Emergent Carotid Artery Stenting in Patients With Acute Ischemic Stroke With Tandem Lesions: One-Year Follow-Up Results From the SECURIS Study

BACKGROUND AND OBJECTIVES: Management of carotid lesions during endovascular therapy (EVT) in patients with acute ischemic stroke (AIS) due to tandem lesions (TL) remains controversial, and long-term prognosis data are scarce. We evaluated 90-day and 1-year follow-up outcomes of emergent carotid artery stenting (eCAS) vs non-eCAS in these patients. METHODS: Data from a prospective mandatory population-based registry of Code Stroke in Catalonia (Spain) between 2017 and 2023 were analyzed. Patients with large vessel occlusion and ipsilateral ≥50% atheromatous cervical internal carotid artery (ICA) stenosis undergoing EVT were identified. eCAS and non-eCAS groups were compared. The primary outcome was the shift in the modified Rankin Scale (mRS) score at 90 days and 1 year of follow-up, adjusted using inverse probability of treatment weighting. Stratified analyses in predefined key subgroups according to sex, age, degree of ICA stenosis, Alberta Stroke Program Early CT Score, baseline NIH Stroke Scale, and previous IV thrombolysis were performed. Secondary outcomes included successful recanalization (modified Thrombolysis In Cerebral Infarction ≥2b), 90-day favorable functional outcome (mRS 0-2), hemorrhagic transformation (HT), and 90-day mortality. RESULTS: Among 578 patients included (mean age 70.2 years old, 140 [24.2%] women), 344 patients (59.5%) underwent eCAS. eCAS was associated with a better functional outcome at 90 days (common odds ratio [cOR] for a 1-point less on the mRS score 1.47, 95% CI 1.20-1.82, p < 0.001) and 1 year of follow-up (cOR of 1.47, 95% CI 1.16-1.85, p = 0.001), and with higher successful recanalization rates (OR 4.28, 95% CI 2.61-7.0, p < 0.001), without increasing HT risk or mortality. The benefit of eCAS was consistent in both moderate (50%-69%) and severe (≥70%) ICA stenosis subgroups. Among the eCAS group, patients under dual antiplatelet therapy at 24 hours showed higher rates of favorable functional outcome (54.6% vs 22.9%, p < 0.001). Potential treatment effect differences were observed for women and older patients. DISCUSSION: In this population-based study of patients with AIS due to TL, eCAS was associated with a better mid-term and long-term functional outcome without safety concerns, even in moderate ICA stenosis. Limitations include the observational design and possible unmeasured confounders. Further studies are needed to explore the mechanisms underlying the differential effects of eCAS in women and older patients. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that in patients with AIS and TL undergoing EVT, eCAS is associated with favorable functional outcome at 90 days compared with EVT alone.