Rescue therapy for mechanical thrombectomy refractory occlusions with detachable stent–retrievers and GP IIb/IIIa inhibitors

Abstract

BACKGROUND: Endovascular mechanical thrombectomy with stent–retrievers is an effective and safe treatment in acute stroke patients with anterior circulation proximal occlusions. However, around 25 % of cases the recanalization is not possible, and additional therapies remain controversial. We aim to present our preliminary experience treating refractory occlusions by means of intra–arterial antiplatelets (GP IIb/IIIa inhibitors) and stent detachment.

METHODS: We prospectively studied patients treated with endovascular therapy in our Center in Doha (Qatar), from April 2015 to September 2016. Those with refractory occlusions underwent additional “off protocol” therapy if: 1) low risk of reperfusion bleeding was estimated, 2) high suspicion of underlying unstable atherosclerotic plaque and/or “very sticky clot”, and 3) good pre–procedure collateral status. Different approaches were chosen based on periprocedural findings and expert opinion. Frequency, rescue therapy methodology, clinical and radiological outcome will be described.

RESULTS: During the study period, 39 patients were treated with endovascular therapy. 7 (18 %) did not experience recanalization, and rescue therapy was initiated in 6 (15 %). Of them, 3 cases were treated with early stent detachment followed by a standard dose of IA antiplatelets, whereas 3 were treated with a sequence of stent deployment plus low dose of IA antiplatelets after the second failed pass, followed by stent retrieval and reassessment. All of them experienced complete recanalization, except one case treated only with IA antiplatelets. None of the patient experienced early neurological deterioration, symptomatic hemorrhagic transformation, or re–occlusion at inpatient follow–up MRA. Only one of the patients treated with early stenting presented mRS ≥2 at 90 days, while another had an asymptomatic intra–stent stenosis in a follow up DSA at 6 months.

CONCLUSION: Additional rescue therapy for refractory occlusions to standard mechanical thrombectomy may be a necessary approach to increase the rate of recanalization and good clinical outcome. We describe our early preliminary experience with different techniques, which requires further discussion and study.