Frontline ADAPT therapy to treat patients with symptomatic M2 and M3 occlusions in acute ischemic stroke: initial experience with the Penumbra ACE and 3MAX reperfusion system

5-French SOFIA: Safe Access and Support in the Anterior Cerebral Artery, Posterior Cerebral Artery, and Insular Middle Cerebral Artery

Introduction

Distal access catheters are an infrequent focus of technical notes in neurointervention. The 5-French SOFIA's unique design allows for compatibility with 6-French guide catheters, while its supple construction allows for remarkably distal access for a catheter with a 0.055-inch inner diameter.

Methods

The authors reviewed a prospectively maintained endovascular database for cases utilizing the 5-French SOFIA from February 2017 through November 2017. Case type, SOFIA location, microcatheter used, and catheter-related complications were noted.

Results

Over the evaluated period, the 5-French SOFIA was utilized in 33 cases, including 13 aneurysm treatments, 10 arteriovenous shunt embolizations, 5 stroke thrombectomies, and 5 other cases. Of 5 flow diversion cases, 1 was for a symptomatic cavernous internal carotid artery aneurysm necessitating transradial access, another for a ruptured A3 aneurysm, and another for a middle cerebral artery (M2) aneurysm; 2 were more proximal aneurysms. Thrombectomies were for M2 (n = 3) or A2 (n = 2) occlusions. In all cases, the 5-French SOFIA reached its anticipated distal target without complication or the need to utilize a smaller/alternative catheter. Of these 33 cases, there were 10 cases of distal SOFIA target locations: 6 M2/M3, 3 anterior cerebral arteries (ACA), and 1 posterior cerebral artery (PCA). M2/M3 and PCA catheterization was achieved over 2.1-Fr microcatheters; ACA catheterization employed a 2.9-Fr microcatheter for pipeline embolization and a deployed stentriever in the setting of two thrombectomies.

Conclusion

The 5-French SOFIA can be safely utilized for distal, superselective catheterization in the context of complex neurointervention, including aneurysm and arteriovenous shunt embolization and distal thrombectomy.

First-Line A Direct Aspiration First-Pass Technique vs. First-Line Stent Retriever for Acute Ischemic Stroke Therapy: A Meta-Analysis

Background: Recent trials have proved the efficacy of mechanical thrombectomy over medical treatment for patients with acute ischemic stroke, with the balance of equivalent rates of adverse events. Stent retrievers were applied predominantly in most trials; however, the role of other thrombectomy devices has not been well validated. A direct aspiration first-pass technique (ADAPT) is proposed to be a faster thrombectomy technique than the stent retriever technique. This meta-analysis investigated and compared the efficacy and adverse events of first-line ADAPT with those of first-line stent retrievers in patients with acute ischemic stroke.

Methods: A structured search was conducted comprehensively. A total of 1623 papers were found, and 4 articles were included in our meta-analysis. The Critical Appraisal Skills Programme tools were applied to evaluate the quality of studies. The primary outcome was defined as the proportion of patients with the Thrombolysis in Cerebral Ischemia (TICI) scale of 2b/3 at the end of all procedures. Secondary outcomes were the proportion of patients with functional independence (modified Rankin scale of 0–2) at the third month, the proportion of patients with the Thrombolysis in Cerebral Ischemia (TICI) scale of 2b/3 by primary chosen device, and the proportion of patients who received rescue therapies. Safety outcomes were the symptomatic intracranial hemorrhage (sICH) rate and the mortality rate within 3 months.

Results: One randomized controlled trial, one prospective cohort study, and two retrospective cohort studies were included. No significant difference between these 2 strategies of management were observed in the primary outcome (TICI scale at the end of all procedures, odds ratio [OR] = 0.78), two secondary outcomes (functional independence at the third month, OR = 1.16; TICI scale by primary chosen device, OR = 1.25), and all safety outcomes (sICH rate, OR = 1.56; mortality rate, OR = 0.91). The proportion of patients who received rescue therapies was higher in the first-line ADAPT group (OR = 0.64).

Conclusions: Among first-line thrombectomy devices for patients with ischemic stroke, ADAPT with the latest thrombosuction system was as efficient and safe as stent retrievers.

Contact Aspiration versus Stent-Retriever Thrombectomy for Distal Middle Cerebral Artery Occlusions in Acute Ischemic Stroke: Meta-Analysis

PURPOSE

The evidence for endovascular therapy and choice of technique in distal middle cerebral artery (MCA) M2 segment occlusions in acute ischemic stroke remains controversial. We aimed to conduct a systematic review and meta-analysis primarily comparing reperfusion rates of stent-retrieval versus contact aspiration for M2 occlusions.

MATERIALS AND METHODS

Study selection included cohorts of patients with distal MCA occlusions in acute ischemic strokes treated with an endovascular approach including stent-retrieval or contact aspiration. Twelve studies were selected for meta-analysis for a total of 835 cases. Meta-analysis by proportions was conducted on parameters including baseline and procedural characteristics, thrombolysis in cerebral infarction (TICI) 2b-3 outcomes, and 90-day modified Rankin scale (mRS) outcomes.

RESULTS

Hypertension and hyperlipidemia were more prevalent in stent-retriever patients. Pooled baseline National Institute of Health Stroke Scale scores and Alberta Stroke Program Early Computed Tomography Score imaging scores were similar. Pooled time onset of symptoms to door arrival was higher for the stent-retrieval group (154 vs. 97.4 minutes, P=0.01), as was time to groin puncture (259.9 vs. 156.2 minutes, P=0.02), but there was no difference in procedure time. The TICI 2b-3 recanalization rate was similar (80.5% vs. 86.8%, P=0.168). The frequency of mRS 0-2 at 90-day was also similar (74.5% vs. 59.9%, P=0.120), and an excellent mRS 0-1 was lower for stent-retrievers (39.9% vs. 65.6%, P=0.003). A significant negative correlation was found between onset to groin puncture time and the proportion of patients with a good mRS (r=-0.71, P=0.048).

CONCLUSION

Both endovascular techniques achieved recanalization rates greater than 80% and 90-day outcomes of minimal disability with similar complication rates. The literature is skewed by aspiration cases being performed sooner after onset of stroke compared to stent-retriever cases.

Larger ACE 68 aspiration catheter increases first-pass efficacy of ADAPT technique

PURPOSE

To report the efficacy of A Direct Aspiration first-Pass Thrombectomy (ADAPT) technique with larger-bore ACE aspiration catheters as first-line treatment for anterior circulation emergent large vessel occlusions (ELVOs), and assess for the presence of a first-pass effect with ADAPT.

METHODS

We retrospectively reviewed 152 consecutive patients with anterior circulation ELVOs treated with the ADAPT technique as first-line treatment using ACE60, 64, or 68 at our institution. Baseline characteristics, procedural variables, and modified Rankin Scale (mRS) at 90 days were recorded.

RESULTS

Fifty-seven patients were treated with ACE60 (37.5%), 35 with ACE64 (23%), and 60 with ACE68 (39.5%). Median groin puncture to reperfusion time was 30 min with ACE60, 26 min with ACE64, and 19.5 min with ACE68. Successful reperfusion after the first ADAPT pass was 33% with ACE60 and 53% with ACE68 (P=0.04). The stent-retriever rescue rate was 26% with ACE60, 3% with ACE64, and 10% with ACE68 (P=0.004). In multivariate logistic regression analysis, use of the ACE68 aspiration catheter was an independent predictor of successful reperfusion after the first ADAPT pass (P=0.016, OR1.67, 95% CI 1.1 to 2.54), and successful reperfusion after the first ADAPT pass was an independent predictor of good clinical outcome at 90 days (P=0.0004, OR6.2, 95% CI 2.27 to 16.8).

CONCLUSION

Use of the larger-bore ACE 68 aspiration catheter was associated with shorter groin puncture to reperfusion time, higher rate of successful reperfusion after the first ADAPT pass, and lower rate of stent-retriever rescue. Further, a first-pass effect was demonstrated in our ADAPT patient cohort.