Antegrade VS Retrograde Approach for Tandem Lesion: A Systematic Review and Meta-analysis

Introduction: Tandem lesions involve occlusions in both an intracranial large vessel and the cervical branch of the internal carotid artery, often due to atherosclerosis or arterial dissection, accounting for 15-30% of large vessel occlusion strokes. Managing these occlusions requires careful choice between antegrade and retrograde approaches. This study reviews the literature to evaluate the advantages and drawbacks of each approach, focusing on procedural ease and patient recovery.

Methods: A systematic review and meta-analysis following PRISMA guidelines and the Cochrane Handbook was conducted. Medline, Embase, Cochrane, and Web of Science databases were searched. Studies with ≥4 patients reporting on tandem lesions treated with retrograde or antegrade approaches were included. Key endpoints included overall mortality, intracranial hemorrhage, functional outcomes, successful reperfusion, and complications.

Results: This analysis included 36 studies with 3,038 patients, with 63% managed with an antegrade approach and 36% with a retrograde approach. The 90-day mortality was similar between groups, with 14% for antegrade (95% CI: 11%-18%) and 15% for retrograde (95% CI: 10%-21%). Rates of any intracranial hemorrhage (ICH) and symptomatic ICH were comparable between groups, with both antegrade and retrograde approaches showing 17% for ICH and 6% for symptomatic ICH. Functional outcomes favored the retrograde approach, with 51% (95% CI: 45%-56%) achieving favorable functional outcomes (mRS < 3) compared to 44% (95% CI: 40%-48%) in the antegrade group. Successful reperfusion (SR) rates were higher in the retrograde group, with SR in 83% (95% CI: 77%-88%) using TICI grades of 2b-3, versus 78% (95% CI: 73%-83%) in the antegrade group. Complications were similar between approaches, with a 15% rate in the antegrade group and 17% in the retrograde group.

Conclusion : Antegrade and retrograde approaches show comparable safety for treating tandem lesions. However, the retrograde approach may offer advantages in functional outcomes and reperfusion success, although variability in reperfusion criteria highlights the need for further research. These findings suggest potential benefits of retrograde management, emphasizing the importance of an individualized approach based on patient anatomy and clinical presentation.