SECURIS
(2025)Objective
To evaluate 90-day and 1-year follow-up outcomes of emergent carotid artery stenting (eCAS) vs non-eCAS in patients with acute ischemic stroke due to tandem lesions undergoing endovascular therapy.
Study Summary
• Higher successful recanalization rates with eCAS (OR 4.28, P<0.001)
• No increased hemorrhagic transformation risk or mortality
• Benefit consistent in both moderate (50%-69%) and severe (≥70%) ICA stenosis
Intervention
Population-based registry study comparing emergent carotid artery stenting during endovascular therapy versus conservative management in patients with tandem lesions (≥50% atheromatous cervical ICA stenosis + large vessel occlusion).
Inclusion Criteria
Age ≥18 years, previous mRS 0-3, symptom onset ≤24 hours, large vessel occlusion of anterior circulation, concomitant atheromatous cervical ICA stenosis ≥50%, treatment with any EVT modality
Study Design
Arms: eCAS group (emergent carotid stenting during EVT) vs non-eCAS group (conservative management)
Patients per Arm: eCAS: 344 patients, non-eCAS: 234 patients
Outcome
• Successful recanalization: 91.7% eCAS vs 73.0% non-eCAS
• Hemorrhagic transformation: 16.9% eCAS vs 12.5% non-eCAS (NS)
Bottom Line
Emergent carotid artery stenting during endovascular therapy was associated with better functional outcomes at 90 days and 1 year without safety concerns, even in moderate ICA stenosis.
Major Points
- Population-based registry study from Catalonia, Spain including 578 patients with tandem lesions
- eCAS performed in 59.5% (344/578) of patients
- Better functional outcome with eCAS at 90 days (cOR 1.47, 95% CI 1.20-1.82, P<0.001) and 1 year (cOR 1.47, 95% CI 1.16-1.85, P=0.001)
- Higher successful recanalization rates with eCAS (91.7% vs 73.0%, OR 4.28, P<0.001)
- No increased hemorrhagic transformation risk (16.9% vs 12.5%, P=0.142) or mortality
- Benefit consistent in both moderate (50%-69%) and severe (≥70%) ICA stenosis subgroups
- Potential treatment effect differences observed for women and older patients
- Dual antiplatelet therapy at 24 hours associated with better outcomes in eCAS group (54.6% vs 22.9%, P<0.001)
Study Design
- Study Type
- Observational study based on prospective mandatory population-based registry
- Randomization
- No
- Blinding
- 90-day mRS assessed blindly and centrally; 1-year mRS assessed by treating neurologist (not blinded)
- Sample Size
- 578
- Follow-up
- 90 days and 1 year
- Centers
- 10
- Countries
- Spain
Primary Outcome
Definition: Shift in modified Rankin Scale (mRS) score at 90 days and 1 year of follow-up
| Control | Intervention | HR/OR | P-value |
|---|---|---|---|
| Median mRS 3 (2-5) at 90 days | Median mRS 3 (1-5) at 90 days | - (90 days: cOR 1.47 (1.20-1.82); 1 year: cOR 1.47 (1.16-1.85)) | 90 days: P<0.001; 1 year: P=0.001 |
Limitations & Criticisms
- Observational design with possible unmeasured confounders
- Non-randomized treatment allocation potentially subject to selection bias
- 1-year mRS assessment not centrally evaluated and not blinded to eCAS status
- Radiologic image analyses not centralized or blinded to eCAS status
- Decision-making for stent placement at discretion of treating practitioner
- Absence of data on stroke recurrence during follow-up
- Exclusion of patients with missing follow-up data may introduce bias
- Some data collected retrospectively by participating centers
Citation
Neurology® 2025;105:e214067. doi:10.1212/WNL.0000000000214067