Acute stroke treatment using the Penumbra endovascular mechanical thrombolysis device: a single-centre experience

Foot Embolization During Limb Salvage Procedures in Critical Limb Ischemia Patients Successfully Managed With Mechanical Thromboaspiration: A Technical Note

PURPOSE

To illustrate the use of a mechanical thromboaspiration device originally designed for clot retrieval in acute stroke in the treatment of acute distal embolism occurring during percutaneous revascularization of the femoropopliteal and below-the-knee arterial segments.

TECHNIQUE

The Penumbra system was adapted for aspiration of thrombus in the distal foot arteries as a standalone device. The 2 over-the-wire, tapered lumen catheters have long working lengths (139 cm for the 4MAX to 153 cm for the 3MAX) that allow advancement below the ankle even with a retrograde contralateral approach. Once the occluded arterial segment is reached, the catheters are connected to the dedicated pump for continuous vacuum aspiration. The use of the device is illustrated in 3 diabetic patients (1 woman and 2 men; ages 88, 70, and 73 years, respectively) undergoing limb salvage procedures who experienced distal embolization that would have seriously jeopardized the foot circulation. The lumens of the occluded arteries were restored without complication.

CONCLUSION

While further evaluation in a larger cohort of patients is needed, this initial experience using the Penumbra system in the peripheral vasculature suggests that this is a rapid, effective approach to address intraprocedural foot embolization and avoid possible grave clinical sequelae.

What is meant by "TICI"?

BACKGROUND

In 2003, Higashida et al proposed the Thrombolysis In Cerebral Infarction scale to evaluate angiographic intracranial flow. Our aim is to review how subsequently published studies define TICI.

MATERIALS AND METHODS

We used the ISI Web of Knowledge and SciVerse Scopus databases to search for "TICI" and "thrombolysis in cerebral infarction" and for articles that cited the original TICI paper from January 2004 through May 2012. Articles were categorized according to their definition of the TICI categories, typically grades 0-4, with grade 2 (partial reperfusion) subdivided into 2a and 2b, and rate of contrast entry to the perfused area. In addition, we catalogued the type of redefinitions of TICI subcategory 2 and additions of new categories.

RESULTS

Of 236 articles screened, 74 were included. Eight (11%) explicitly followed the TICI scale as originally defined. Thirty-seven (50%) cited Higashida but did not define their scale. Fifteen (21%) used and explained modified scales. Thirteen (18%) used the term TICI, but did not define the scale and did not cite Higashida. Eighteen (24%) specified a 2a subcategory. Nine defined grade 2a as <67% filling, 6 defined it as <50%, and 3 did not offer a percentage. Two studies added a 2c subcategory. Fifty-two (70%) used a cutoff level to define "successful reperfusion." Of these, 65% used TICI ≥2, 33% used TICI ≥2b, and 2% used TICI = 3.

CONCLUSIONS

There is substantial variability in the definition and/or application of the TICI scale in the literature. This variability could considerably impact our understanding of results of revascularization studies.