Tratamiento hiperagudo de las lesiones de la arteria carótida interna extracraneal en las oclusiones en tándem: comparación de diferentes opciones terapéuticas y de su impacto en la aparirición de complicaciones y en el pronóstico funcional.

Student thesis: Doctoral thesis

Abstract

Endovascular treatment of extracranial internal carotid artery (ICA) lesion in the setting of tandem occlusions (TIO) is a therapeutic challenge. On the one hand, recanalization rate with fibrinolytic agents is lower compared to isolate intracranial occlusions. On the other hand, there are two competing rationales: to establish and maintain extracranial ICA patency, and to avoid hemorrhagic transformation, one of the leading causes of early neurological worsening and poor functional outcome. Methods: Prospective observational study of consecutive patients admitted to the Emergency Room of Vall d’Hebron University Hospital with TIO undergoing EVT. Extracranial ICA lesion was treated with stenting (balloon-expandable [BX] or self-expandable [SX], depending on the study period) or angioplasty alone. Primary outcome was a combined positive outcome composed by absence of extracranial ICA high-grade restenosis or reocclusion (efficacy) and absence of hemorrhagic transformation (HT) (safety) at 24 hours. Secondary outcomes included efficacy, safety, and clinical and functional outcomes. A pre-specified subanalysis was performed to assess differences between BX and SX stents. Results: One-hundred thirteen patients fulfilled the inclusion criteria. Patients undergoing stenting presented more frequently the combined positive outcome (65.3% vs. 19.5%, P< 0.001) and less frequently extracranial ICA high-grade restenosis or reocclusion (22.2% vs. 80.5%, P< 0.001) than angioplasty alone patients. Similar rates of hemorrhagic transformation, symptomatic hemorrhagic transformation, clinical, and poor functional outcomes were found between groups. Extracranial ICA high-grade restenosis or reocclusion was independently related to poor functional outcome (OR 11 5.76, 95% CI 1.10-14.22). BX-stenting presented less frequently early neurological worsening (3.4% vs. 23.3%, P= 0.041) and tended to present a lower frequency of symptomatic HT (3.4% vs. 16.3%, P=0.069) than SX-stenting. Conclusions: Hyperacute extracranial ICA stenting in the setting of TIO presents more frequently the combined positive outcome of efficacy and safety than AA. BX stents are a promising alternative to SX stents in this particular scenario, due to the similar rate of extracranial ICA reocclusion or high-grade restenosis, a lower frequency of early neurological worsening, and a tendency to present less cases of symptomatic hemorrhagic transformation. Extracranial ICA reocclusion or high-grade restenosis predicts poor functional outcome.
Date of Award27 Jun 2019
Original languageSpanish
SupervisorCarlos Molina Caterino (Director), David Rodriguez-Luna (Director) & Jose Alvarez Sabin (Tutor)

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