Relevance of cervical internal carotid artery patency after thrombectomy in tandem occlusion. Are we missing an opportunity to revascularize?

Background: Treatment options for cervical internal carotid artery (c-ICA) occlusion in tandem occlusions (TOs) include emergent carotid artery stenting (eCAS) and angioplasty. We attempted to determine the impact of c-ICA reocclusion on the risk of recurrent ischemic stroke (IS) and stroke-related death, as well as functional independence.

Methods: Patients with TOs undergoing endovascular thrombectomy (EVT) from April 2016 to October 2024 were included. The primary outcome was the 90-day composite of recurrent IS and stroke-related death. Secondary outcomes included the rate of 90-day functional independence (modified Rankin Scale (mRS) 0-2) and mortality. We used binary logistic regression to explore the association between c-ICA reocclusion and the outcomes and to identify predictors of c-ICA reocclusion or future revascularization.

Results: We included 163 patients, 85.9% with successful recanalization. Angioplasty and eCAS were performed in 70% and 19%, respectively. c-ICA reocclusion occurred in 22% at a median of 3.5 (0-41.7) days. c-ICA reocclusion increased the odds of recurrent IS or stroke-related death (adjusted OR (aOR) 2.90, 95% CI 1.07 to 8.30, P=0.036) and was associated with lower rates of independence (aOR 0.18, 95% CI 0.05 to 0.58, P=0.004). Among patients who did not undergo eCAS, c-ICA angioplasty (aHR 0.28, 95% CI 0.09 to 0.86, P=0.026) and residual stenosis (aHR 1.04, 95% CI 1.02 to 1.07, P<0.001) were independent predictors of reocclusion or future revascularization.

Conclusions: Maintaining c-ICA patency after EVT might be essential due to the association of reocclusion with recurrent IS, stroke-related death, and worse functional outcomes. Residual c-ICA stenosis and angioplasty are valuable predictors of c-ICA patency that can guide management during EVT.