How to prevent post MT early reocclusion?

Post-thrombectomy Reocclusion in Acute Ischemic Stroke: Recanalization Strategies and Adjunctive Therapies

Post-thrombectomy reocclusion poses a significant challenge, often leading to recurrent neurological deterioration and poor long-term prognosis. This review aims to provide an in-depth analysis of the mechanisms underlying reocclusion, the risk factors associated with its occurrence, and the current strategies for its prevention and management, with a particular focus on the role of adjunctive pharmacological therapies and the potential benefits of repeat EVT.

Risk Factors for Reocclusion

Underlying mechanisms of reocclusion following EVT could attributed to residual thrombus, arterial stenosis, endothelial injury, and recurrent embolism, and might be further identified by intravascular imaging, such as OCT. Considering the risk factors, the Lausanne cohort study reported a 24-hour reocclusion rate of 6.6%, highlighting the significant impact of residual thrombus or stenosis on the risk of reocclusion. Other factors identified in this study include intracranial internal carotid artery occlusion, transient occlusion during EVT, and atherosclerotic etiology. A meta-analysis of multiple studies revealed a 7-day reocclusion rate of 4.9% within the same vessel, with atherosclerosis being the predominant cause.

Adjunctive Pharmacological Therapies

The role of adjunctive pharmacological therapies in preventing reocclusion following EVT has been a subject of extensive research. The recently published POST-TNK, POST-UK, and ATTENTION-IA trials have all demonstrated that adjunctive intra-arterial thrombolytic therapy, whether with tenecteplase or urokinase, does not significantly improve functional outcomes in patients with near-complete to complete reperfusion (eTICI 2c-3) following EVT, although lacking 24h reocclusion assessment. However, these findings contrast with the CHOICE trial, which reported benefits of intra-arterial alteplase without increasing sICH risk in patients including those with lower reperfusion grades (eTICI 2b-50/67).

In the realm of adjunctive anticoagulants and antiplatelets, the MOST trial and the MR CLEAN MED study have provided valuable insights. The MOST trial demonstrated that intravenous eptifibatide, a glycoprotein IIb/IIIa inhibitor, did not significantly improve clinical outcomes or target vessel reperfusion rates in patients undergoing EVT, although it was found to be safe with no increased risk of symptomatic intracranial hemorrhage. Argatroban, an anticoagulant, showed inefficacy and hemorrhagic side effects similar to heparin in the MR CLEAN MED study. The use of tirofiban, a GPIIbIIIa inhibitor, has also been explored along with a number of EVT studies with or without bailout angioplasty. Data from the BASILAR registry has shown that simultaneous intravenous and intra-arterial tirofiban can improve reperfusion rates and functional outcomes in patients with basilar artery occlusion, especially for large artery atherosclerosis. Several observational studies suggest that tirofiban may be particularly beneficial in patients with severe atherosclerotic disease and vascular wall injury. However, caution is warranted due to the potential for increased symptomatic intracranial hemorrhage with intra-arterial administration, according to data from the ANGEL-ACT and INSPIRE registry.

Repeat Mechanical Thrombectomy

The feasibility and efficacy of repeat EVT in patients with recurrent vessel occlusion have been reported in several studies. Although repeat EVT is relatively rare, it is not without precedent. A multicenter study and systematic review reported that approximately 0.4% of patients underwent a second EVT within 30 days, with an average interval of 4.5 days. Cardiogenic embolism was identified as the most common cause of recurrent occlusion, followed by large artery atherosclerosis. Despite the challenges associated with repeat EVT, 46% of the patients achieved functional independence at 90 days, while 18% succumbed to the disease. These findings suggest that repeat EVT can be a viable option in selected patients, particularly those with recurrent embolism or significant residual stenosis.

Emerging Therapies and Future Directions

A comprehensive understanding of the underlying mechanisms and risk factors is essential for the development of effective preventive strategies. While adjunctive pharmacological therapies and repeat EVT offer potential benefits, their optimal use remains to be fully elucidated. The upcoming INSIST-IT, BRETIS-TNK II, and PROST-2 trials would provide extra evidence regarding the role of adjunctive pharmacological therapies in preventing reocclusion. Additionally, the potential benefits of adjunctive intraarterial and/or intravenous antiplatelets, such as cangrelor, an ADP receptor antagonist with comparable efficacy to prevent reocclusion and even lower hemorrhagic risk, require further verification for extended application.

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