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Endovascular Treatments for Carotid Atherosclerotic Tandem Occlusion

In acute anterior circulation large-vessel occlusion, approximately 10% to 25% of cases involve carotid tandem lesions, characterized by severe stenosis or occlusion of the extracranial internal carotid artery (ICA) concurrently leading to intracranial arterial occlusion (e.g., intracranial ICA, middle cerebral artery, and anterior cerebral artery). Regarding etiologies, TITAN registry revealed that atherosclerosis accounted for approximately 70%, arterial dissection for 20%, cardioembolism for 10%, and other rare causes as carotid web.

The diagnosis of tandem lesion etiologies can be indicated by past medical history, such as atherosclerotic risk factors (e.g., hypertension, diabetes mellitus, hyperlipidemia, smoking) and comorbidities (e.g., coronary artery disease, peripheral artery disease), predisposing factors for arterial dissection (e.g., neck trauma, fibromuscular dysplasia), and cardioembolic etiologies (e.g., atrial fibrillation, valvular heart diseases). However, the crucial diagnostic tools remain preoperative and intraoperative imaging. In atherosclerotic stenosis or occlusion, the occlusion stump may present as a "pipestem" or "linear" sign. On computed tomography angiography (CTA) MIP imaging, plaques, calcifications, and the carotid ring sign may be observed. In multiphase CTA source images, no delayed contrast filling is seen. Relatively better collaterals especially via the ophthalmic artery might be seen. Computed tomography perfusion imaging (CTP) is of great value for identifying intracranial occluded arteries and assessing the infarct core volume; when only multimodal CT (brain NCCT + CTA + CTP) is performed, a longer Tmax threshold (>10 seconds), could be used to identify extracranial carotid stenosis.

Regarding thrombectomy techniques for tandem occlusion, the optimal sequence for intracranial and extracranial lesions remains controversial. Current literature suggests that retrograde treatment may achieve better 90-day functional outcomes, likely due to shorter reperfusion times compared with antegrade treatment(predisposing carotid angioplasty/stenting). However, without an established proximal access, the passage of the aspiration catheter may be challenging. Early techniques such as SEIMLESS and ReWised CARe have been described. Currently, several techniques are widely applied in clinical practice, including the PEARS (Protect-Expand-Aspiration-Revascularization-Stent) technique, Double PT (pass-thrombectomy-protective thrombectomy) technique, RETS (reperfusion-expanding-thrombectomy-stenting) technique using a balloon-guiding catheter (BGC), PEACE (Passing Extracranial Artery Occlusion by Intermediate Catheter With Expanding Microballoon) technique, Dilator-Dotter technique using a conical tip dilator and Neuromax, BATS (BAT-Aspiration-Thrombectomy-Stenting) technique, relay-balloon technique, and LADDER technique. The key concepts of these techniques lies in blood flow control and the proximal and distal protection during carotid angioplasty to prevent thrombus migration and distal embolization. In terms of devices, a proximal access compatible with a 6F intermediate catheter, such as a balloon-guiding catheter or a neuro-long sheath, combined with a large-diameter long stent retriever can efficiently remove large thrombus burdens and reduce the risk of anterior cerebral artery embolism. A preangioplasty small balloon that can shuttle the guiding catheter to cross C1 lesions without restoring antegrade flow in the absence of distal protection devices, and distal protection devices can be deployed and retrieved through a 6F intermediate catheter. Recently, the COSIS (Chronic artery OccluSion recanalization with the Intracranial protection of Stent retriever) technique, originally used for carotid artery chronic occlusion recanalization, has been successfully applied in tandem occlusion thrombectomy cases. This technique utilizes a specific stent retriever deployed through a preangioplasty balloon as the distal protection device, particularly suitable for cases with no significant retrograde flow to the cervical segment and unclear vascular conditions that preclude safety of a distal protection devices. However, exchanging through less supportive stent pusher wire might occasionally lead to system collapse, loss of access to the true lumen and catastrophic consequences.

Carotid artery reocclusion (CRO) is associated with poor clinical outcomes. Carotid stenting is a protective factor against CRO, and closed-cell stents have an even lower reocclusion rate compared with open-cell stents. Although no available randomized controlled trials support concurrent carotid stenting, large registries such as TITAN and ETIS have demonstrated that concurrent stenting may offer benefits for preventing vessel reocclusion, hypoperfusion, and favorable 90 day outcomes without significantly increasing sICH risk. However, individual cases should consider the risks of hyperperfusion hemorrhagic transformation, acute in-stent thrombosis, and tolerance to dual antiplatelet therapy. The typical antiplatelet regimen for emergency stenting is intravenous antiplatelets during the procedure followed by oral dual antiplatelet therapy. Studies have shown that glycoprotein IIb/IIIa inhibitors (GPI) such as tirofiban combined with intravenous thrombolysis is associated with an increased risk of sICH compared with cangrelor plus intravenous thrombolysis or tirofiban alone. The IRIS study showed that superiority of combined IVT to EVT alone was limited to 140minutes on-set time window. Then whether modified paradigms bypassing ER directly to the angio suite apply for tandem occlusion patients beyond 140 minutes but within 6 hours, with NIHSS and ASPECTS scores above 6, to reduce sICH risk, warrants further investigation.

References

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