Platelet inhibition strategies in rescue stenting after failed thrombectomy: a large retrospective multicenter registry

Abstract

Intracranial arteriosclerosis; Ischemic stroke; Platelet aggregation inhibitors

Arteriosclerosi intracranial; Ictus isquèmic; Inhibidors de l'agregació plaquetària

Arteriosclerosis intracraneal; Ictus isquémico; Inhibidores de la agregación plaquetaria

Background: Rescue stenting (RS) is a bailout strategy for failed thrombectomy. Optimal platelet inhibition strategy after RS remains unclear. Objectives: We aimed to describe and compare different platelet inhibition strategies during/after RS. Design: Retrospective cohort study across 34 international centers. Methods: Patients with large vessel occlusion and RS after failed thrombectomy (2019–2023) were included. Periprocedural and postprocedural platelet inhibition strategies were described and compared, focusing on glycoprotein IIb/IIIa (GPIIb/IIIa) inhibitors, single antiplatelet therapy (SAPT), and dual antiplatelet therapy (DAPT). We assessed the effects of platelet inhibition strategy and potentially covariates on the primary outcome of 90-day modified Rankin Scale (mRS) using ordinal shift analysis with proportional odds models. Results: RS was performed in 589 patients (mean age 67.9 years, 60.8% male). Numerous combinations of platelet inhibitors were administered. Periprocedural GPIIb/IIIa inhibitors were used in 61.5% of patients. Postprocedural DAPT was administered to 80.5% and SAPT to 13.3%. Functional independence (mRS 0–2) was achieved in 40.7%, while 26.3% died within 90 days. Stent occlusion occurred in 20.5%, with 67.6% of these occlusions within 24 h. Postprocedural stent-occlusion was independently associated with worse functional outcome at 90 days (OR 4.1, 95% CI 2.3–7.2, p < 0.001). No significant association between periprocedural GPIIb/IIIa inhibitors, and 90-day mRS or stent occlusion was found. Postprocedural SAPT was associated with worse functional outcomes (adjusted odds ratio (aOR) 2.4, 95% CI 1.1–5.0, p = 0.02), higher mortality (aOR 2.1, 95% CI 1.05–4.0, p = 0.03), and increased stent occlusion rates (aOR 4.8, 95% CI 2.3–9.7, p < 0.001) compared to postprocedural DAPT. Symptomatic intracranial hemorrhage occurred in 6.8% of patients, with no significant difference between antiplatelet regimens. Conclusion: Extensive heterogeneity exists in platelet inhibition strategies following RS. Stent occlusion is associated with worse clinical outcomes, and the first 24 h post-RS are critical for stent patency. Compared to SAPT, DAPT was associated with better functional outcome, lower mortality, and lower stent occlusion rates.

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: No project-specific funding was received for this study. V.S.-Z. is recipient of a research grants from Basel University, Bangerter-Rhyner-Foundation Basel and Freiwillige Akademische Gesellschaft Basel, Basel, Switzerland.