Emergent Carotid Artery Stenting in Atherosclerotic Disease of the Internal Carotid Artery With Tandem Intracranial Occlusion - Journal of Vascular Surgery

Review of a prospective registry of patients who were treated for anterior circulation acute ischemic stroke at a single center during a 22-month period (dates not provided). Of 156 patients submitted to mechanical thrombectomy for anterior circulation ischemic stroke, 16 (10%) were treated for tandem lesions using mechanical thrombectomy with stent retriever to treat middle cerebral artery thrombotic occlusion followed by emergency carotid artery stenting (eCAS) to treat occlusive or near-occlusive atherosclerotic disease of the cervical internal carotid artery. The authors performed this “reverse” technique as opposed to the “anterograde” technique where eCAS is performed first and mechanical thrombectomy second. A loading dose of clopidogrel was given after exclusion of intracranial hemorrhage by computed tomography scan. Successful recanalization was achieved in 94% (15/16) of patients and a favorable outcome was observed in 69% (11/16) of patients at 3-month follow-up. Emergent CAS may be a safe treatment option for select patients with acute anterior circulation ischemic stroke who have occlusive or near-occlusive atherosclerotic disease of the cervical internal carotid artery associated with middle cerebral artery thrombotic occlusion. The interested reader needs to carefully read the article to review the specific criteria for treatment of these patients using this technique. Of note, 25% (4/16) of patients treated with mechanical thrombectomy followed by eCAS in this small series suffered asymptomatic (n = 3) or symptomatic (n = 1) intracranial hemorrhage. I suspect very few vascular surgeons have the training or experience to treat acute ischemic stroke using mechanical thrombectomy with stent retriever. Nonetheless, we should be aware of evolving technology to treat acute ischemic stroke when carotid artery atherosclerotic occlusive disease is the culprit.