Utilization of Carotid Artery Stenting and Angioplasty in Tandem Occlusion Stroke in the United States

Purpose: Tandem occlusions are concurrent occlusions of the internal carotid artery (ICA) as well as the middle cerebral artery (MCA). Historically, these occlusions were treated with thrombectomy. Endovascular management of tandem occlusions via carotid artery angioplasty or stenting (CAS) have been increasingly reported; however, the outcomes of these studies have been conflicting. In this study, we aim to investigate the outcomes of adjunctive CAS versus thrombectomy alone in the management of tandem occlusions.

Materials and Methods: The Healthcare Cost and Utilization Project-National Inpatient Sample (HCUP-NIS) was queried between 2007 and 2018 for patients undergoing stenting or angioplasty for tandem occlusions stroke treated with thrombectomy (intracranial and internal carotid artery occlusions). Patients who underwent CAS among patients who had concurrent thrombectomy were compared with those who did not receive CAS by inpatient mortality and nonroutine discharge and patient profile. Cochran-Armitage test was conducted to assess the linear trend of utilization of CAS. Elixhauser Comorbidities index scores, based on 31 comorbidities, were calculated. All estimates were nationalized using discharge weights provided by HCUP.

Results: A total of 16,438 admissions from 2007 to 2018 involved tandem occlusions; 4689 (28.5%) of them involved stenting, angioplasty, or both. Adjusting for patient demographics, those with higher ECI had lower odds of undergoing CAS (odds ratio [OR], 0.84; P < 0.001). Trend in utilization of CAS remained stationary (trend: -0.41%; P = 0.250). There was a decrease in trend in mortality among those with CAS (-0.95%; P = 0.031). The trend in nonroutine discharge among those with CAS remained stationary (0.69%; P = 0.120). Admissions involving CAS had similar odds of nonroutine discharge as those who underwent thrombectomy alone (OR, 0.81; P = 0.068), but those with higher ECI had higher odds of nonroutine discharge (OR, 1.28; P < 0.001).

Conclusions: Our analysis indicated that the trend in use of CAS remained stationary in our 12-year study, a decrease in trend of nonroutine among those with CAS, and the odds of nonroutine is higher among that group. The use of CAS for tandem occlusions requires careful patient selection based on demographics and risk factors because these may influence outcomes, including nonroutine discharge. A multidisciplinary approach is encouraged when evaluating the use of CAS for the management of tandem occlusions.