Rescue Stenting for Failed Mechanical Thrombectomy in Acute Ischemic Stroke: Systematic Review and Meta-analysis

BACKGROUND: When mechanical thrombectomy (MT) fails to achieve successful reperfusion, rescue stenting (RS) has proven to be a feasible rescue therapy. However, the available evidence remains underpowered to assess clinical outcomes. We aimed to compare the safety and efficacy of RS versus routine medical management in patients with failed MT using an aggregated meta-analysis. METHODS: A systematic review was performed from inception to July 2022 of all studies using RS after failed MT. Outcomes of interest included a modified Rankin scale score of 0-2 at 90 days, successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b-3) after RS and symptomatic intracranial hemorrhage. A random-effects meta-analysis between the RS and medical treatment arms was performed to calculate pooled odds ratios (OR) for each outcome. We assessed the certainty of evidence using the Grading of Recommendation, Assessment, Development, and Evaluation approach. Statistical heterogeneity across studies was assessed with I2 statistics. RESULTS: A total of 12 studies included 1855 participants, 729 in the RS arm and 1126 in the medical treatment arm. The pooled results indicated that RS was associated with a significantly higher proportion of patients with a modified Rankin scale score of 02 at 90 days (RS: 41% versus 21%; OR,3.27; [95% CI 2.08-5.16]; I2=64%; moderate-certainty evidence) and a decreased risk of mortality at 90 days (RS: 22.5% versus 33.8%; OR, 0.47; [95% CI 0.32-0.69]; I2=45%; low-certainty evidence), compared with medical treatment after failed MT. The pooled rate of successful reperfusion after RS was 87% (95% CI 82-91; I2=57%; low-certainty evidence). The rate of symptomatic intracranial hemorrhage did not differ between groups (RS: 8.5% versus 11.7%; OR, 0.85; [95% CI 0.59-1.20]; I2=7%; low-certainty evidence). CONCLUSION: RS is a promising strategy for maximizing recovery in acute stroke patients after first line MT fails to achieve meaningful reperfusion. However, randomized trials using a standardized approach/technique and MT failure definition are warranted to confirm these results.