Emergent Carotid Stenting During Thrombectomy in Tandem Occlusions Secondary to Dissection: A STOP-CAD Secondary Study
Authors: Sousa João André , Rodrigo-Gisbert Marc , Shu Liqi , Luo Anqi , Xiao Han , Mahmoud Noor A. , Shah Asghar , Oliveira Santos Ana Luyza , Moore Marina , Mandel Daniel M , Heldner Mirjam R , Barata Vasco , Bernardo-Castro Sara , Henninger Nils , Muppa Jayachandra , Arnold Marcel , Nehme Ahmad , Rothstein Aaron , Khazaal Ossama , Kaufmann Josefin E. , Engelter Stefan T , Traenka Christopher , Metanis Issa , Leker Ronen R , Nolte Christian H , Ghannam Malik , Samaniego Edgar A. , AlMajali Mohammad , Poppe Alexandre Y , Romoli Michele , Frontera Jennifer A. , Zedde Marialuisa , Kam Wayneho , Mac Grory Brian , Saleh Velez Faddi Ghassan , Ranasinghe Tamra , Siegler James E. , Zubair Adeel S. , Marto João Pedro , Klein Piers , Nguyen Thanh N. , Abdalkader Mohamad , Mantovani Gabriel Paulo , Simpkins Alexis N. , Sen Shayak , Elnazeir Marwa , Yaghi Shadi , Sargento-Freitas Joao , Requena Manuel 
Published: January 2025

Background:
The optimal endovascular management of cervical carotid dissection causing tandem occlusion remains uncertain. We investigated the impact of emergent carotid stenting during endovascular treatment (EVT) for acute ischemic stroke (AIS) in patients with tandem occlusion secondary to cervical carotid artery dissection.

Methods:
This was a secondary analysis of patients treated with EVT for AIS due to occlusive carotid artery dissection and tandem occlusion included in the retrospective international Antithrombotic Treatment for Stroke Prevention in Cervical Artery Dissection (STOP-CAD) study. We compared patients with and without emergent stenting. The primary efficacy and safety outcomes were 90-day functional independence (modified Rankin Scale 0-2) and symptomatic intracranial hemorrhage (sICH) within 24h after EVT. Procedural outcome was successful intracranial recanalization (mTICI 2b/3). We used mixed-effect logistic regression adjusting for site, age, and NIHSS. In additional analyses, we used inverse probability of treatment weighting and adjusted for ASPECTS.

Results:
Of the 4023 patients enrolled in STOP-CAD, 328 presented with anterior circulation AIS due to tandem occlusion and underwent EVT. The median age was 51 years (interquartile range 44-58), and 96 patients (29.3%) were female. One hundred fifty patients (45.7%) underwent emergent stenting. There was no significant association between stenting and 90-day functional independence (62.0% vs 59.7%; aOR 1.23, 95% CI 0.82-1.86, p=0.315) or sICH (7.3% vs 7.9%; aOR OR 0.95, 95% CI 0.41-2.2, p=0.913). Emergent carotid stenting was associated with successful intracranial recanalization (81.8% vs 76.6% aOR 2.62, 95% CI 1.52-4.5, p<0.001). Results did not meaningfully change in additional analyses.

Conclusion:
In patients presenting with an acute anterior circulation tandem occlusion secondary to cervical carotid artery dissection, emergent stenting was associated with a higher likelihood of successful intracranial recanalization but not improved functional outcomes or increased sICH. It remains unclear whether emergent stenting led to successful intracranial recanalization or patients with successful intracranial recanalization were more likely to be stented. Randomized trials are warranted.