Instant Reocclusion following Mechanical Thrombectomy of in situ Thromboocclusion and the Role of Low-Dose Intra-Arterial TirofibanKang D.-H.a, c · Kim Y.-W.a, b · Hwang Y.-H.b · Park S.-P.b · Kim Y.-S.a · Baik S.K.d
Departments of aRadiology, bNeurology and cNeurosurgery, Kyungpook National University Hospital, Daegu, and dDepartment of Radiology, Pusan National University Yangsan Hospital, Pusan, Republic of Korea
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Background: An in situ thromboocclusion (IST) is defined as an infarct extensively involving all or most of a stenosed arterial territory, which is one major stroke mechanism related to intracranial atherosclerosis (ICAS). We focused on ISTs occurring in major cerebral arteries and analyzed their rate of instant reocclusion during mechanical thrombectomy (MT) compared with non-ISTs. Also, we introduced a treatment strategy of low-dose intra-arterial tirofiban administration to prevent such reocclusion following repeat recanalization, and evaluated its safety and efficacy. Methods: We analyzed 168 consecutive patients treated with MT over a 2-year period from May 2011 to April 2013. During MT, if angiography following a successful recanalization showed stenosis at the occlusion site, we performed additional angiographic runs every 10 min for 30 min after the recanalization. Then, if angiography revealed reocclusion, we performed a repeat recanalization, using the same MT technique but additionally followed by low-dose intra-arterial tirofiban infusion. Time-of-flight MR angiography or CT angiography was performed to confirm any underlying ICAS at the occlusion site 5-7 days after the procedure. The patients who had confirmed underlying ICAS were included in the IST cohort. Results: Of 168 enrolled patients, we excluded 36 who could not be checked for underlying ICAS at the occlusion site for one of the following reasons: recanalization failure (n = 11), rescue stenting after tirofiban failure (n = 5) and lack of follow-up vascular imaging (n = 20). The incidence of IST was 30.3% (40/132). All IST patients were confirmed to have underlying ICAS by follow-up vascular imaging. Instant reocclusion after successful recanalization was significantly more frequent in the IST cohort [26/40 (65%) vs. 3/92 (3.3%); p < 0.001]. Regarding the efficacy of low-dose intra-arterial tirofiban infusion, 85.7% of the reocclusion patients finally achieved a thrombolysis in cerebral infarction score 2/3 recanalization, but in the remaining 14.3% of the cases, the condition was refractory to the procedure and required rescue stenting. There were no cases of symptomatic intracranial hemorrhage following the procedure. Conclusions: In situ thromboocclusion was characterized by a significantly higher chance of instant reocclusion during MT. In such cases, low-dose intra-arterial tirofiban administration may be effective and safe. However, future confirmation by prospective multicenter trials seems necessary.
© 2014 S. Karger AG, Basel
- Kim JS, Nah H-W, Park SM, Kim S-K, Cho KH, Lee J, Lee Y-S, Kim J, Ha S-W, Kim E-G, Kim D-E, Kang D-W, Kwon S-U, Yu K-H, Lee B-C: Risk factors and stroke mechanisms in atherosclerotic stroke: intracranial compared with extracranial and anterior compared with posterior circulation disease. Stroke 2012;43:3313-3318.
Qureshi AI, Siddiqui AM, Kim SH, Hanel RA, Xavier AR, Kirmani JF, et al: Reocclusion of recanalized arteries during intra-arterial thrombolysis for acute ischemic stroke. AJNR Am J Neuroradiol 2004;25:322-328.
- Heo JH, Lee KY, Kim SH, Kim DI: Immediate reocclusion following a successful thrombolysis in acute stroke: a pilot study. Neurology 2003;60:1684-1687.
- Janjua N, Alkawi A, Suri MFK, Qureshi AI: Impact of arterial reocclusion and distal fragmentation during thrombolysis among patients with acute ischemic stroke. AJNR Am J Neuroradiol 2008;29:253-258.
- Ohman EM, Califf RM, Topol EJ, Candela R, Abbottsmith C, Ellis S, et al: Consequences of reocclusion after successful reperfusion therapy in acute myocardial infarction. TAMI Study Group. Circulation 1990;82:781-791.
- Gibson CM, Cannon CP, Piana RN, Breall JA, Sharaf B, Flatley M, et al: Angiographic predictors of reocclusion after thrombolysis: results from the Thrombolysis in Myocardial Infarction (TIMI) 4 trial. J Am Coll Cardiol 1995;25:582-589.
- Valenti R, Vergara R, Migliorini A, Parodi G, Carrabba N, Cerisano G, et al: Predictors of reocclusion after successful drug-eluting stent-supported percutaneous coronary intervention of chronic total occlusion. J Am Coll Cardiol 2013;61:545-550.
- Kellert L, Hametner C, Rohde S, Bendszus M, Hacke W, Ringleb P, Stampfl S: Endovascular stroke therapy: tirofiban is associated with risk of fatal intracerebral hemorrhage and poor outcome. Stroke 2013;44:1453-1455.
- Kwon J-H, Shin SH, Weon YC, Hwang JC, Baik SK: Intra-arterial adjuvant tirofiban after unsuccessful intra-arterial thrombolysis of acute ischemic stroke: preliminary experience in 16 patients. Neuroradiology 2011;53:779-785.
- Kang DH, Kim YW, Hwang YH, Park J, Hwang JH, Kim YS: Switching strategy for mechanical thrombectomy of acute large vessel occlusion in the anterior circulation. Stroke 2013;44:3577-3579.
- Kang DH, Hwang YH, Kim YS, Park J, Kwon O, Jung C: Direct thrombus retrieval using the reperfusion catheter of the Penumbra System: forced-suction thrombectomy in acute ischemic stroke. AJNR Am J Neuroradiol 2011;32:283-287.
- Saver JL, Jahan R, Levy EI, Jovin TG, Baxter B, Nogueira RG, Clark W, Budzik R, Zaidat OO, et al: Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial. Lancet 2012;380:1241-1249.
- Higashida RT, Furlan AJ, Roberts H, Tomsick T, Connors B, Barr J, et al: Trial design and reporting standards for intra-arterial cerebral thrombolysis for acute ischemic stroke. Stroke 2003;34:e109-e137.
- Hacke W, Kaste M, Fieschi C, von Kummer R, Davalos A, Meier D, Larrue V, Bluhmki E, Davis S, Donnan G, Schneider D, Diez-Tejedor E, Trouillas P: Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European-Australasian Acute Stroke Study Investigators. Lancet 1998;352:1245-1251.
- Nogueira RG, Lutsep HL, Gupta R, Jovin TG, Albers GW, Walker GA, Libeskind DS, Smith WS, et al: Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trial. Lancet 2012;380:1231-1240.
- Pagola J, Rubiera M, Flores A, Rodríguez-Luna D, Piñeiro S, Muchada MA, Quintana M, Alvarez-Sabin J, Molina CA, Ribo M: Selecting endovascular treatment strategy according to the location of intracranial occlusion in acute stroke. Cerebrovasc Dis 2013;35:502-506.
- Kimura K, et al: Atrial fibrillation as a predictive factor for severe stroke and early death in 15,831 patients with acute ischaemic stroke. J Neurol Neurosurg Psychiatry 2005;76:679-683.
- Michel P, Odier C, Rutgers M, Reichhart M, Maeder P, Meuli R, et al: The Acute STroke Registry and Analysis of Lausanne (ASTRAL): design and baseline analysis of an ischemic stroke registry including acute multimodal imaging. Stroke 2010;41:2491-2498.
- Siebler M, Hennerici MG, Schneider D, von Reutern GM, Seitz RJ, Röther J, Witte OW, Hamann G, Junghans U, Villringer A, Fiebach JB: Safety of Tirofiban in acute Ischemic Stroke: the SaTIS trial. Stroke 2011;42:2388-2392.
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