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Daniel Cooke MDUCSF Dept. of Radiology and Biomedical Imaging

UCSF Vascular Symposium

April 7, 2017

Disclosures

• None

Outline

• Cases

• Etiology

• Evidence– Tandem– Cervical

• Techniques

• MedicationsCASES

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ETIOLOGY

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ACO: Etiology

• Atherosclerosis• Atrial fibrillation• Dissection

– 3/100K/year– 5 - 20% of stroke < 45 years age– Younger (< 60 years)– Male– Causes

• Spontaneous (37%)• Trauma (48%)

– 0.7% MVC» Mortality – 14%» CAS – 4% (no effect on mortality/LOS)

• Iatrogenic (16%)Pham MH, Rahme RJ, Arnaout O, Hurley MC, Bernstein RA, Batjer HH, Bendok BR. Endovascular stenting of extracranial carotid and vertebral artery dissections: a systematic review of the literature. Neurosurgery. 2011 Apr;68(4):856-66; discussion 866

Kray JE, Dombrovskiy VY, Vogel TR. Carotid artery dissection and motor vehicle trauma: patient demographics, associated injuries and impact of treatment on cost and length of stay. BMC Emerg Med. 2016 Jul 8;16(1):23

EVIDENCE

ACO: Tandem

• Goyal et al. (Lancet, 2016)– Meta analysis – 1287 pts

• 68 years • NIHSS 17• 4.4% sICH

• 15.3% Mortality • 21% ICA occlusion (274 pts)

Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM, Dávalos A, Majoie CB, van der Lugt A, de Miquel MA, Donnan GA, Roos YB, Bonafe A, Jahan R, DienerHC, van den Berg LA, Levy EI, Berkhemer OA, Pereira VM, Rempel J, Millán M, Davis SM, Roy D, Thornton J, Román LS, Ribó M, Beumer D, Stouch B, Brown S, Campbell BC, van Oostenbrugge RJ, Saver JL, Hill MD, Jovin TG; HERMES collaborators.. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016 Apr 23;387(10029):1723-31

ACO: Tandem

• Goyal et al. (Lancet, 2017)– Meta analysis – 1287 pts

• 9.5% Tandem occlusion (122) : MR CLEAN (75), ESCAPE (21), REVASCAT (19), EXTEND IA (7)

Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM, Dávalos A, Majoie CB, van der Lugt A, de Miquel MA, Donnan GA, Roos YB, Bonafe A, Jahan R, DienerHC, van den Berg LA, Levy EI, Berkhemer OA, Pereira VM, Rempel J, Millán M, Davis SM, Roy D, Thornton J, Román LS, Ribó M, Beumer D, Stouch B, Brown S, Campbell BC, van Oostenbrugge RJ, Saver JL, Hill MD, Jovin TG; HERMES collaborators.. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016 Apr 23;387(10029):1723-31

27.8% mRS ≤ 2

45.9% mRS ≤ 2

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ACO: Cervical

• Paciaroni et al. (J Neurology, 2015)– ICARO-3 study – 648 pts (non-randomized)

• 65 years mean age – median NIHSS 16– 11 - 14% dissection

• IVT vs. EVT (16% stent, 66% IA tPA)– 27% vs. 32% mRS ≤ 2, p = 0.1

» 27 vs. 35% mRS ≤ 2, p = 0.05 adjusted for non-dual tx– Complications

» 17% vs. 37% sICH, p = 0.0001» 23% vs. 18% mortality, p = 0.07

Paciaroni M, Inzitari D, Agnelli G, Caso V, Balucani C, Grotta JC, Sarraj A, Sung-Il S, Chamorro A, Urra X, Leys D, Henon H, Cordonnier C, Dequatre N, Aguettaz P, Alberti A, Venti M, Acciarresi M, D'Amore C, Zini A, Vallone S, Dell'Acqua ML, Menetti F, Nencini P, Mangiafico S, Barlinn K, Kepplinger J, Bodechtel U, Gerber J, Bovi P, Cappellari M, Linfante I, DabusG, Marcheselli S, Pezzini A, Padovani A, Alexandrov AV, Shahripour RB, Sessa M, Giacalone G, Silvestrelli G, Lanari A, Ciccone A, De Vito A, Azzini C, Saletti A, Fainardi E, Orlandi G, Chiti A, Gialdini G, Silvestrini M, Ferrarese C, Beretta S, Tassi R, Martini G, Tsivgoulis G, Vasdekis SN, Consoli D, Baldi A, D'Anna S, Luda E, Varbella F, Galletti G, Invernizzi P, DonatiE, De Lodovici ML, Bono G, Corea F, Sette MD, Monaco S, Riva M, Tassinari T, Scoditti U, Toni D. Intravenous thrombolysis or endovascular therapy for acute ischemic stroke associated with cervical internal carotid artery occlusion: the ICARO-3 study. J Neurol. 2015 Feb;262(2):459-68

ACO: Mixed

• Gliem et al. (PLOS ONE, 2017)– 78 pts

• 43 cervical only, 35 Tandem (6 dissection)• Overall

– Cervical (43): median NIHSS 8; 58% mRS ≤ 3 – Tandem (35): median NIHSS 16; 29% mRS ≤ 3; p <

0.001, p = 0.01.» sICH

• 4.3% vs. 29% (IV vs. EVT)

Gliem M, Lee JI, Barckhan A, Turowski B, Hartung HP, Jander S. Outcome and Treatment Effects in Stroke Associated with Acute Cervical ICA Occlusion. PLoS One. 2017 Jan 12;12(1

ACO: Mixed

• Gliem et al. (PLOS ONE, 2017)– 27 non-treated

• Cervical (21): 67% mRS ≤ 3• Tandem (6): 0% mRS ≤ 3, p = 0.006

– 51 treated• Cervical (22)

– IV (10): 40% mRS ≤ 3– IV+EVT (12): 58% mRS ≤ 3; p = 0.67

• Tandem (29)– IV (13): 8% mRS ≤ 3– IV+EVT (16): 57% mRS ≤ 3; p = 0.008

Gliem M, Lee JI, Barckhan A, Turowski B, Hartung HP, Jander S. Outcome and Treatment Effects in Stroke Associated with Acute Cervical ICA Occlusion. PLoS One. 2017 Jan 12;12(1

TECHNIQUE

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ACO: Technique

• IA thrombolysis

• Angioplasty

• Stenting• Approach

– Proximal-to-distal– Distal-to-proximal

ACO: Technique

• Access– 10F sheath

• Triaxial system– 9F Balloon guide– ≥ 5F intermediate/aspiration– 0.027 microcatheter

• 0.14 – 0.16 microwire

• Technique– Define true lumen– Distal access ≥ 5F intermediate/aspiration

ACO: Technique

• Spiotta et al. (JNIS, 2014)– 16 pts (Tandem)

• 68 years mean age (± 12.3)• Median NIHSS 13• Proximal-to-distal• Outcome

– 100%TICI 2b/3 – 56% mRS ≤ 2

• Complications– 6% sICH– 19% Mortality

Spiotta AM, Lena J, Vargas J, Hawk H, Turner RD, Chaudry MI, Turk AS. Proximal to distal approach in the treatment of tandem occlusions causing an acute stroke. J Neurointerv Surg. 2015 Mar;7(3):164-9

ACO: Technique

Spiotta AM, Lena J, Vargas J, Hawk H, Turner RD, Chaudry MI, Turk AS. Proximal to distal approach in the treatment of tandem occlusions causing an acute stroke. J Neurointerv Surg. 2015 Mar;7(3):164-9

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ACO: Technique

• Marnet et al. (AJNR, 2016)– 57/258 pts (22% Tandem)

• 8% dissection• 63 years mean age

– 52 vs. 67 (dissection vs. non-dissection), p < 0.05

• Median NIHSS 17.5• Complications

– 5% sICH– 19% Mortality

Marnat G, Mourand I, Eker O, Machi P, Arquizan C, Riquelme C, Ayrignac X, Bonafé A, Costalat V. Endovascular Management of Tandem Occlusion Stroke Related to Internal Carotid Artery Dissection Using a Distal to Proximal Approach: Insight from the RECOST Study. AJNR Am J Neuroradiol. 2016 Jul;37(7):1281-8

ACO: Technique

• Marnet et al. (AJNR, 2016)– 57/258 pts (22% Tandem)

• Distal-to-proximal approach– 25% dissection cases required stent– Dissection vs. Non-dissection

» 70% vs. 82% TICI2b/3» 70% vs. 50% ≤ mRS 2

Marnat G, Mourand I, Eker O, Machi P, Arquizan C, Riquelme C, Ayrignac X, Bonafé A, Costalat V. Endovascular Management of Tandem Occlusion Stroke Related to Internal Carotid Artery Dissection Using a Distal to Proximal Approach: Insight from the RECOST Study. AJNR Am J Neuroradiol. 2016 Jul;37(7):1281-8

ACO: Technique

• Lockau et al. (Neuroradiology, 2015)– 37/245 pts (15% Tandem)

• 35% dissection• 63 years mean age

– 52 vs. 68 (dissection vs. non-dissection), p < 0.01

• Median NIHSS 17• Outcome

– 73%TICI 2b/3 – 46% mRS ≤ 2

• Complications– 11% sICH– 19% Mortality

Lockau H, Liebig T, Henning T, Neuschmelting V, Stetefeld H, Kabbasch C, Dorn F. Mechanical thrombectomy in tandem occlusion: procedural considerations and clinical results. Neuroradiology. 2015 Jun;57(6):589-98

ACO: Technique

• Lockau et al. (Neuroradiology, 2015)– 37 pts

• 32% Proximal-to-distal• 68% Distal-to-proximal

– PTD vs. DTP: » 110 min vs. 43 min, p < 0.001» 33% vs. 52% mRS ≤ 2, p = 0.319

Lockau H, Liebig T, Henning T, Neuschmelting V, Stetefeld H, Kabbasch C, Dorn F. Mechanical thrombectomy in tandem occlusion: procedural considerations and clinical results. Neuroradiology. 2015 Jun;57(6):589-98

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MEDICATION

ACO: Medication

• Antiplatelet– Procedure vs. post-procedure– Single vs. dual– IV – PO/NG/PR

ACO: Medication

• Xian et al. (JAMA Neurology, 2016)– 85,072 pts (IV tPA)

• 45.7% (38,844) antiplatelet +– 5% vs. 3.7% sICH

» AOR 1.19 ASA» AOR 1.47 ASA and Clopidogrel

– 2% antiplatelet > non-antiplatelet, mRS ≤ 1» AOR 1.14

Xian Y, Federspiel JJ, Grau-Sepulveda M, Hernandez AF, Schwamm LH, Bhatt DL, Smith EE, Reeves MJ, Thomas L, Webb L, Bettger JP, Laskowitz DT, Fonarow GC, Peterson ED. Risks and Benefits Associated With Prestroke Antiplatelet Therapy Among Patients With Acute Ischemic Stroke Treated With Intravenous Tissue Plasminogen Activator. JAMA Neurol. 2016 Jan;73(1):50-9

Conclusions

• Acute carotid intervention is safe and effective– Time to revascularization - Brain– Mechanical thrombectomy

• Avoid IA thrombolysis

• Dissection vs. other• Stenting

– Hemorrhage vs. thrombosis• Monotherapy first 24hrs

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Thank you

Questions?

Daniel.cooke@ucsf.edu

ACO: Tandem

• Sivan-Hoffman et al. (ER, 2017)– Meta analysis – 237 pts

• 193 pts cervical stenting• Median NIHSS 17• 83% TICI 2b/3

• 46% mRS ≤ 2– 13% mortality – 4% sICH

Sivan-Hoffmann R, Gory B, Armoiry X, Goyal M, Riva R, Labeyrie PE, Lukaszewicz AC, Lehot JJ, Derex L, Turjman F. Stent-Retriever Thrombectomy for Acute Anterior Ischemic Stroke with Tandem Occlusion: A Systematic Review and Meta-Analysis. Eur Radiol. 2017 Jan;27(1):247-254

ACO: Mixed

• Delgado et al. (JNIS, 2016)– 24 pts (dissection)

• 47 years mean age (± 13.5)– 79% male– median NIHSS 16

• 11 cervical only, 13 Tandem – Cervical (11): 72% mRS ≤ 2– Tandem (13): 69% mRS ≤ 2

Delgado F, Bravo I, Jiménez E, Murías E, Saiz A, Vega P, López-Rueda A, Blasco J, Macho J, González A. Endovascular treatment in the acute and non-acute phases of carotid dissection: a therapeutic approach. J Neurointerv Surg. 2017 Jan;9(1):11-16

ACO: Mixed

• Delgado et al. (JNIS, 2016)– Tandem

• 87.5% TICI 2b/3

– Complications (all) • 8% sICH• 21% emboli

– 11% associated with ICA recanalization

• 4% mortality

Delgado F, Bravo I, Jiménez E, Murías E, Saiz A, Vega P, López-Rueda A, Blasco J, Macho J, González A. Endovascular treatment in the acute and non-acute phases of carotid dissection: a therapeutic approach. J Neurointerv Surg. 2017 Jan;9(1):11-16

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ACO: Mixed

• Kurre et al. (INR, 2016)– 73/1603 pts (dissection, 4.6%)

• 48 years mean age (31- 71)– 67% male

• 29 cervical only, 44 Tandem – Cervical (29): median NIHSS 7; 79% mRS ≤ 2– Tandem (44): median NIHSS 12; 55% mRS ≤ 2, p =

0.002; 0.047

Kurre W, Bansemir K, Aguilar Pérez M, Martinez Moreno R, Schmid E, Bäzner H, Henkes H. Endovascular treatment of acute internal carotid artery dissections: technical considerations, clinical and angiographic outcome. Neuroradiology. 2016 Dec;58(12):1167-1179

ACO: Mixed

• Kurre et al. (INR, 2016)– Tandem

• 85% TICI 2b/3– 84% Proximal-to-distal

» 48% complete– 16% Distal-to-proximal

– Complications (all) • 5% sICH• 21% emboli

– 11% associated with ICA recanalization

• 10% mortality

Kurre W, Bansemir K, Aguilar Pérez M, Martinez Moreno R, Schmid E, Bäzner H, Henkes H. Endovascular treatment of acute internal carotid artery dissections: technical considerations, clinical and angiographic outcome. Neuroradiology. 2016 Dec;58(12):1167-1179