Endovascular Recanalization of Acute Tandem Cervical Carotid and Intracranial Occlusions: Efficacy of Cervical Balloon Angioplasty Alone Then Intracranial Target Recanalization Strategy

Objective: Tandem cervical carotid and intracranial occlusions are a well-known cause of complicated endovascular thrombectomy (EVT) in acute ischemic stroke. We aimed to evaluate safety and efficacy of an anterograde approach, which involved carotid balloon angioplasty (BA) alone without carotid artery stenting (CAS) followed by intracranial target recanalization (TR). Methods: Between April 2009 and March 2017, 62 patients with tandem lesions confirmed in the cervical carotid and simultaneously in the intracranial arteries had EVT performed to target these lesions. Clinical, imaging, and angiographic outcomes for these patients were analyzed and compared. Results: Overall, successful reperfusion was achieved in 80.6% (50/62) and a favorable outcome in 61.3% (38/62) of patients. BA alone was enough to maintain access for TR in 85.5% (group A and B; 53/62), although more than one half (31/53; group B) required rescue CAS at the end of EVT due to elastic recoil. In contrast, emergent CAS was additionally required for the remaining 9 patients to maintain distal access (group C). In a subgroup comparison, procedure time (PT) to target recanalization was significantly shorter in group A and B than group C (P = 0.002). A multivariate regression model revealed age, parenchymal hematoma, and PT to target recanalization as independent predictors of favorable outcome. Conclusions: EVT for tandem cervical carotid and intracranial occlusions showed optimistic results in terms of clinical and angiographic outcome. The anterograde EVT strategy of cervical BA alone then intracranial TR was effective in 85.5% of patients, which was likely to reduce PT to target recanalization.