Rescue angioplasty and stenting in refractory acute vertebrobasilar occlusion after mechanical thrombectomy: A single center experience.

Abstract

Objective: Acute vertebrobasilar occlusion can led to a fatal outcome, but lack of established procedures poses many difficulties in its management. Although mechanical thrombectomy (MT) has shown positive outcomes recently, high reocclusion rate remains a hurdle. This study is to share experience and to review technical challenges of rescue angioplasty and/or stenting (RAS) for refractory occlusions after MT in posterior circulation ischemic stroke (PCIS).

Methods: Out of 494 patients with acute ischemic stroke from January 2014 to December 2022 in a Hospital, PCIS was identified in 50 patients. 2 extracranial vertebral artery occlusion patients were excluded. For 48 patients, MT was applied as the primary treatment. RAS was done for reocclusion after MT in 15 patients. We evaluated patient characteristics and clinical course, emphasizing the technical aspects of treatment.

Results: Compared to those without rescue procedures, RAS group had a higher percentage of large artery atherosclerosis as an etiology (p<0.001), long segment occlusions (p=0.03), and was more likely to involve posterior inferior cerebellar artery (p=0.007). There was no difference in functional outcome at 6 months between these two groups. Reopening could not achieve (N=2, 13.3%) and procedural complication rate (iatrogenic rupture) is 6.7% in RAS group. Rescue procedures were complicated with dissection, plaque rupture and migration, device damage, and misplacement of the balloon/stent. Avoiding these traps, finding true lumen, and reconstructing the flow by connecting the proximal and distal normal were the keys to the successful RAS.

Conclusions: RAS could be inevitable during endovascular treatment for PCIS and being aware of possible events and technical strategies would navigate interventionists to successful recanalization and the better outcomes.