Balloon-Expandable Stenting as a Bridging Therapy in Patients With Acute Stroke and Tandem Occlusions

Stenting extracranial internal carotid artery (ICA) lesions in acute ischemic stroke with tandem lesions is technically challenging. Its safety is highly debated because of the requirement of dual-antiplatelet therapy. The optimal stenting device, timing, and periprocedural antiplatelet therapy for extracranial ICA stenting in the setting of acute tandem occlusion are still unclear.

We performed a retrospective study of patients with acute ischemic stroke attributable to tandem lesions who underwent endovascular treatment during a 5-year period receiving either conventional self-expanding carotid stents (SX) or balloon-expandable carotid stent (BX). BX stents were restented with an SX in the subacute phase. Primary outcomes of interest were extracranial ICA patency at follow-up and symptomatic intracranial hemorrhage.

A total of 112 patients admitted from April 2016 to April 2021 were included. Dual-antiplatelet therapy immediately following endovascular treatment was more frequently administered in the SX group (35/39 [89.7%]) compared with the BX group (20/73 [27.4%]) (P<0.001). Patients in the BX stent group (3/73 [4.1%]) developed a lower rate of symptomatic intracranial hemorrhage compared with patients in the SX stent group (7/39 [17.9%]) (P=0.031). No differences in extracranial ICA high-grade restenosis or reocclusion were found between groups at 24 hours after procedure (BX: 20/73 [27.4%]; SX: 9/39 [23.1%]; P=0.673).

In patients with acute ischemic stroke and tandem occlusions, a bridging therapy including BX stents with less-aggressive antiplatelet therapy and subsequent definitive SX stenting to treat extracranial ICA lesions resulted in a lower rate of symptomatic hemorrhagic transformation and no differences in stent patency.