JACC: CAS can help curb carotid artery occlusions
For patients with acute atherosclerotic extracranial internal carotid artery occlusions, carotid artery stenting (CAS) may be a feasible and safe option, at least within the first six hours of symptom onset, according to a study published in the Nov. 29 issue of the Journal of the American College of Cardiology. An accompanying editorialist summed that rather than continue “turf wars,” interventionalists must work together on stroke teams to perform CAS, which could expand on-call stroke coverage and improve stroke care.

“The treatment of extracranial internal carotid artery (ICA) occlusions is a dramatic challenge because IV thrombolysis has low recanalization rates, ranging from 4 percent to 32 percent depending on the vessel (4 percent for ICA occlusions and 32 percent for middle cerebral artery [MCA] occlusions),” Panagiotis Papanagiotou, MD, of Saarland University Hospital in Homburg, Germany, and colleagues wrote. “For these types of lesions, treatment with standard IV thrombolysis alone leads to a good clinical outcome in only 17 percent of the cases with a death rate of as high as 55 percent.”

To better understand the technical successes of CAS for acute extracranial ICA occlusion, Papanagiotou et al enrolled 22 patients who underwent CAS within six hours of symptom onset. Eighteen of the patients had an additional intracranial occlusion at the level of the terminal segment of the ICA and at the level of the middle cerebral artery. The intracranial occlusions were treated with either the Penumbra system of the Solitaire stent-based recanalization system or a combination mechanical recanalization and intra-arterial thrombolysis strategy.

The researchers analyzed the results of recanalization procedures via angiography post-procedure, and patients’ neurologic status was evaluated prior to and post-procedure.

The authors reported that revascularization was successful in 21 patients, and that there was no acute stent thrombosis that occurred during the study. A TIMI flow grade of 2 or 3 was achieved in 11 of the 18 patients and the overall recanalization rate was 63 percent.

Additionally, the authors reported that 41 percent of patients had a modified Rankin Scale score of equal two or less than two at 90 days. The mortality rate was 13.6 percent at 90 days; these patients died of a large infarction and swelling of the brain.

“Successful recanalization of the occluded vessels is associated with improved outcome after acute ischemic stroke,” the authors added.

While the authors noted that it is common practice to administer dual-antiplatelet therapy one day prior to intervention, the ideal medical regimen for CAS procedures for acute stroke remains unknown. “[I]t must be borne in mind that aggressive anticoagulation, especially in combination with thrombolytics, may increase the risk of ICH,” the authors wrote.

“These data indicate that CAS in acute atherosclerotic extracranial ICA occlusion with severe stroke symptoms is feasible, safe, and beneficial if performed within the first six hours,” the authors concluded.

In an accompany editorial, Christopher J. White, MD, of the Ochsner Medical Institutions in New Orleans, said, “Unfortunately, American medicine has failed to make 'on-demand' (24 h/day, seven days a week, 365 days a year) reperfusion therapy as accessible for stroke as it has for heart attacks.

“Our failure to offer timely on-demand access to stroke reperfusion therapy is a national healthcare embarrassment—an 'elephant in the room' that no one is talking about. The only way to let this elephant out of the room is to remove the barriers to on-demand stroke reperfusion therapy,” White offered.

While IV tissue plasminogen activator (t-PA) for acute stroke was approved by the FDA in 1996 (only if administered within three hours after onset to patients without contraindications), this treatment strategy is used in only 2 percent of stroke patients. White offered that the main reasons these patients are not treated with IV t-PA are due to the fact that they present too late (three to four and a half hours after symptom onset) or are poor candidates for IV t-PA.

Many of these patients receive catheter-based reperfusion therapy, but “due to manpower shortages of specialized stroke physicians, there are few hospitals that offer on-demand, catheter-based stroke therapy,” White noted. “One way to lessen the impact of the limited number of stroke neurologists is to use telemedicine. With an effective telemedicine program, a single stroke neurologist can support acute stroke care in multiple remote hospitals.”

Another solution that could help curb this issue is utilizing CAS, which is oftentimes performed by a variety of different specialties with a multidisciplinary team.

“American medicine cannot afford to allow political infighting to constrain the number of willing interventionalists from participating in acute stroke care,” White concluded. “We can improve access to on-demand stroke therapy with telemedicine systems that allow a stroke neurologist to participate in the care of stroke patients at multiple sites, and we can dramatically increase stroke interventionalists by recruiting CAS-capable providers to the stroke team."

White summed: “The time has come for a patient-focused national quality mandate to improve on-demand access to stroke reperfusion therapy. We did it for heart attacks. Now we need to do it for strokes.”