1Waseem Wahood,2Aya Akhras, 2Aya Akhras, 2Ameneh Baghestani, 3Waleed Brinjikji,

1Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, 2Mohammed Bin Rashid University of Medicine and Health Sciences, 3Department of Radiology, Mayo Clinic, MN


Tandem occlusions are concurrent occlusions of the internal carotid artery (ICA) as well as the middle cerebral artery (MCA). Historically, these occlusions were treated with thrombectomy. Endovascular management of tandem occlusions via carotid artery stenting (CAS) and/or angioplasty have been increasingly reported, however the outcomes of these studies have been conflicting. In this study, we aim to investigate the trends and in-hospital outcomes of adjunctive CAS versus angioplasty only in the management of tandem occlusions.

Material(s) and Method(s):

The Healthcare Cost and Utilization Project-National Inpatient Sample (HCUP-NIS) was queried between 2009 and 2018, for patients undergoing stenting or angioplasty for tandem occlusions stroke treated with thrombectomy (intracranial and internal carotid artery occlusions). Outcomes included inpatient mortality, non-routine discharge and patient profile. Cochran-Armitage test was conducted to assess the linear trend of utilization of CAS. Jointpoint regression was conducted to indicate infliction point in change in trend. All estimates were nationalized using discharge weights provided by HCUP.


There was a total of 510,169 admission involving MT with either stenting (n=6,632, 65.2%) or angioplasty (n=3,357, 34.8%) between 2006-2018. Adjusting for patient demographics, females were more likely to have stenting over angioplasty (OR: 0.74; 95% CI: 0.60-0.90; p=0.003). Comparing the trends in the two procedures, stenting remained stationary compared to angioplasty (p=0.10). Trend in CAS increased from 2006-2013 by 3.76% (95% CI: 1.91 to 5.61; p<0.001) and decreased by -1.54% per year (95% CI: -2.84 to -0.24; p=0.020) between 2013-2018. Admissions involving CAS had similar odds of non-routine discharge (OR: 0.78 p=0.063) and lower odds of inpatient mortality (OR: 0.58; p<0.001) compared to those who received angioplasty only.


Our analysis indicated that the trend in utilization of CAS increased between 2006 and 2013 and decreased between 2013 and 2018 compared to angioplasty in our 13-year study; the odds of non-routine discharge were similar and inpatient mortality were lower in CAS compared to angioplasty. The utilization of CAS for tandem occlusions requires careful patient selection, based on demographics and risk factors, as this may influence outcomes, including non-routine discharge. A multi-disciplinary approach is encouraged when evaluating the use of CAS for the management of tandem occlusions.