Emergent carotid stenting versus no stenting for acute ischemic stroke due to tandem occlusion: a meta-analysis

AZ, DAdS and SP are joint senior authors.

Introduction

Acute ischemic strokes (AIS) due to tandem occlusions (TOs), defined as cervical internal carotid artery (ICA) high-grade stenosis or occlusion and ipsilateral intracranial occlusion, account for about 10%–15% of all large-vessel occlusions (LVOs). Most of the endovascular randomized trials assessing the efficacy of mechanical thrombectomy (MT) in the treatment of AIS^1–5 excluded patients with a TO, mainly due to high heterogeneity in presentation, including diverging sites for intracranial and extracranial occlusion and a broad range of clinical severity, and in treatment approaches.^{1 6}

Despite the HERMES meta-analysis, which showed that the endovascular thrombectomy has an equivalent therapeutic effect in patients with isolated intracranial occlusions and TOs,⁷ there is a lack of data about the management of the extracranial stenosis or occlusion.⁸ Overall, although the need for intracranial revascularization is evident, the optimal approach for the treatment of extracranial occlusion is extreme uncertain. Emergent carotid artery stenting (eCAS) is often performed in the context of MT in cases with TO,^{9 10} even though its safety is unconfirmed. Additionally, the hemorrhagic risk related to periprocedural antithrombotic agents required for eCAS and the risk of early recurrent ischemic events of eCAS and the carotid artery angioplasty (CAA) or no carotid treatment are extremely variable in observational series.^11–18

We aimed to provide a systematic review and meta-analysis to assess the efficacy and safety of eCAS in patients with AIS with TOs, in comparison with a no-stenting approach.

Methods

Protocol and registration

This systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.¹⁹ The study protocol was registered with PROSPERO: CRD42021279218. The manuscript followed the PRISMA statement.²⁰

Search strategy and selection criteria

We searched Medline, EMBASE and Scopus electronic databases from January 1, 2004 to March 7, 2022, with no language restrictions. Search terms included MeSH and Emtree terms as well as specific keywords for stroke, thrombectomy procedure, and angioplasty/stenting, including: (1) ischemic stroke, stroke, cerebral infarct*, tandem*, tandem occlusion*, (2) thrombectom*, mechanical thrombectomy, (3) carotid, carotid artery, stents, carotid artery stenting, angioplasty, carotid artery angioplasty. Reference lists of relevant studies were also hand searched.

Eligibility criteria and study selection

We included studies assessing...