Use of a Balloon Guide Catheter during Endovascular Treatment of Acute Ischaemic Stroke due to Large Vessel Occlusion in the Anterior Circulation in Patients with an Atherosclerotic Tandem Lesion.

Abstract

Approximately 15 - 20% of patients with anterior circulation large vessel occlusion (LVO) acute ischaemic stroke (AIS) have a tandem carotid lesion, usually caused by atherosclerosis. These lesions are associated with worse outcomes compared with isolated LVO AIS. During endovascular thrombectomy (EVT), balloon guide catheters (BGCs) may reduce distal embolisation and subsequently improve outcomes, but evidence in this population is limited. This study aimed to evaluate the impact of BGC use on EVT outcomes in patients with anterior circulation LVO AIS and atherosclerotic tandem lesions. Prospectively collected data from the Multicentre Randomised CLinical trial of Endovascular treatment for Acute ischaemic stroke in the Netherlands (MR CLEAN) Registry, MR CLEAN-NO IV, and MR CLEAN-MED trials were analysed. Patients with anterior circulation LVO AIS and a tandem carotid lesion who underwent EVT with or without BGC were included. The primary outcome was a favourable shift on the modified Rankin Scale (mRS). Secondary outcomes included functional independence (mRS ≤ 2 at 90 days), successful re-perfusion (expanded treatment in cerebral infarction score [eTICI] ≥ 2B), embolisation into new territory (ENT), serious adverse events, vascular access site complications, and neurological impairment measured with the National Institutes of Health Stroke Scale (NIHSS) at 24 - 48 hours after EVT. Among 718 included patients, 403 (56.1%) underwent EVT with BGC and 315 (43.9%) without. BGC use was not associated with a favourable mRS shift (adjusted common odds ratio 1.14, 95% confidence interval 0.87 - 1.51; p = .35) or functional independence at 90 days (40.4% vs. 43.8%; p = .36). ENT rates were similar (5.8% vs. 6.5%; p = .70). However, baseline differences between the treatment groups suggest potential selection bias in the use vs. non-use of BGC. These findings do not provide conclusive evidence for the routine use of BGC in patients with anterior circulation LVO AIS with an atherosclerotic tandem carotid lesion.