lingua: Inglese

Overview of evidence on emergency carotid stenting in patients with acute ischemic stroke due to tandem occlusions: a systematic review and meta-analysis

Andreia COELHO , Miguel LOBO, Ricardo GOUVEIA, Diogo SILVEIRA, Jacinta CAMPOS, Rita AUGUSTO, Nuno COELHO, Alexandra CANEDO

Angiology and Vascular Surgery Department, Centro Hospitalar de Vila Nova de Gaia e Espinho, Vila Nova de Gaia, Portugal


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INTRODUCTION: Endovascular intracranial thrombectomy (IT) has established itself as the standard of care in treating large-vessel anterior circulation acute ischemic stroke (AIS). However, internal carotid artery (ICA) stenosis/occlusion hampers distal access and controversy about simultaneous emergency ICA stenting ensues. The purpose of this review was to evaluate the safety of emergency ICA stenting in combination with IT for AIS with tandem occlusions. To our knowledge this is the first meta-analysis to evaluate emergency ICA stenting in tandem occlusions, combining results from studies with a control group.
EVIDENCE ACQUISITION: A systematic review and meta-analysis was conducted according to the recommendations of the Preferred Reporting Items for Systematic reviews and Meta- Analyses (PRISMA) statement.
EVIDENCE SYNTHESIS: A total of 649 potentially relevant articles were initially selected. After reviewing at title or abstract level, 87 articles were read in full and 23 were included. These studies recruited 1000 patients, 220 submitted to IT with no emergency ICA stenting and 780 to IT and emergency ICA stenting. Successful revascularization (Thrombolysis in cerebral infarction scale - TICI≥2b) was achieved in 48.6-100%. Good outcome (modified Rankin scale - mRS≤2) ranged from 18.2-100%. Symptomatic intracranial haemorrhage (sICH) ranged from 0-45.7% (overall n=168; 17.2%). Mortality at 90 days ranged from 0-45.4% (overall n=114; 11.7%). Time to recanalization was significantly longer in the stenting group with an overall mean difference of 1.76 (95% Confidence Interval: 1.59-1.93).
CONCLUSIONS: In this meta-analysis time to recanalization was significantly longer in the emergency ICA stenting group. There was no benefit from emergency stenting in parameters such as successful revascularization (TICI≥2b), clinical outcome (mRS≤2) or 90-day mortality. Data on sICH were scarce. Emergency ICA stenting appears to increase time to revascularization and increase the risk of complications with no demonstrated clinical benefit. Furthermore, no prospective, randomized controlled trials demonstrating relative efficacy and safety of concomitant ICA stenting have been published to date. Additional studies must be undertaken to define the role of angioplasty and stenting of the extracranial carotid arteries in the early management of acute stroke in tandem occlusions. Until then, we recommend that ICA stenting concommintant to thrombectomy in acute stroke patients should be avoided.


KEY WORDS: Stroke (MeSH) - Carotid stenosis (MeSH) - Endarterectomy - Carotid (MeSH) - Stents (MeSH) - Thrombectomy (MeSH) - Thrombolytic therapy (MeSH)

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Publication History

Article first published online: January 23, 2018
Manuscript accepted: January 23, 2018
Manuscript received: November 11, 2017

Per citare questo articolo

Coelho A, Lobo M, Gouveia R, Silveira D, Campos J, Augusto R et al. Overview of evidence on emergency carotid stenting in patients with acute ischemic stroke due to tandem occlusions: a systematic review and meta-analysis. J Cardiovasc Surg 2018 Jan 23. DOI: 10.23736/S0021-9509.18.10312-0

Corresponding author e-mail

andreiasmpcoelho@gmail.com