ESOC 2024 | The impact of IVT before EVT in patients with carotid tandem lesions
Fabiano Cavalcante, MD, PhD Candidate, from Amsterdam UMC, Amsterdam, Netherlands, discusses his study encompassing more than 2000 patients from 190 centers, which assessed if outcomes of combined intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT) versus EVT alone differed by tandem lesion status. It was found that the presence of a tandem lesion did not modify the impact of IVT compared to those without a tandem lesion. It is also highlighted from his research that acute stenting during EVT in patients with carotid tandem lesions resulted in better functional outcomes, despite the need for additional antiplatelets and the consequential increase in bleeding rates associated with IVT. This interview was conducted at the 10th European Stroke Organisation Conference (ESOC) 2024 in Basel, Switzerland.
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Transcript
These patients represent about 15% of all patients treated with thrombectomy, so they are a large group of patients and they are very particular due to individual characteristics of the tandem lesion itself and of the treatments that the tandem lesion will require. So it’s possible that the treatments that work for the general population might not work as well or differently for the patients with tandem lesions and we are particular interested the effect of intravenous thrombolysis for patients that could directly receive endovascular treatment because it remains unclear if for these patients, a combination of both treatments is superior to just doing the thrombectomy right away...
These patients represent about 15% of all patients treated with thrombectomy, so they are a large group of patients and they are very particular due to individual characteristics of the tandem lesion itself and of the treatments that the tandem lesion will require. So it’s possible that the treatments that work for the general population might not work as well or differently for the patients with tandem lesions and we are particular interested the effect of intravenous thrombolysis for patients that could directly receive endovascular treatment because it remains unclear if for these patients, a combination of both treatments is superior to just doing the thrombectomy right away.
We actually investigated these results in the IRIS collaboration which is an individual participant data meta-analysis including more than 2,000 patients in six randomized clinical trials from more than 15 countries in 190 centers. In all of these trials we had patients with tandem lesions and all of these patients were presented directly to centers that could do the thrombectomy right away. So we identified if the effect of the combination of intravenous thrombolysis and then the thrombectomy versus the thrombectomy alone was different in patients with and without tandem lesions. We did not see that the presence of the tandem lesion alone modified the effect of intravenous thrombolysis.
What we did see, what was quite interesting was the effect of acute stenting because that is another point, that just having a tandem lesion tandem lesion does not tell you much because many things happen to these patients. A very important thing that can happen is that it can be decided to treat the tandem lesion during the endovascular treatment with angioplasty or placing a stent and if that happens additional medication are necessary. Additional antiplatelets are necessary. Which could mean that intravenous thrombolysis could cause more bleeding which we do observe in our data, although not statistically significant. But the effect of acute stenting actually led to better functional outcomes in these patients even if they had received intravenous thromboylsis and had a higher rate of bleeding, the benefit of death stenting was still preserved in this population.
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