Cervical Internal Carotid Artery Reocclusion After Endovascular Thrombectomy in Tandem Occlusion: A Meta-Analysis

BACKGROUND: Reocclusion after endovascular thrombectomy in tandem occlusions may contribute to disability, but its mechanism and the role of emergent carotid artery stenting remain unclear. We conducted a meta-analysis to evaluate the impact of cervical internal carotid artery (c-ICA) reocclusion on functional outcomes, recurrent ischemic stroke, and the potential benefit of emergent stenting. METHODS: We systematically searched Medline, EMBASE, and Scopus for studies reporting c-ICA reocclusion after endovascular thrombectomy for tandem occlusions. The primary outcome was c-ICA reocclusion incidence; secondary outcomes included recurrent ischemic stroke and 90-day functional outcome (modified Rankin Scale score, 0–2). Random-effects models were used. Metaregression, sensitivity, and power analyses were performed. RESULTS: Fifty-one studies (4998 patients: 3444 received emergent carotid artery stenting and 1554 did not) were included. Overall, c-ICA reocclusion incidence was 10.8% (95% CI, 8.0%–14.3%). In patients treated with emergent carotid artery stenting, reocclusion occurred in 10.9% versus 28.2% without stenting (risk difference, –14.7% [95% CI, –20.2 to –9.2]). c-ICA treatment approach was not associated with recurrent ischemic stroke (odds ratio, 1.00 [95% CI, 0.33–3.01]), whereas c-ICA reocclusion was associated with worse functional outcome (odds ratio, 0.45 [95% CI, 0.28–0.71]). Metaregression identified no significant moderators. Sensitivity analyses confirmed adequate power to detect moderate associations. CONCLUSIONS: c-ICA reocclusion after endovascular thrombectomy in tandem occlusions is common and associated with worse functional outcome, likely due to infarct progression. Emergent carotid artery stenting reduces reocclusion rates but does not modify the risk of ischemic stroke. Future studies should refine procedural strategies and integrate physiological markers to better characterize the risk of reocclusion and outcomes.