Mechanical Thrombectomy in Acute Occlusion of the Carotid-T: A Retrospective Single Centre Study in 51 Patients

First-line thrombectomy strategy for carotid terminus occlusions: A systematic review and meta-analysis

Background

Little research has focused on the performance of mechanical thrombectomy (MT) in carotid terminus occlusions (CTOs). Therefore, the best first-line thrombectomy strategy for CTOs remains unclear.

Purpose

To compare the safety and efficacy outcomes of three first-line thrombectomy techniques in CTOs.

Methods

A systematic literature search was conducted in Ovid MEDLINE, Ovid Embase, Scopus, Web of Science, and Cochrane Central Register of Clinical Trials databases. Studies providing safety and efficacy outcomes for endovascular treatment of CTOs were included. Data regarding successful recanalization, functional independence, symptomatic intracranial hemorrhage (sICH), and first pass efficacy (FPE) were extracted from the included studies. A random-effects model was used to calculate prevalence rates and their corresponding 95% confidence intervals (CI), and subgroup analyses were performed to assess the impact of the initial MT technique on safety and efficacy outcomes.

Results

Six studies with 524 patients were included. The overall successful recanalization rate was 85.84% (95% CI = 77.96-94.52), and subgroup analysis did not show a significant difference among the three first-line MT techniques. Overall rates of functional independence and FPE were 39.73% (95% CI = 32.95-47.89) and 32.09% (95% CI = 22.93-44.92), respectively. The combined stent retriever (SR) and aspiration (ASP) technique achieved significantly higher first-pass efficacy rates compared to SR or ASP alone. The overall sICH rate was 9.89% (95% CI = 4.88-20.07), and subgroup analysis did not demonstrate a significant difference across groups. The sICH rates of SR, ASP, and SR + ASP were 8.49% (95% CI = 1.76-40.93), 6.8% (95% CI = 4.59-10.09), and 7.12% (95% CI = 0.27-100), respectively.

Conclusions

Our results support that MT is highly effective for CTOs with functional independence rates of 39%. Additionally, in our meta-analysis, the SR + ASP technique was associated significantly greater rates of FPE compared to SR or ASP alone, without an increase in sICH rates. Prospective, large-scale studies are necessary to determine the optimal first-line MT technique in the endovascular treatment of CTOs.

Successful Reperfusion is Associated with Favorable Functional Outcome despite Vessel Perforation during Thrombectomy: A Case Series and Systematic Review

BACKGROUND

Arterial perforation is a potentially serious complication during endovascular thrombectomy.

PURPOSE

Our aim was to describe interventional approaches after arterial perforation during endovascular thrombectomy and to determine whether reperfusion remains associated with favorable outcome despite this complication.

DATA SOURCES

Data from consecutive patients with acute stroke undergoing endovascular thrombectomy were retrospectively collected between 2015 to 2020 from a single-center cohort, and a systematic review was performed using PubMed, EMBASE, and Ovid MEDLINE up to June 2020.

STUDY SELECTION

Articles reporting functional outcome after arterial perforation during endovascular thrombectomy were selected.

DATA ANALYSIS

Functional outcomes of patients achieving successful reperfusion (TICI 2b/3) were compared with outcomes of those with unsuccessful reperfusion in our single-center cohort. We then summarized the literature review to describe interventional approaches and outcomes after arterial perforation during endovascular thrombectomy.

DATA SYNTHESIS

In our single-center cohort, 1419 patients underwent endovascular thrombectomy, among whom 32 (2.3%) had vessel perforation and were included in the analysis. The most common hemostatic strategy was watchful waiting (71% of cases). Patients with successful reperfusion had a higher proportion of favorable 90-day mRS scores (60% versus 12.5%; P = .006) and a lower mortality rate (13.3% versus 56.3%, P = .01) than patients without successful reperfusion. Thirteen articles were included in the systematic review. Successful reperfusion also appeared to be associated with better outcomes.

LIMITATIONS

Given the low number of published reports, we performed only a descriptive analysis.

CONCLUSIONS

Arterial perforation during endovascular thrombectomy is rare but is associated with high mortality rates and poor outcome. However, successful reperfusion remains correlated with favorable outcome in these patients.

JET 7 catheter for direct aspiration in carotid T occlusions: preliminary experience and literature review

OBJECTIVE

We report our preliminary experience with the Penumbra JET 7 reperfusion catheter (JET 7), a new large-bore (0.072″) aspiration catheter, in patients with acute ischemic stroke (AIS) due to carotid T occlusion.

METHODS

Data of all eligible patients who received A Direct Aspiration First Pass Technique (ADAPT) for AIS due to carotid T occlusion at our center from March 2018 through June 2020 were retrospectively reviewed. The safety and performance of JET 7 cases and smaller large-bore catheters (LBCs) were compared.

RESULTS

JET 7 was used in 19 patients, and smaller LBCs were used in 41 patients. Median puncture to revascularization time was significantly different between the JET 7 and the smaller LBCs (16 vs. 27 min; P = 0.011). The rate of patients who received rescue therapy with a stent retriever was also significantly different between the JET 7 cases and the smaller LBCs cases (5.3% vs. 22.0%; P = 0.046). Successful revascularization (TICI ≥ 2b) was achieved in 94.7% of JET 7 cases and 75.6% of smaller LBCs cases (P = 0.148). Good functional outcome (mRS 0-2) at 90 days occurred in 63.2% of JET 7 cases and 46.3% of smaller LBCs cases (P = 0.274).

CONCLUSIONS

In this early experience, ADAPT with JET 7 could be considered as one of the possible first-line therapies in carotid T occlusion, showing good rate of vascularization and lower rate of rescue therapy in comparison with smaller LBCs.

Initial Clinical Experience of Repeat Thrombectomy with a Retrieval Stent (RTRS) with Continuous Proximal Flow Arrest by Balloon Guide Catheter for Acute Intracranial Carotid Occlusion

Background

Balloon guide catheters (BGCs) have good performance in terms of radiological outcomes in acute ischemic thrombectomy. It is not uncommon for BGCs to be blocked by thrombi, especially in cases with acute intracranial internal carotid artery (ICA) occlusion. Our initial experience using repeat thrombectomy with a retrieval stent (RTRS) with continuous proximal flow arrest by BGC for acute intracranial ICA occlusion is presented.

Methods

In patients with acute intracranial ICA occlusion treated with RTRS, clinical data, including the National Institutes of Health Stroke Scale (NIHSS) score at admission and modified Rankin Scale (mRS) score at 90 days, and procedural data, including the Extended treatment in Cerebral Infarction (eTICI) score, procedural time, and complications, were analyzed.

Results

Thirty-two consecutive patients (12 men (37.5%); mean age: 73 years) were treated with RTRS using a BGC. The median NIHSS score was 19. The median puncture-to-reperfusion time was 46 minutes (range: 22-142 minutes). All patients were successfully revascularized; eTICI 2c or better recanalization was achieved in 30 (93.8%) patients. No procedure-related complications or symptomatic intracranial hemorrhage occurred. Two cases (6.3%) had distal emboli, but none had emboli to the anterior cerebral artery. Fourteen patients (43.8%) achieved a good outcome with an mRS score of 0-2 at 90 days, and 8 patients (25.0%) died.

Conclusions

In patients with intracranial ICA occlusion, RTRS with proximal flow arrest by BGC is effective and safe, achieving good clinical and angiographic outcomes. This method may reduce the incidence of distal emboli in thrombectomy with stent retrievers.

Clinical and radiological outcomes of mechanical thrombectomy in simultaneous anterior cerebral artery and middle cerebral artery occlusion

Objective

Simultaneous anterior cerebral artery (ACA) and middle cerebral artery (MCA) occlusion is rare. We investigated the clinical and radiological outcomes of patients with simultaneous ACA and MCA occlusion treated with mechanical thrombectomy.

Methods

We analyzed the clinical and radiological outcomes of 12 patients with simultaneous ACA and MCA occlusion treated with mechanical thrombectomy from January 2018 to December 2020. The clinical outcome was assessed using the modified Rankin Score (mRS) after 3 months of thrombectomy. The radiological outcome was assessed using the thrombolysis in cerebral infarction (TICI) score.

Results

The median National Institutes of Health Stroke Scale score at hospital arrival was 18 (interquartile range, 16-20). M1 was the most common occlusion lesion (n=8), and A3 was the most common lesion in the ACA (n=6). Six patients were first treated for MCA occlusion and later for ACA occlusion (MCA group). Other patients were first treated for ACA occlusion and later for MCA occlusion (ACA group). There was no difference in clinical outcomes between the MCA and ACA groups (p=0.180). Successful recanalization (TICI ≥2b) of MCA was achieved in 10 patients (83.3%). Successful recanalization of ACA was achieved in 10 patients (83.3%). Successful recanalization of both ACA and MCA occlusion was observed in eight patients (66.7%). Three patients (25%) had good clinical outcomes (mRS ≤2).

Conclusions

In our series, simultaneous ACA and MCA occlusion showed relatively poor successful recanalization rates and poor clinical outcomes despite treatment with mechanical thrombectomy.

Mechanical Thrombectomy in Acute Terminal Internal Carotid Artery Occlusions Using a Large Manually Expandable Stentretriever (Tiger XL Device): Multicenter Initial Experience

Background: The recently introduced Tigertriever XL Device for treatment of cerebral vessel occlusions combines manual adjustability and maximum length in one device. In this study, we report our initial experience with the Tigertriever XL in terminal ICA occlusions. Methods: Retrospective multicenter analysis of acute terminal ICA occlusions treated by mechanical thrombectomy using the Tigertriever XL Device. Results: 23 patients were treated using the Tigetriever XL due to an acute occlusion of the terminal ICA. The overall successful reperfusion rate after a median of two maneuvers using the Tigertriever XL Device was 78.3% (mTICI 2b-3). In 43.5% (10/23) additional smaller devices were applied to treat remaining occlusions in downstream territories, which resulted in a final successful reperfusion rate of 95.7%. Device related complications did not occur. Two symptomatic intracerebral hemorrhages (sICH) were observed. Conclusions: The Tigertriever XL Device might be a helpful tool in the treatment of ICA terminus occlusions with large clot burden resulting in high reperfusion rates. This is mainly related to the manual adjustability of the device combined with the maximum length.

Y-Stent Rescue Technique for Failed Thrombectomy in Patients With Large Vessel Occlusion: A Case Series and Pooled Analysis

Objective: Y-stent thrombectomy is a recent rescue technique for failed thrombectomy in patients with emergent large vessel occlusion. We presented case series of using Y-stent rescue technique at different sites and investigate its feasibility and safety through pooled analysis of collected case report or series. Methods: Twenty-eight cases were screened from stroke databank who underwent thrombectomy between January 2015 and June 2019. Clinical, procedural, and follow-up data were investigated and pooled analysis of published literature was analyzed. Results: The occlusion sites include carotid terminus in 14 patients; siphon segment in 3; middle cerebral artery (MCA) in 4; basilar terminus in 7. The overall recanalization rate reached 85.7% (arterial occlusive lesion score 2-3); and final reperfusion rate 85.7% (modified Thrombolysis in Cerebral Infarction 2b-3). After literature review, totally, 52 cases were included. Good clinical outcome was achieved in 26 (50%) and mortality in 7 (17.3%). There is no significant difference on the SAH complication at different sites. Literature review shows no difference between each site in the reperfusion and complication rate. Conclusion: Our case series results suggest that high recanalization rate can be effectively achieved with Y-stent rescue technique for patients with refractory emergent large vessel occlusion. The safety of using this technique at different sites needs further investigation for patients.

Endovascular treatment for acute carotid T and carotid non-T occlusion: A retrospective multicentre study of 81 patients

BACKGROUND

The functional prognosis of patients with carotid T occlusion is poor, but few comprehensive studies have investigated carotid non-T occlusion, in which the terminal internal carotid artery portion is unobstructed. We aimed to elucidate the clinical features of carotid non-T occlusion by comparing patients with acute carotid T occlusion and carotid non-T occlusion.

METHODS

Among 362 patients who underwent thrombectomy between January 2015 and June 2018, 20 and 61 were diagnosed with carotid non-T occlusion and carotid T occlusion, respectively. We compared preoperative clinical findings, treatment strategies, treatment complications and functional outcomes between the two groups.

RESULTS

Age, sex, preoperative National Institutes of Health stroke scale, cerebral infarction subtypes and medical history did not significantly differ. In contrast, preoperative diffusion-weighted imaging-Alberta Stroke Program early computed tomography scores were 9 (1-11) and 6.5 (0-11) for the carotid non-T occlusion and carotid T occlusion groups, respectively (P = 0.015). The duration of treatment or the median number of passes (2.5 vs. 2.0), the numbers of patients with thrombolysis in cerebral infarction 2b/3, bleeding complications and modified Rankin scale scores of 0-2 on postoperative day 90 did not significantly differ between the two groups. Manual aspiration before, internal carotid artery arrest while crossing a lesion and injection into the contralateral side were significantly more frequent in patients with carotid non-T occlusion. Intracranial internal carotid artery stenosis was significantly more frequent in patients with carotid non-T occlusion (n = 4, 20%) than carotid T occlusion (n = 0), and 10% of patients with carotid non-T occlusion had arterial dissection.

CONCLUSION

Patients with carotid non-T occlusion more frequently had a background of intracranial internal carotid artery stenosis or arterial dissection than patients with carotid T occlusion. Specific treatment strategies should be developed to improve the clinical outcomes of patients with carotid non-T occlusion.

Mechanical Thrombectomy of Distal Occlusions in the Anterior Cerebral Artery: Recanalization Rates, Periprocedural Complications, and Clinical Outcome

BACKGROUND AND PURPOSE

Patients with acute ischemic stroke in the anterior circulation are at risk for either primary or, following mechanical thrombectomy, secondary occlusion of the anterior cerebral artery. Because previous studies had only a limited informative value, we report our data concerning the frequency and location of distal anterior cerebral artery occlusions, recanalization rates, periprocedural complications, and clinical outcome.

MATERIALS AND METHODS

We performed a retrospective analysis of prospectively collected data of patients with acute ischemic stroke undergoing mechanical thrombectomy in the anterior circulation between June 2010 and April 2015.

RESULTS

Of 368 patients included in this analysis, we identified 30 (8.1%) with either primary (n = 17, 4.6%) or secondary (n = 13, 3.5%) embolic occlusion of the distal anterior cerebral artery. The recanalization rate after placement of a stent retriever was 88%. Periprocedural complications were rare and included vasospasms (n = 3, 10%) and dissection (n = 1, 3.3%). However, 16 (53.5%) patients sustained an (at least partial) infarction of the anterior cerebral artery territory. Ninety days after the ictus, clinical outcome according to the modified Rankin Scale score was the following: 0-2, n = 11 (36.6%); 3-4, n = 9 (30%); 5-6, n = 10 (33.3%).

CONCLUSIONS

Occlusions of the distal anterior cerebral artery affect approximately 8% of patients with acute ischemic stroke in the anterior circulation receiving mechanical thrombectomy. Despite a high recanalization rate and a low complication rate, subsequent (partial) infarction in the anterior cerebral artery territory occurs in approximately half of patients. Fortunately, clinical outcome appears not to be predominately unfavorable.