Recanalizaiton Of Symptomatic Non-acute Intracranial And Extracranial Large Artery Occlusion

Part One : Outcomes of late endovascular recanalization for symptomatic non-acute atherosclerotic intracranial large artery occlusionObjectives: The optimal treatment of symptomatic non-acute atherosclerotic intracranial large artery occlusion(NAILAO)beyond 24 h from onset remains uncertain.We investigate the outcomes of late endovascular recanalization for symptomatic NAILAO.Methods: From September 2013 to July 2018,with safety as the first principle,late endovascular recanalization for symptomatic NAILAO beyond 24 h from onset was attempted in 32 consecutive patients.Primary efficacy outcome was technical success of recanalization with Thrombolysis in Cerebral Infarction grade of 2b or 3 on catheter angiography at the end of the final procedure.Primary safety outcome was any stroke or death within 30 days.Secondary efficacy outcome was functional independence at 90 days(modified Rankin Scale,m RS:0-2).Results: The median time from imaging-documented occlusion to treatment was 25.5 days(interquartile range:10.5–36.5)for all patients.Technical success in recanalization was achieved in 17 patients(53.1%,17/32).The overall 30-day rate of any stroke or death was 6.3%(2/32)in all patients.There was no statistical difference in 30-day rate of any stroke or death between the recanalization group(5.9%,1/17)and the failure group(6.7%,1/15)(P= 0.927).The rate of functional independence at 90 days(70.5%,12/17)was increased significantly as compared with that before operation(23.5%,4/17)in the recanalized group(P = 0.015).The rate of functional independence at 90 days(66.7%,10/15)was not different from that before operation(66.7%,10/15)in the failure group(P = 1.00).The median score reduction in m RS from baseline at 90 days was 1.0(interquartile range: 1.0–2.0)in the recanalized group versus 0(interquartile range: 0.0-0.0)in the failure group(P<0.001).Conclusion: For carefully selected patients with symptomatic NAILAO beyond 24 h from onset,late endovascular recanalization is technically feasible.The periprocedural safety of late endovascular recanalization is acceptable,which still needs to be further improved.Successful recanalization may effectively improve the degree of disability in such patients.However,it should be emphasized that revascularization of NAILAO is a high risk procedure,which should only be performed by experienced operators with safety as the first principle.Part Two:Outcomes of multimodal in situ recanalization for symptomatic chronic internal carotid artery occlusionObjectives: To investigate the outcomes of multimodal in situ recanalization for symptomatic chronic internal carotid artery occlusion(CICAO).Methods: Between May 2014 and October 2018,78 consecutive patients with symptomatic CICAO underwent multimodal in situ recanalization at our center.Multimodal in situ recanalization includes endovascular therapy(ET),carotid endarterectomy(CEA),and hybrid surgery.Primary end points: 1)technical success of recanalization with Thrombolysis in Cerebral Infarction grade of 2b or 3 on catheter angiography at the end of the final procedure;2)any stroke or death within 30 days after operation,and ipsilateral transient ischemic attack(TIA)or ischemic stroke from day 31 to one year after operation.Secondary endpoints: 1)functional independence at 90 days(modified Rankin Scale,m RS:0-2);disabling stroke within one year;3)ipsilateral ischemic stroke or transient ischemic attack(TIA)from day 31 to one year after operation.Results: A total of 58 patients were successfully recanalized,of which 11 were recanalized with ET(19.0%,11/58),8 were recanalized with CEA(13.8%,8/58),and 39 were recanalized with hybrid surgery(67.2%,39 / 58).The overall recanalization rate of multimodal in situ recanalization was 74.4%(58/78),which was significantly higher than 24.4%(19/78)from the ET or CEA alone(P <0.001).The median duration of clinical follow-up was 24.0 months(interquartile range: 12.8-42.0)for all patients.All patients had clinical follow-up of ?1 year.The overall rate of the primary end point in the two groups was 9.0%(7/78).There was no statistical difference in primary end points within 1 year between the recanalization group(10.3%,6/58)and the failure group(15.0%,3/20)(P= 0.687).The thirty-day rate of ischemic stroke was 9.0%(7/78)for all patients.There was no statistical difference in thirty-day rates of ischemic stroke between the recanalization group(10.3%,6/58)and the failure group(5.0%,1/20)(P= 0.670).The rate of disabling stroke within 1 year in the recanalization group was 1.7%(1/58),and the difference was not statistically significant compared with the failure group(5.0%,1/20)(P = 0.450).The median score reduction in m RS from pre-operation at 90 days was 0.0(interquartile range: 0.0–1.0)in the recanalization group versus 0(interquartile range: 0.0-0.0)in the failure group(P=0.012).The rate of ipsilateral ischemic stroke or TIA between day 31 and 1 year was 1.7%(1/58)in the recanalization group,which was significantly lower than that in the failure group(20.0 %,4/20)(odds ratio: 0.09,95% confdence interval: 0.01-0.73,P = 0.014).Conclusion: Our pilot study shows that multimodal in situ recanalization is technically feasible for carefully selected patients with symptomatic CICAO.Compared with the initial ET or CEA alone,multimodal recanalization significantly improves technical success.However,this treatment has a high risk of perioperative stroke,and the safety needs to be further improved.It is not clear whether multimodal in situ recanalization can reduce the incidence of ipsilateral ischemic stroke within 1 year in symptomatic CICAO patients.Part Three:Risk factors for reocclusion after recanalization of symptomatic chronic internal carotid artery occlusionObjectives: To investigate risk factors for reocclusion after multimodal in situ recanalization of symptomatic chronic internal carotid artery occlusion(CICAO).Methods: Between May 2014 and October 2018,a total of 78 consecutive patients with symptomatic CICAO underwent multimodal in situ recanalization at our center.45 patients who were successfully recanalized and followed up with angiography were enrolled into this study.Patients were divided into the reocclusion group and non-reocclusion group according to the results of angiography follow-up.A retrospective analysis of the prospectively registered data was conducted to assess the risk factors for reocclusion after CICAO recanalization.Results: The median duration of clinical follow-up was 20.0 months(interquartile range: 12.0-41.5),and the median follow-up of angiography was 12.0 months(interquartile range: 6.8-18.0).During the follow-up period,11 patients(24.4%,11/45)had internal carotid artery reocclusion,of which 1 was symptomatic.The median time from operation to imaging-diagnosed reocclusion was 7.0 months(interquartile range: 6.0-11.0).Asymptomatic internal carotid artery restenosis occurred in 7 patients(15.6%,7/45),and 5 of which underwent stenting.The cumulative probability of reocclusion at 1 year after operation was 28.1%(95% confidence interval: 9.9%-49.8%).Multivariate Cox regression analysis showed that posttreatment local residual stenosis rate of >50%(hazard ratio: 9.766,95% confidence interval: 1.907-50.011,P = 0.009)and time from imaging-documented occlusion to operation of >90 days(hazard ratio: 4.843,95% confidence interval: 1.358-17.275,P = 0.015)were independent risk factors for reocclusion after CICAO recanalization.Conclusion: Posttreatment local residual stenosis rate of >50% and time from imaging-documented occlusion to operation of >90 days were independent risk factors for reocclusion after CICAO recanalization.