Emergent Stenting After IVT
(2019)Objective
To evaluate the safety of emergent carotid artery stenting (CAS) plus mechanical thrombectomy (MT) in patients with tandem occlusion who received prior intravenous thrombolysis (IVT).
Study Summary
• Mortality was significantly lower in the IVT group compared to no-IVT, though this did not remain significant after adjustment.
• Rates of reperfusion and favorable outcome were similar across groups.
Intervention
Multicenter observational analysis of 205 patients from the TITAN registry with tandem occlusions treated with CAS-MT. Patients were stratified based on receipt of prior IV thrombolysis (IVT vs. no-IVT).
Inclusion Criteria
Acute ischemic stroke patients with anterior circulation tandem occlusion due to atherosclerosis, treated with emergent CAS + MT between 2012 and 2016.
Study Design
Arms: IVT + CAS-MT vs. CAS-MT without IVT
Patients per Arm: IVT: 125; No-IVT: 80
Outcome
• Parenchymal hematoma: 15% vs. 18%; P=0.65
• 90-day mortality: 8% vs. 20%; P=0.017 (not significant after adjustment)
• Favorable outcome (mRS 0–2 at 90 days): 62% vs. 51%; P=0.15
• Successful reperfusion (TICI 2b–3): 82% vs. 80%; P=0.86
• Procedural complications: 12% vs. 11%; P=0.999
Bottom Line
In the TITAN registry (205 patients with atherosclerotic tandem occlusions treated with CAS-MT), prior IV thrombolysis did not increase hemorrhagic risk. sICH: 5% (IVT) vs 8% (no-IVT; P=0.544). PH1-2: 15% vs 18% (P=0.647). Functional independence (mRS 0-2): 62% vs 51% (P=0.145). Unadjusted mortality was lower with IVT (8% vs 20%; P=0.017) but not significant after multivariate adjustment.
Major Points
- IVT before CAS-MT does not increase sICH: 5% vs 8% (P=0.544). Not associated on multivariate analysis.
- Parenchymal hematoma similar: 15% vs 18% (P=0.647).
- Reperfusion equivalent: mTICI 2b-3 in 82% vs 80% (P=0.856).
- Functional outcome similar: mRS 0-2 62% vs 51% (P=0.145).
- Unadjusted mortality lower with IVT (8% vs 20%; P=0.017) — lost on multivariate adjustment (confounded by longer onset-to-groin in no-IVT).
- Procedural complications equivalent: 12% vs 11%.
- Heparin used less with IVT (14% vs 35%; P<0.001) — operators avoided additional anticoagulation.
- Overall sICH 5.9% — consistent with meta-analysis benchmarks for tandem thrombectomy.
- 205 patients, international multicenter retrospective registry (TITAN). Stryker-funded.
- Supports bridging IVT before CAS-MT in tandem occlusions when indicated.
Study Design
- Study Type
- Multicenter, retrospective, observational registry study
- Randomization
- No
- Blinding
- No blinding; adjudication of outcomes based on standardized criteria
- Sample Size
- 205
- Follow-up
- 90 days
- Centers
- 20
- Countries
- United States, France, Germany, Spain, Netherlands
Primary Outcome
Definition: Symptomatic intracerebral hemorrhage within 24h
| Control | Intervention | HR/OR | P-value |
|---|---|---|---|
| 8% | 5% | - | 0.544 |
Limitations & Criticisms
- Retrospective and observational design limits causal inference
- Heterogeneous antiplatelet protocols across sites
- Only periprocedural antithrombotic data collected
- Possible selection bias in IVT administration
- Small sample size for safety endpoints
Citation
Stroke. 2019;50:2250-2252. DOI: 10.1161/STROKEAHA.118.024733