E-158 Tandem carotid occlusions with delayed carotid stenting

Introduction/purpose Management of tandem carotid occlusions is not yet well-defined. Though several authors have proposed acute carotid stenting followed and intracranial mechanical thrombectomy, the subsequent need for immediate antiplatelet therapy comes with an associated risk of potentially devastating hemorrhage. We sought to demonstrate that carotid stenting can be safely delayed in tandem carotid occlusions with good clinical outcomes. Materials and methods Between July 2015 and July 2016, we report our first ten consecutive patients with tandem carotid occlusions to our university comprehensive stroke center. Demographics, technical variations, recanalization rates and times, and clinical follow-up are reported. The abstract will be updated with additional consecutive cases of tandem occlusion through June 2018. Results A total cohort of our first ten consecutive patients (avg NIHSS=17) included seven carotid occlusions and three 95%–99% carotid bulb stenosis. Tandem intracranial occlusions included three at M2, four at M1, and three ‘T’ lesions at the ICA terminus. All patients were initially wire re-canalized, followed by prolonged PTA and mechanical thrombectomy. Nine patients received IV tPA (avg DTN 31 min) and five were drip-n-ship. The average tPA to groin puncture time was 104 min, and the average groin puncture to recanalization time was 50 min. TICI 2b/3 recanalization was obtained in nine of ten patients with only one patient 2a/2b. Nine patients had delayed carotid stenting between days 7–14 post-stroke. One patient had silently re-occluded the carotid bulb on the day of planned stenting, one patient had a small reperfusion hemorrhage prior to antiplatelet therapy (90 d MRS=0), and one patient had a small ICH after stent placement (90 d MRS=3). All patients had a 90 d MRS=/ Conclusion It appears that tandem carotid occlusions can be treated with emergent prolonged PTA of the extra-cranial carotid occlusion followed by intra-cranial mechanical thrombectomy. Delayed carotid stenting appears to be safe and may lead to good clinical outcomes. Further studies are needed to confirm the findings in this small cohort. Disclosures C. Green: None. B. Wiseman: None. A. Ferrell: None. P. Brown: None. P. Kvamme: None.