Giannopoulos, Stefanos

Abstract BACKGROUND Recent randomized control trials (RCTs) established that mechanical thrombectomy is superior to medical therapy for patients with stroke due to a large vessel occlusion. OBJECTIVE To compare the safety and efficacy profile of the different mechanical thrombectomy strategies. METHODS A random-effects meta-analysis was performed and the I 2 statistic was used to assess heterogeneity according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. RESULTS Nineteen studies with a total of 2449 patients were included. No differences were identified between the stent retrieval and direct aspiration groups in terms of modified Thrombolysis in Cerebral Infarction (mTICI) 2b/3 and mTICI 3 recanalization rates, and favorable outcomes (modified Rankin Scale [mRS] ≤ 2). Adverse event rates, including 90-d mortality, symptomatic intracerebral hemorrhage (sICH), and subarachnoid hemorrhage (SAH), were similar between the stent retrieval and direct aspiration groups. The use of the stent retrieval was associated with a higher risk of vasospasm (odds ratio [OR]: 2.98; 95% confidence interval [CI]: 1.10-8.09; I 2 : 0%) compared to direct aspiration. When compared with the direct aspiration group, the subgroup of patients who underwent thrombectomy with the combined approach as a first-line strategy had a higher likelihood of successful mTICI 2b/3 (OR: 1.47; 95% CI: 1.02-2.12; I 2 : 0%) and mTICI 3 recanalization (OR: 3.65; 95% CI: 1.56-8.54), although with a higher risk of SAH (OR: 4.33; 95% CI: 1.15-16.32). CONCLUSION Stent retrieval thrombectomy and direct aspiration did not show significant differences. Current available evidence is not sufficient to draw conclusions on the best surgical approach. The combined use of a stent retriever and aspiration as a first-line strategy was associated with higher mTICI 2b/3 and mTICI 3 recanalization rates, although with a higher risk of 24-h SAH, when compared with direct aspiration.

Purpose: To examine the safety profile of transcervical access (TCA) in comparison with the transfemoral approach (TFA) in carotid artery stenting. Materials and Methods: A systematic review and meta-analysis was performed according to current guidelines. Eleven eligible studies including 11,592 patients (10,736 in the TFA group and 856 in the TCA group) were identified through a search of the PubMed, Scopus, and Cochrane databases up to October 2018. A random effects model meta-analysis was conducted, and the I 2 statistic was used to assess heterogeneity. Publication bias was assessed using funnel plots and quantified using the Egger method. Results: The TFA group had a statistically significantly higher risk of periprocedural (30-day) stroke compared with the TCA group (OR 1.98, 95% CI 1.08 to 3.63, p=0.027; I 2 =0%). Also, patients in the TFA group had a significantly higher risk of developing new ischemic lesions (OR 2.97, 95% CI 1.48 to 5.96, p=0.002; I 2 =0%) on diffusion-weighted magnetic resonance imaging (DW-MRI). No differences in terms of transient ischemic attack (OR 1.50, 95% CI 0.73 to 3.10, p=0.268; I 2 =5.9%), myocardial infarction (OR 0.64, 95% CI 0.30 to 1.35; p=0.242; I 2 =0%), local hematoma (OR 0.53, 95% CI 0.12 to 2.25, p=0.389; I 2 =0%), or mortality (OR 1.35, 95% CI 0.62 to 2.92, p=0.449; I 2 =0%) were identified between the groups. Conclusion: TCA is associated with a significantly lower risk for periprocedural stroke and DW-MRI ischemic lesions compared with TFA. Other periprocedural outcomes were similar between the groups.

Purpose:To compare periprocedural complications and in-stent restenosis rates associated with open- vs closed-cell stent designs used in carotid artery stenting (CAS). Methods: A systematic search was conducted to identify all randomized and observational studies published in English up to October 31, 2017, that compared open- vs closed-cell stent designs in CAS. Identified studies were included if they reported the following outcomes: stroke, transient ischemic attack (TIA), myocardial infarction (MI), hemodynamic depression, new ischemic lesions detected on imaging, and death within 30 days, as well as the incidence of in-stent restenosis. A random-effects model meta-analysis was employed. Model results are reported as the odds ratio (OR) and 95% confidence interval (CI). The I 2 statistic was used to assess heterogeneity. Results: Thirty-three studies (2 randomized trials) comprising 20, 291 patients (mean age 71.3±3.0 years; 74.6% men) were included. Patients in the open-cell stent group had a statistically significant lower risk of restenosis ⩾40% (OR 0.42, 95% CI 0.19 to 0.92; I 2 =0%) and ⩾70% (OR 0.23, 95% CI 0.10 to 0.52; I 2 =0%) at a mean follow-up of 24 months. No statistically significant differences were identified for periprocedural stroke, TIA, new ischemic lesions, MI, hemodynamic depression, or death within 30 days after CAS. Sensitivity analysis of the 2 randomized controlled trials only did not point to any significant differences either. Conclusion: Use of open-cell stent design in CAS is associated with a decreased risk for restenosis when compared to the closed-cell stent, without significant differences in periprocedural outcomes.