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PT  - JOURNAL ARTICLE
AU  - Scarcia, Luca
AU  - Colò, Francesca
AU  - Alexandre, Andrea M.
AU  - Brunetti, Valerio
AU  - Pedicelli, Alessandro
AU  - Arba, Francesco
AU  - Ruggiero, Maria
AU  - Piano, Mariangela
AU  - Gabrieli, Joseph D.
AU  - Ros, Valerio Da
AU  - Romano, Daniele G.
AU  - Cavallini, Anna
AU  - Salsano, Giancarlo
AU  - Panni, Pietro
AU  - Limbucci, Nicola
AU  - Caragliano, Antonio A.
AU  - Russo, Riccardo
AU  - Bigliardi, Guido
AU  - Milonia, Luca
AU  - Semeraro, Vittorio
AU  - Lozupone, Emilio
AU  - Cirillo, Luigi
AU  - Clarençon, Frederic
AU  - Zini, Andrea
AU  - Broccolini, Aldobrando
AU - the emergent Carotid Artery Stenting (eCAS) study group
TI  - Effects of emergent carotid stenting performed before or after mechanical thrombectomy in the endovascular management of patients with tandem lesion: a multicenter retrospective matched analysis
AID  - 10.3174/ajnr.A8421
DP  - 2024 Jul 18
TA  - American Journal of Neuroradiology
PG  - ajnr.A8421
4099  - http://www.ajnr.org/content/early/2024/07/29/ajnr.A8421.short
4100  - http://www.ajnr.org/content/early/2024/07/29/ajnr.A8421.full
AB  - BACKGROUND AND PURPOSE: Mechanical thrombectomy (MT) along with emergent carotid stenting (eCAS) have been suggested to have a greater benefit in patients with tandem lesion (TL), compared to other strategies of treatment. Nonetheless, there is no agreement on whether the intracranial occlusion should be treated before the cervical ICA lesion, or vice versa. In this retrospective multicenter study, we sought to compare clinical and procedural outcomes of the two different treatment approaches in patients with TL.MATERIALS AND METHODS: The prospective databases of 17 comprehensive stroke centers were screened for consecutive patients with TL who received MT and eCAS. Patients were divided in two groups based on whether they received MT before eCAS (MT-first approach) or eCAS before MT (eCAS-first approach). Propensity score matching (PSM) was used to estimate the effect of the retrograde versus the anterograde approach on procedure-related and clinical outcome measures. These included the mTICI score 2b-3, other procedure-related parameters and adverse events after the endovascular procedure, and the ordinal distribution of the 90-day mRS scores.RESULTS: A total of 295 consecutive patients were initially enrolled. Among these, 208 (70%) received MT before eCAS. After PSM, 56 pairs of patients were available for analysis. In the matched population, the MT-first approach resulted in a higher rate of successful intracranial recanalization (91% versus 73% in the eCAS-first approach, p=0.025) and shorter groin-to-reperfusion time (72 ± 38 minutes versus 93 ± 50 minutes in the anterograde approach, p=0.017). Despite a higher rate of efficient recanalization in the MT-first group, we did not observe a significant difference concerning the ordinal distribution of the 90-day mRS scores. Rates of procedure-related adverse events and occurrence of both parenchymal hemorrhage type 1 and type 2 were comparable.CONCLUSIONS: Our study demonstrates that in patients with TL undergoing endovascular treatment, prioritizing the intracranial occlusion is associated with an increased rate of efficient MT and faster recanalization time. However, this strategy does not bring an advantage in long-term clinical outcome. Future controlled studies are needed to determine the optimal treatment technique.ABBREVIATIONS: AIS = acute ischemic stroke; eCAS = emergent carotid stenting; ICA = internal carotid artery; GTR = groin-torecanalization; IVT = intravenous thrombolysis; LVO = large vessel occlusion; MCA, middle cerebral artery; MT = mechanical thrombectomy; PSM = propensity score matching; SMD = standardized mean difference; STROBE = STrengthening the Reporting of OBservational studies in Epidemiology; TL = tandem lesion.