Mechanical Thrombectomy Improves Outcome for Large Vessel Occlusion Stroke after Cardiac Surgery

https://doi.org/10.1016/j.jstrokecerebrovasdis.2021.105851Get rights and content

Abstract

Background

Stroke is a feared complication of cardiac surgery. Modern clot-retrieval techniques provide effective treatment for large vessel occlusion (LVO) strokes. The purpose of this study was to 1) report the incidence of LVO stroke after cardiac surgery at a large academic center, and 2) describe outcomes of postoperative LVO strokes.

Methods

All patients experiencing stroke within 30 days after undergoing cardiac surgery at a single center in 2014-2018 were reviewed. LVOs were identified through review of imaging and medical records, and their characteristics and clinical courses were examined.

Results

Over the study period, 7,112 cardiac surgeries, including endovascular procedures, were performed. Acute ischemic stroke within 30 days after surgery was noted in 163 patients (2.3%). Among those with a stroke, 51/163 (31.3%) had a CTA or MRA, and 15/163 (9.2%) presented with LVO stroke. For all stroke patients, the median time from surgery to stroke was 2 days (interquartile range, IQR, 0–6 days), and for patients with LVO, the median time from surgery to stroke was 4 days (IQR 0–6 days). The overall rate of postoperative LVO was 0.2% (95% CI 0.1–0.4%), though only 6/15 received thrombectomy. LVO patients receiving thrombectomy were significantly more likely to return to independent living compared to those managed medically (n = 4/6, 66.6% for mechanical thrombectomy vs. n = 0/9, 0% for medical management, P = .01). Of the 9 patients who did not get thrombectomy, 6 may currently be candidates for thrombectomy given new expanded treatment windows.

Conclusions

The rate of LVO after cardiac surgery is low, though substantially elevated above the general population, and the majority do not receive thrombectomy currently. Patients receiving thrombectomy had improved neurologic outcomes compared to patients managed medically. Optimized postoperative care may increase the rate of LVO recognition, and cardiac surgery patients and their caregivers should be aware of this effective therapy.

Introduction

Stroke is one of the most devastating complications of surgery, and the highest risk procedures for postoperative stroke are cardiothoracic. Published rates of clinically significant stroke are as high as 10% for multiple valve surgeries1 and 33% in ventricular assist device surgeries,2 and newer endovascular techniques of cardiac intervention such as transcatheter aortic valve placement (TAVR) also put patients at significant risk for stroke.3, 4, 5, 6 The incidence of clinically silent, radiographic infarct after cardiac procedures is much higher, with one study finding radiographic brain infarcts in 69% of patients undergoing aortic valve surgery.7 Until recently, there were few treatment options for postoperative stroke given that recent surgery is a contraindication to the intravenous administration of tissue-type plasminogen activator (tPA). Postoperative interventions were often limited to attempts at intra-arterial pharmacologic thrombolysis, which although they appeared safe did not offer dramatic improvements in outcomes.8 In 2015, the efficacy of modern clot-retrieval techniques for patients presenting with large vessel occlusion (LVO) was proven, and intra-arterial thrombectomy procedures have become the standard of care.9 In 2018, two randomized controlled trials examining longer treatment windows (up to 24 hours after last known normal (LKN) time) showed the superiority of thrombectomy to maximal medical management for candidates with small infarct cores, identified by advanced imaging.10,11 Two previous studies have examined thrombectomy for LVO after cardiac surgery, though neither showed a statistically significant difference in neurologic outcome for patients treated with thrombectomy.12,13 The purpose of this study was to 1) report the incidence of LVOs after cardiac surgery at a large academic center, and 2) examine patient factors, procedural characteristics, postoperative management practices, and neurologic outcomes in these patients. We hypothesized that the availability of new effective treatments for stroke may warrant changes to postoperative management of cardiac surgery patients.

Section snippets

Methods

At our institution, during the first part of the study period, from 2014 to 2017, thrombectomy was attempted for patients presenting within 6 hours of LKN and LVO on CTA, or within the protocol of the DEFUSE-3 trial for later presentation, though no post-CT surgery patients were found eligible for enrollment in DEFUSE-3 due to low ASPECTs scores. Beginning in 2018, thrombectomy was attempted for patients beyond the 6-hour time window, with advanced imaging.

After receiving Institutional Review

Results

All cardiothoracic surgery cases during the study period were examined (n = 7,112 procedures), including 5,184 cases involving valve repair or replacement and 1,060 endovascular procedures. Clinical status was verified at 30 days after surgery by trained research nurses, with 52 patients lost to follow-up. One hundred eighty-one patients were deceased at 30 days after surgery. Acute ischemic stroke within 30 days after surgery was noted in 163 patients (2.3%). Among those with a stroke, 51/163

Discussion

Surgery is a risk factor for stroke, given a proinflammatory state, a higher incidence of preexisting comorbidities in the surgical population, and, in the case of cardiac surgery, the increased risk of cardio-embolic sources from the surgical site as well as a high incidence of arrhythmias perioperatively.5,15 Yet, we found that overall stroke incidence rates are relatively low after cardiac surgery and that LVOs are quite uncommon.

Among patients who presented with LVO, we found that patients

Conclusions

Among patients who had cardiac surgery at a tertiary-care academic medical center, 0.2% (95% CI 0.1–0.4%) had LVO stroke within 30 days (all within the first 2 weeks) postoperatively. LVO patients receiving thrombectomy had a significantly higher rate of good neurologic outcomes compared to those who did not (66.6% vs. 0%, P = .01). Given new expanded treatment windows, twice as many may be eligible for thrombectomy today if screened by advanced neuroimaging. Surgical teams, patients, and all

Funding/Grant Support

None.

Presentations

Work based on portions of this project was presented in electronic abstract format at the Society for NeuroInterventional Surgery Annual Meeting in Miami Beach, FL, July 22, 2019.

Declaration of Competing Interest

None.

Acknowledgments

None.

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