Recurrent Thrombectomy in Patients with Prior Mechanical Endovascular Revascularization: A Single Center Experience

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Background: Mechanical endovascular reperfusion therapy (MER) has become standard of care for treatment of large vessel occlusion (LVO) acute ischemic strokes (AIS) within 24 hrs of last known well. Nearly 25% of all stroke patients have a recurrent event in 5 years. Intravenous alteplase use in AIS patients with recent ischemic stroke history is avoided due to the risk of intracranial hemorrhage, but this may not be the case for MER. Bouslama et al found no statistically significant differences in reperfusion rates, hemorrhagic complications, clinical outcomes, and mortality between patients who had repeated thrombectomy (RT) and those who had a single thrombectomy. Methods: This is a retrospective case series study of endovascular database for patients who underwent RT in our institution from March 2016 till March 2018. Demographic, clinical, procedural date, imaging and clinical outcomes were evaluated. Results: Total 145 patients with AIS received MER, 8 (5.5%) RT occurred in 5 patients. Mean age was 67 ± 21 years. Four of the five patients were females. All patients achieved successful reperfusion (TICI 2b-3). Three patients underwent one RT, one had two RT, and one had three RT. The average time between consecutive MER (8 total periods) was 106 days. The time between the first to last MER for each patient ranged from 3 days to 2 years. All patients were optimized on their medical therapy after the first stroke. Four of the five patients (80%) had RT in the same vascular territory. One patient had post procedure focal high grade stenosis after the 3rd intervention in the same artery that was treated with elective angioplasty. One RT was complicated with fatal intracranial hemorrhage due to late presentation despite presence of large area of penumbra. Average MRS was 2.4. Conclusion: In patients presented with recurrent LVO, RT appears to be effective and relatively safe. Based on the available literature, prior MER should not discourage aggressive treatment that might lead to a good clinical outcome. It is unclear if prior MER therapy causes endothelial injury with risk for in situ de-novo stenosis or thrombus formation. Reperfusion injury risk in a recently infarcted territory should be weighted carefully when considering as hemorrhagic complications remain possible.



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