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The ReWiSed CARe Technique

Simultaneous Treatment of Atherosclerotic Tandem Occlusions in Acute Ischemic Stroke

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Abstract

Background

Endovascular treatment of acute cerebral large vessel occlusions and concomitant atherosclerotic lesions of the ipsilateral internal carotid artery (ICA) are a matter of debate. This article reports a multi-center experience using the retriever wire supported carotid artery revascularization (ReWiSed CARe) technique allowing simultaneous treatment of both lesions.

Methods

The study retrospectively analyzed 23 patients with acute tandem occlusions (TO) who underwent ReWiSed CARe at 3 German centers. Clinical, including demographics and National Institutes of Health Stroke Scale (NIHSS) and procedural, including angiographic evaluation of recanalization, data were evaluated. Favorable clinical outcome was defined as modified Rankin Scale (mRS) score ≤2 at 90 days.

Results

The median age was 70 years (interquartile range [IQR] 65–80 years) and 70% were male. The median baseline NIHSS was 15 (IQR 11–17). Out of 23 patients, 22 (96%) had an intracranial occlusion of the anterior circulation. Successful stent retriever deployment with subsequent carotid artery treatment was feasible in all cases without displacement of the stent retriever during the procedure. Overall, successful reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] ≥2b) was achieved in 22/23 (96%) patients with 10/23 (44%) individuals completely reperfused (mTICI 3). The median groin puncture to stent retriever deployment was 29 min (IQR 23–46) and groin puncture to final revascularization was 63 min (IQR 56–78). The median NIHSS at discharge was 5 (IQR 3–12) with favorable clinical outcome at 90 days in 11 out of 20 patients (55%).

Conclusion

Endovascular treatment using ReWiSed CARe is safe, fast and efficient in TO patients with underlying atherosclerotic lesion of the extracranial ICA.

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References

  1. Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, Roy D, Jovin TG, Willinsky RA, Sapkota BL, Dowlatshahi D, Frei DF, Kamal NR, Montanera WJ, Poppe AY, Ryckborst KJ, Silver FL, Shuaib A, Tampieri D, Williams D, Bang OY, Baxter BW, Burns PA, Choe H, Heo JH, Holmstedt CA, Jankowitz B, Kelly M, Linares G, Mandzia JL, Shankar J, Sohn SI, Swartz RH, Barber PA, Coutts SB, Smith EE, Morrish WF, Weill A, Subramaniam S, Mitha AP, Wong JH, Lowerison MW, Sajobi TT, Hill MD; ESCAPE Trial Investigators. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372:1019–30.

    Google Scholar 

  2. del Zoppo GJ, Poeck K, Pessin MS, Wolpert SM, Furlan AJ, Ferbert A, Alberts MJ, Zivin JA, Wechsler L, Busse O, Greenlee R Jr, Brass L, Mohr JP,  Feldmann E, Hacke W, Kase CS, Biller J, Gress D, Otis SM. Recombinant tissue plasminogen activator in acute thrombotic and embolic stroke. Ann Neurol. 1992;32:78–86.

    Article  Google Scholar 

  3. Berkhemer OA, Borst J, Kappelhof M, Yoo AJ, van den Berg LA, Fransen PSS, Beumer D, Schonewille WJ, Nederkoorn PJ, Wermer MJH, Marquering HA, Lingsma HF, Roos YBWEM, van Oostenbrugge RJ, Dippel DWJ, van Zwam WH, Majoie CBLM, Emmer BJ, van der Lugt A; MR CLEAN Investigators. Extracranial carotid disease and effect of intra-arterial treatment in patients with proximal anterior circulation stroke in MR CLEAN. Ann Intern Med. 2017;166:867–75.

    Article  Google Scholar 

  4. Assis Z, Menon BK, Goyal M, Demchuk AM, Shankar J, Rempel JL, Roy D, Poppe AY, Yang V, Lum C, Dowlatshahi D, Thornton J, Choe H, Burns PA, Frei DF, Baxter BW, Hill MD; ESCAPE Trialists. Acute ischemic stroke with tandem lesions: Technical endovascular management and clinical outcomes from the ESCAPE trial. J Neurointerv Surg. 2018;10:429–33.

    Article  Google Scholar 

  5. Wilson MP, Murad MH, Krings T, Pereira VM, O’Kelly C, Rempel J, Hilditch CA, Brinjikji W. Management of tandem occlusions in acute ischemic stroke—Intracranial versus extracranial first and extracranial stenting versus angioplasty alone: A systematic review and meta-analysis. J Neurointerv Surg. 2018;10:721–8.

    Article  Google Scholar 

  6. Akpinar CK, Gürkaş E, Aytac E. Carotid angioplasty-assisted mechanical thrombectomy without urgent stenting may be a better option in acute tandem occlusions. Interv Neuroradiol. 2017;23:405–11.

    Article  Google Scholar 

  7. Maus V, Borggrefe J, Behme D, Kabbasch C, Abdullayev N, Barnikol UB, Yeo LLL, Brouwer PA, Söderman M, Möhlenbruch M, Liebig T, Fink GR, Mpotsaris A. Order of treatment matters in ischemic stroke: Mechanical thrombectomy first, then carotid artery stenting for tandem lesions of the anterior circulation. Cerebrovasc Dis. 2018;46:59–65.

    Article  Google Scholar 

  8. Behme D, Knauth M, Psychogios MN. Retriever wire supported carotid artery revascularization (ReWiSed CARe) in acute ischemic stroke with underlying tandem occlusion caused by an internal carotid artery dissection: Technical note. Interv Neuroradiol. 2017;23:289–92.

    Article  Google Scholar 

  9. ZZaidat OO, Yoo AJ, Khatri P, Tomsick TA, von Kummer R, Saver JL, Marks MP, Prabhakaran S, Kallmes DF, Fitzsimmons BF, Mocco J, Wardlaw JM, Barnwell SL, Jovin TG, Linfante I, Siddiqui AH, Alexander MJ, Hirsch JA, Wintermark M, Albers G, Woo HH, Heck DV, Lev M, Aviv R, Hacke W, Warach S, Broderick J, Derdeyn CP, Furlan A, Nogueira RG, Yavagal DR, Goyal M, Demchuk AM, Bendszus M, Liebeskind DS; Cerebral Angiographic Revascularization Grading (CARG) Collaborators; STIR Revascularization working group; STIR Thrombolysis in Cerebral Infarction (TICI) Task Force. Recommendations on angiographic revascularization grading standards for acute ischemic stroke: A consensus statement. Stroke. 2013;44:2650–63.

    Article  Google Scholar 

  10. Maus V, Henkel S, Riabikin A, Riedel C, Behme D, Tsogkas I, Hesse AC, Abdullayev N, Jansen O, Wiesmann M, Mpotsaris A, Psychogios MN. The SAVE technique. Clin Neuroradiol. 2018 Jul 19. doi: 10.1007/s00062-018-0702-4. [Epub ahead of print]

    Article  PubMed  Google Scholar 

  11. Humphries W, Hoit D, Doss VT, Elijovich L, Frei D, Loy D, Dooley G, Turk AS, Chaudry I, Turner R, Mocco J, Morone P, Fiorella D, Siddiqui A, Mokin M, Arthur AS. Distal aspiration with retrievable stent assisted thrombectomy for the treatment of acute ischemic stroke. J Neurointerv Surg. 2015;7:90–4.

    Article  Google Scholar 

  12. Behme D, Mpotsaris A, Zeyen P, Psychogios MN, Kowoll A, Maurer CJ, Joachimski F, Liman J, Wasser K, Kabbasch C, Berlis A, Knauth M, Liebig T, Weber W. Emergency stenting of the extracranial internal carotid artery in combination with anterior circulation thrombectomy in acute ischemic stroke: A retrospective multicenter study. AJNR Am J Neuroradiol. 2015;36:2340–5.

    Article  CAS  Google Scholar 

  13. Sivan-Hoffmann R, Gory B, Armoiry X, Goyal M, Riva R, Labeyrie PE, Lukaszewicz AC, Lehot JJ, Derex L, Turjman F. Stent-retriever thrombectomy for acute anterior ischemic stroke with tandem occlusion: A systematic review and meta-analysis. Eur Radiol. 2017;27:247–54.

    Article  Google Scholar 

  14. Keulers A, Nikoubashman O, Mpotsaris A, Wilson SD, Wiesmann M. Preventing vessel perforations in endovascular thrombectomy: Feasibility and safety of passing the clot with a microcatheter without microwire: The wireless microcatheter technique. J Neurointerv Surg. 2018 Dec 7. doi: 10.1136/neurintsurg-2018-014267. [Epub ahead of print]

    Article  PubMed  Google Scholar 

  15. Sultan-Qurraie A, Witt T, de Havenon A, Ribo M, Zaidat OO. SEIMLESS: Simultaneous extracranial, intracranial management of (tandem) lessions in stroke. J Neurointerv Surg. 2019 Jan 23. doi: 10.1136/neurintsurg-2018-014403. [Epub ahead of print]

    Article  PubMed  Google Scholar 

  16. Yi HJ, Lee DH, Sung JH. Clinical usefulness of waiting after stent deployment in mechanical thrombectomy: Effect of the clot integration. World Neurosurg. 2018;119:e87–e93.

    Article  Google Scholar 

  17. Kannath SK, Rajan JE, Sylaja PN, Sarma PS, Sukumaran S, Sreedharan SE, Kapilamoorthy TR. Dwell time of stentriever influences complete revascularization and first-pass TICI 3 revascularization in acute large vessel occlusive stroke. World Neurosurg. 2018;110:169–73.

    Article  Google Scholar 

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Authors and Affiliations

  1. Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany

    Volker Maus, Daniel Behme & Marios-Nikos Psychogios

  2. Institute of Diagnostic and Interventional Radiology, Neuroradiology and Nuclear Medicine, Knappschaftskrankenhaus Bochum, Ruhr University Bochum, In der Schornau 23–25, 44892, Bochum, Germany

    Volker Maus

  3. Department of Neuroradiology, University Hospital Augsburg, Augsburg, Germany

    Christoph Maurer & Ansgar Berlis

  4. Department of Radiology and Neuroradiology, Helios Hospital Wiesbaden, Wiesbaden, Germany

    Andrei Tropine & Stephanie Tritt

  5. Department of Neuroradiology, Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Basel, Switzerland

    Marios-Nikos Psychogios

Authors
  1. Volker Maus
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  2. Daniel Behme
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  3. Christoph Maurer
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  4. Andrei Tropine
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  6. Ansgar Berlis
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  7. Marios-Nikos Psychogios
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Corresponding author

Correspondence to Volker Maus.

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Conflict of interest

V. Maus, D. Behme, A. Tropine, S. Tritt and A. Berlis declare that they have no competing interests. C. Maurer has educational grant (Microvention, Stryker). M.-N. Psychogios received travel grants and (modest) fees from Stryker, Phenox, Penumbra, Acandis and Siemens.

Additional information

Volker Maus and Daniel Behme contributed equally to the manuscript.

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Maus, V., Behme, D., Maurer, C. et al. The ReWiSed CARe Technique. Clin Neuroradiol 30, 489–494 (2020). https://doi.org/10.1007/s00062-019-00795-z

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