Adjunct percutaneous transluminal angioplasty and stenting in endovascular thrombectomy with underlying intracranial stenosis: analysis of the TREAT-AIS registry

OBJECTIVE: The aim of this study was to assess the effectiveness of adjunct percutaneous transluminal angioplasty and stenting (PTAS) in endovascular thrombectomy (EVT) for large vessel occlusion (LVO) in acute ischemic stroke with underlying intracranial atherosclerotic disease (ICAD). METHODS: Data from 2019 to 2023 were collected from a multicenter national EVT registry in Taiwan. Patients with ICAD were classified into PTAS and non-PTAS groups according to the adjunct therapy administered. The efficacy and safety outcomes of interest included successful reperfusion, the 90-day modified Rankin Scale (mRS) score, mortality, symptomatic intracerebral hemorrhage (ICH), and EVT complication. Multivariable logistic regression and inverse probability of treatment weighting-adjusted analyses were performed to compare outcomes. RESULTS: A total of 585 patients with ICAD were included in the study, with 94 in the PTAS group and 491 in the non-PTAS group. PTAS was associated with a higher successful reperfusion rate as the primary efficacy outcome (89.4% vs 75.0%; adjusted OR 2.80 [95% CI 1.37-5.75], p < 0.01). This effect was preserved even in the pure angioplasty group (unadjusted OR 2.44 [95% CI 1.08-5.51], p = 0.03; adjusted OR 2.61 [95% CI 1.13-6.08], p = 0.03). Among secondary outcomes, the PTAS group had better ambulatory functional outcomes (mRS score 0-3) (53.7% vs 40.4%; weighted OR 1.53 [95% CI 1.20-1.95], p < 0.01). There was no significant difference in independent functional outcomes (mRS score 0-2) or ordinal 90-day mRS scores. For safety outcomes, symptomatic ICH and EVT-related complications were comparable between groups. No interaction effect was found for the onset-to-puncture time and PTAS. Subgroup analyses revealed that PTAS offered more benefits for posterior circulation strokes. CONCLUSIONS: This study highlights PTAS as complementary therapy in EVT for ICAD-related LVO, with consistent effects across various time metrics (onset-to-puncture time) and no significant increase in adverse events.