Balloon Guide Catheter in Complex Anterior Circulation Mechanical Thrombectomy: Beyond Proximal Occlusion and Flow Reversal

Comparison of balloon guide catheter versus non-balloon guide catheter for mechanical thrombectomy in patients with distal medium vessel occlusion

BACKGROUND

Several studies have established the safety and efficacy of balloon guide catheters (BGCs) for large vessel occlusions. However, the utility of BGCs remains largely unexplored for distal medium vessel occlusions (DMVOs). In this study, we aim to compare the outcomes of BGC vs. Non-BGC in patients undergoing mechanical thrombectomy (MT) for DMVO.

METHOD

This retrospective study from the Stroke Thrombectomy and Aneurysm Registry (STAR) encompassed adult patients with acute anterior cerebral artery, posterior cerebral artery, and middle cerebral artery-M2-3-4 occlusions. Procedure times, safety, recanalization, and neurological outcomes were compared between the two groups, with subgroup analysis based on first-line thrombectomy techniques.

RESULTS

A total of 1508 patients were included, with 231 patients (15.3%) in the BGC group and 1277 patients (84.7%) in the non-BGC group. The BGC group had a lower modified Thrombolysis in Cerebral Infarction (mTICI) score ≥2C (43.2% vs 52.7%, P=0.01), longer time from puncture to intracranial access (15 vs 8 min, P<0.01), and from puncture to final recanalization (97 vs 34 min, P<0.01). In the Solumbra subgroup, the first pass effect (FPE) rate was lower in the BGC group (17.4% vs 30.7%, P=0.03). Regarding clinical outcomes, the BGC group had a lower rate of distal embolization (8.8% vs 14.9%, P=0.03).

CONCLUSION

Our study found that use of BGC in patients with DMVO was associated with lower mTICI scores, decreased FPE rates, reduced distal embolization, and longer procedure times.

Safety and efficacy of the SeparGate™ balloon-guiding catheter in neurointerventional surgery: Study protocol of a prospective multicenter single-arm clinical trial

Background

The balloon-guiding catheter (BGC) reportedly reduces the number of retrievals and occurrence of distal emboli, achieving superior revascularization results and improved clinical outcomes in acute stroke. This study will aim to examine the efficacy and safety of the new SeparGate™ BGC.

Design

This prospective multicenter single-arm clinical trial will aim to include 128 patients who fulfill its inclusion and exclusion criteria. All patients will receive endovascular interventional therapy with BGC assistance. The primary endpoint will be the immediate surgical success rate, while the secondary endpoint will be product performance. The safety evaluation will include serious adverse events such as puncture site hematoma and bleeding, cerebral vasospasm, vessel dissection, vessel perforation, air embolism, thrombus (acute or subacute), vessel occlusion, distal embolization, infection, adverse reaction to antiplatelet and anticoagulant drugs, intracranial hemorrhage, stroke, death, and device defect.

Discussion

The prospective multicenter trial will provide safety and efficacy information for the SeparGate™ BGC. Its findings will provide a clinical reference for endovascular adjuvant therapy of cerebrovascular disease.

Trial registration

ChiCTR1800014459.

Role of Balloon Guide Catheter in Modern Endovascular Thrombectomy

Proximal flow control achieved with a balloon guide catheter (BGC) during endovascular treatment of acute ischemic stroke is reviewed in this article. In clinical practice, BGCs offer a multi-faceted approach for clot retrieval by creating proximal flow arrest, reducing embolic burden, and shortening procedure time. Evaluation of frontline thrombectomy procedures with BGCs revealed advantages of combined use over the conventional guide catheter (CGC), notably in the significant reduction of distal emboli to both the affected and previously unaffected territories. Recently, new measures of early and complete reperfusion at first thrombectomy pass have been identified as independent predictors of improved outcomes, which were consistently demonstrated with use of BGC as a safe and effective option to minimize number of passes during intervention. Prior randomized controlled trials reported the positive correlation between BGC-treated patients and a lower risk of mortality as well as shortened procedure time. While BGC use is more common in stent retriever-mediated mechanical thrombectomy, preliminary data has shown the potential benefit of device application during contact aspiration thrombectomy to achieve successful recanalization. However, the question of which major endovascular strategy reigns superior as a frontline remains to be answered. Along with clinical case assessments, BGC performance during in-vitro simulation was analyzed to further understand mechanisms for optimization of thrombectomy technique.

PROTECT: PRoximal balloon Occlusion TogEther with direCt Thrombus aspiration during stent retriever thrombectomy – evaluation of a double embolic protection approach in endovascular stroke treatment

Purpose

Stent retriever-based mechanical thrombectomy (MT) for emergent large vessel occlusions (ELVO) is often complicated by thrombus fragmentation causing distal embolization and embolization to new vascular territories. Well-established embolic protection approaches include proximal flow arrest and distal aspiration techniques during stent retriever maneuvers. Aiming at the reduction of thrombus fragmentation during MT we evaluated a technical approach combining proximal balloon occlusion together with direct thrombus aspiration during MT: the PROTECT technique.

Methods

We performed a case-control study comparing the PROTECT technique with sole distal aspiration during MT regarding technical and procedural parameters, n=200 patients with ELVO of either the terminus of the internal carotid artery or the proximal middle artery were included.

Results

PROTECT resulted in a shorter procedure time (29 vs 40 min; P=0.002), in a higher rate of successful recanalizations (100% vs 78%; P=0.001) and a higher rate of complete reperfusions (70% vs 39%; P<0.001) compared with sole distal aspiration during MT.

Conclusion

The PROTECT technique is a promising new approach to significantly reduce thrombus fragmentation and, hence distal embolization during MT. This safe and efficient technique needs to be validated in larger trials to confirm our results.

Effective use of balloon guide catheters in reducing incidence of mechanical thrombectomy related distal embolization

BACKGROUND AND PURPOSE

The clinical benefit of endovascular stroke therapy has been demonstrated in several prospective randomized trials. However, in a relevant percentage of patients, mechanical thrombectomy bears the risk of causing new infarction in initially unaffected vascular territories through thrombus fragmentation and migration of clot debris. The goal of this study was to evaluate the use of the balloon guide catheter (BGC) to effectively achieve flow arrest and thrombus aspiration during the intervention to avoid distal embolization.

METHODS

A retrospective study was performed in 139 patients between October 2010 and May 2016 to analyze occlusions in the middle cerebral artery (MCA) or internal carotid artery (ICA) by using a stent retriever with a BGC (n = 73) or a non-BGC (n = 66). The following data were collected: patient age and gender, along with history of diabetes mellitus, hypertension, atrial fibrillation, smoking, obesity, dyslipidemia, and previous ischemic stroke. Data on procedure time, number of passes, and angiographic findings were also collected. The final reperfusion score was rated based on the Thrombolysis in Cerebral Infarction (TICI) grading scale. Successful recanalization was defined as TICI 3 or 2b.

RESULTS

A total of 139 patients underwent mechanical thrombectomy with the stent retriever. Of the 139 patients, 73 (52.5%) underwent placement of a BGC. The mean age was 65.8 ± 13.5 years, and the median National Institutes of Health Stroke Scale (NIHSS) score was 11. The average initial NIHSS score was lower in the BGC group compared with the non-BGC group (mean, 11.2 ± 5.6 vs. 13.2 ± 5.6; P = 0.03). Patients with BGC had fewer incidences of previous ischemic stroke (12.3% vs. 28.8%; P = 0.01). The numbers of passes were similar between the two groups. The procedure time (99 ± 49.4 min vs. 124 ± 72.2 min; P = 0.02) and the time from onset of symptoms to procedure end (302 ± 102 min vs. 357.2 ± 136.1 min; P = 0.009) were shorter in the BGC group. TICI 3 or 2b recanalization scores were higher in the BGC group compared to the non-BGC group [63/73, 86.3% vs. 48/66, 72.7%; odds ratio (OR), 0.6; 95% confidence interval (CI), 0.2-1.4; P = 0.04]. Importantly, distal embolization was less frequent in the BGC group (5/73, 6.8% vs. 21/66, 31.8%; OR, 6.3; 95% CI, 2.2-18.0; P < 0.001).

CONCLUSIONS

The risk of distal embolization was significantly decreased with the use of a BGC.

Efficacy of Balloon-Guiding Catheter for Mechanical Thrombectomy in Patients with Anterior Circulation Ischemic Stroke

Objective

To evaluate the efficacy of balloon guiding catheter (BGC) during thrombectomy in anterior circulation ischemic stroke.

Methods

Sixty-two patients with acute anterior circulation ischemic stroke were treated with thrombectomy using a Solitaire stent from 2011 to 2016. Patients were divided into the BGC group (n=24, 39%) and the non-BGC group (n=38, 61%). The number of retrievals, procedure time, thrombolysis in cerebral infarction (TICI) grade, presence of distal emboli, and clinical outcomes at 3 months were evaluated.

Results

Successful recanalization was more frequent in BGC than in non-BGC (83% vs. 66%, p=0.13). Distal emboli occurred less in BGC than in non-BGC (23.1% vs. 57.1%, p=0.02). Good clinical outcome was more frequent in BGC than in non-BGC (50% vs. 16%, p=0.03). The multivariate analysis showed that use of BGC was the only independent predictor of good clinical outcome (odds ratio, 5.19: 95% confidence interval, 1.07–25.11). More patients in BGC were successfully recanalized in internal carotid artery (ICA) occlusion with small retrieval numbers (<3) than those in non-BGC (70% vs. 24%, p=0.005). In successfully recanalized ICA occlusion, distal emboli did not occur in BGC, whereas nine patients had distal emboli in non-BGC (0% vs. 75%, p=0.001) and good clinical outcome was superior in BGC than in non-BGC (55.6% vs. 8.3%, p=0.01).

Conclusion

A BGC significantly reduces the number of retrievals and the occurrence of distal emboli, thereby resulting in better clinical outcomes in patients with anterior circulation ischemic stroke, particularly with ICA occlusion.