Abstract
INTRODUCTION: The utility of emergent carotid artery stenting (eCAS) during mechanical thrombectomy (MT) for tandem occlusions has been well‐described. Single antiplatelet therapy after eCAS in tandem occlusions prevents the risk of reperfusion hemorrhage, though the risk of in‐stent occlusion remains, and the optimal antiplatelet strategy remains unexplored. We compared intra‐ and postprocedural stent occlusion and hemorrhagic complication rates for anterior circulation tandem strokes in patients with baseline mRS 0‐2 undergoing MT loaded either with oral aspirin/ticagrelor or intravenous eptifibatide for eCAS.; METHODS: Retrospective analysis of institutional thrombectomy database for patient characteristics, thrombectomy details, in‐hospital course, and follow‐up outcomes. Patients were dichotomized into those receiving oral aspirin/ticagrelor load (DAPT cohort) versus intravenous eptifibatide load (Integrilin cohort) prior to eCAS during MT for tandem occlusions. Multivariate binomial logistic regression was conducted to assess for significant predictors of in‐stent thrombosis following MT+eCAS during in‐hospital stay.; RESULTS: We included 138 patients with anterior circulation tandem strokes and baseline mRS 0‐2. There were no differences in baseline demographics. The Integrilin cohort had more patients undergoing MT via radial access (30.4%‐vs‐8.7%,p=0.009) and more patients undergoing retrograde eCAS (34.8%‐vs‐13%,p=0.027). No differences in first pass (TICI2C‐3) or modified first pass (TICI2b‐3) effect rate were observed between the cohorts, through anterograde or retrograde approaches, after all passes (2.22±1.38‐vs‐1.58±0.95,p=0.008). Both had comparable procedural and fluoroscopy duration (p>0.05). No difference in intraprocedural stent occlusion was observed. Patients in the DAPT cohort had lower rates of post‐procedure stent occlusion up to day 7 compared to those in the Integrilin cohort (5.2%‐vs‐30.4%,OR:0.126[0.038‐0.422],p<0.001). No difference in symptomatic or asymptomatic hemorrhage rates were observed‐post procedure. There were no differences in mRS 0‐1, 0‐2 or 0‐3 at day 7, discharge, or 90 days between the treatment groups. Multivariate regression revealed procedural duration (p=0.034) and the number of stents (p=0.039) increased the risk of in‐stent thrombosis while angioplasty following eCAS (p=0.047) reduced the risk. Additionally, using DAPT load as opposed to pre‐eCAS integrilin load was associated with a significantly lower risk of in‐stent thrombosis (p=0.045). Notably, the administration of IV alteplase at the initial visit, hyperacute phase antiplatelets, or heparin infusion did not impact the occurrence of in‐stent thrombosis.; CONCLUSION: Our study demonstrates that loading with aspirin/ticagrelor significantly reduces the rate of post‐procedural in‐stent occlusion in the short term. These results can inform practice patterns for these difficult conditions and hope to validate the findings in a multi‐institutional prospective or randomized controlled studies. [Image: see text]