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Patki P, Simon S, Costanzo F, Manning KB. Current Approaches and Methods to Understand Acute Ischemic Stroke Treatment Using Aspiration Thrombectomy. Cardiovasc Eng Technol 2024:10.1007/s13239-024-00735-0. [PMID: 38886306 DOI: 10.1007/s13239-024-00735-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 05/21/2024] [Indexed: 06/20/2024]
Abstract
Acute ischemic stroke occurs when a blood clot occludes a cerebral artery. Mechanical interventions, primarily stent retrievers and aspiration thrombectomy, are used currently for removing the occluding clot and restoring blood flow. Aspiration involves using a long catheter to traverse the cerebral vasculature to reach the blood clot, followed by application of suction through the catheter bore. Aspiration is also used in conjunction with other techniques such as stent retrievers and balloon guide catheters. Despite the wide use of aspiration, our physical understanding of the process and the causes of the failure of aspiration to retrieve cerebral clots in certain scenarios is not well understood. Experimental and computational studies can help develop the capability to provide deeper insights into the procedure and enable development of new devices and more effective treatment methods. We recapitulate the aspiration-based thrombectomy techniques in clinical practice and provide a perspective of existing engineering methods for aspiration. We articulate the current knowledge gap in the understanding of aspiration and highlight possible directions for future engineering studies to bridge this gap, help clinical translation of engineering studies, and develop new patient-specific stroke therapy.
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Affiliation(s)
- Priyanka Patki
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, PA, 16802, USA
| | - Scott Simon
- Department of Neurosurgery, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Francesco Costanzo
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, PA, 16802, USA
- Center for Neural Engineering, The Pennsylvania State University, University Park, PA, 16802, USA
- Department of Engineering Science and Mechanics, The Pennsylvania State University, University Park, PA, 16802, USA
| | - Keefe B Manning
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, PA, 16802, USA.
- Center for Neural Engineering, The Pennsylvania State University, University Park, PA, 16802, USA.
- Department of Surgery, Penn State Hershey Medical Center, Hershey, PA, USA.
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Shi Y, Zhou Y, Yuan Y, Kong J, Gong M, Chen L, He X, Su H, Gu J. Establishment of an acute arterial mesenteric ischaemia model in canines with an endovascular approach. Front Vet Sci 2024; 11:1373914. [PMID: 38948676 PMCID: PMC11212455 DOI: 10.3389/fvets.2024.1373914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 06/04/2024] [Indexed: 07/02/2024] Open
Abstract
Purpose This study aimed to evaluate the feasibility of establishing an arterial acute mesenteric ischemia (AMI) model in canines using transcatheter autologous thrombus administration. Materials and methods Ten canines were divided into the experimental group (Group A, n = 5) and the sham group (Group B, n = 5). The canines in Group A received thrombus administration to the superior mesenteric artery (SMA) through a guiding catheter, while the canines in Group B received normal saline administration. Blood samples were collected and tested at baseline and 2 h after modelling. Canines in Group A underwent manual thromboaspiration after blood and intestine samples were collected. Ischaemic grades of intestinal mucosa were evaluated under light microscopes. Results The AMI models were successfully conducted in all canines without procedure-related vessel injury or death. At the 2-h follow-up, the high-sensitivity C-reactive protein and D-dimer in Group A were significantly higher than in Group B (5.72 ± 1.8 mg/L vs. 2.82 ± 1.5 mg/L, p = 0.024; 2.25 ± 0.8 μg/mL vs. 0.27 ± 0.10 μg/mL, p = 0.005; respectively). The mean histopathologic intestinal ischaemic grade in Group A was significantly higher than in Group B (2.4 ± 0.5 vs. 0.8 ± 0.4, p < 0.001). After a median of 2 times of thromboaspiration, 80% (4/5) of the canines achieved complete SMA revascularisation. Conclusion This experimental study demonstrated that establishing an arterial model in canines using endovascular approaches was feasible. The present model may play an important role in the investigation of endovascular techniques in the treatment of arterial AMI.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Jianping Gu
- Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
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Liu R, He H, Zhang L, Fan Y, Wang J, Wang W. In vitro models for the experimental evaluation of mechanical thrombectomy devices in acute ischemic stroke. Interv Neuroradiol 2023; 29:759-767. [PMID: 35971288 PMCID: PMC10680957 DOI: 10.1177/15910199221118404] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/13/2022] [Accepted: 07/17/2022] [Indexed: 11/16/2022] Open
Abstract
Mechanical thrombectomy has become an important method for the treatment of acute ischemic stroke for large vessel occlusions. The current hotspots of mechanical thrombectomy are optimizing the treatment methods, improving the recanalization rate and reducing complications. The in vitro model has become a common and convenient method for mechanical thrombectomy research. This review summarizes the in vitro model in the following aspects: the preparation of clot analogues; the experimental platform; the application of the in vitro model in the testing of thrombectomy devices; and the advantages, limitations and future trends of the in vitro experimental model. This review describes the characteristics and applications of the in vitro experimental model with the hope that the in vitro experimental model will be further improved and play a more effective role in the study of mechanical thrombectomy.
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Affiliation(s)
- Ronghui Liu
- School of Biological Science and Medical Engineering, Beijing Advanced Innovation Center for Biomedical Engineering, Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, Beihang University, Beijing, China
- Key Laboratory of Biomedical Engineering and Translational Medicine, Ministry of Industry and Information Technology, Research Center for Biomedical Engineering, Medical Innovation & Research Division, Chinese PLA General Hospital, Beijing, China
| | - Hongping He
- Key Laboratory of Biomedical Engineering and Translational Medicine, Ministry of Industry and Information Technology, Research Center for Biomedical Engineering, Medical Innovation & Research Division, Chinese PLA General Hospital, Beijing, China
| | - Luo Zhang
- Key Laboratory of Biomedical Engineering and Translational Medicine, Ministry of Industry and Information Technology, Research Center for Biomedical Engineering, Medical Innovation & Research Division, Chinese PLA General Hospital, Beijing, China
| | - Yubo Fan
- School of Biological Science and Medical Engineering, Beijing Advanced Innovation Center for Biomedical Engineering, Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, Beihang University, Beijing, China
| | - Jun Wang
- Department of Neurology, the First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Weidong Wang
- Key Laboratory of Biomedical Engineering and Translational Medicine, Ministry of Industry and Information Technology, Research Center for Biomedical Engineering, Medical Innovation & Research Division, Chinese PLA General Hospital, Beijing, China
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Settecase F, Kim WT, English JD. AXS Vecta 0.071-0.074 Inch Aspiration Catheters for Mechanical Thrombectomy: Case Series and Literature Review. Neurointervention 2023; 18:47-57. [PMID: 36328761 PMCID: PMC9986352 DOI: 10.5469/neuroint.2022.00283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 09/09/2022] [Indexed: 11/06/2022] Open
Abstract
Aspiration catheters are widely used for thrombectomy either alone or in combination with a stent-retriever, with a distal inner diameter and trackability keys to their success. In an illustrative case series, we report our clinical experience with AXS Vecta (Stryker Neurovascular, Fremont, CA, USA), available in both 0.071-inch and 0.074-inch distal inner diameters, including the first 2 Vecta 74 cases reported. A literature review on AXS Vecta is also provided. In our series, 9 thrombectomies were performed (Vecta 71: 2 M1, 5 M2 occlusions; Vecta 74: 1 M1 and 1 ICA-terminus occlusion). The AXS Vecta was successfully delivered to the target site in all cases. In 7 of 9 cases, the catheter was delivered over a Tenzing 7 delivery catheter (Route 92 Medical, San Mateo, CA, USA). For 2 of 9 combination approach cases, Vecta was delivered using the stent-retriever wire as a rail. The median improvement in NIHSS score during hospitalization was 9 (IQR 5-12). Successful mTICI 2C or 3 recanalization was achieved in 8 of 9 (89%) patients after a median 2 (IQR 1-2) passes. Our median groin-to-reperfusion time was 23 (IQR 12.5-32) minutes, with no procedural complications. Two previous clinical studies of a total of 29 patients treated with Vecta 71 reported successful mTICI 2b-3 recanalization in 89-90% of cases. The Median groin-to-reperfusion time was 30 minutes. Complications were seen in 2 of 29 (6.9%) cases (vessel perforation and/or intracerebral hemorrhage). These data support the efficacy, deliverability, and safety of AXS Vecta for mechanical thrombectomy.
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Affiliation(s)
- Fabio Settecase
- Neurointerventional Radiology, California Pacific Medical Center, San Francisco, CA, USA.,Neurointerventional Radiology, Mills-Peninsula Medical Center, Burlingame, CA, USA
| | - Warren T Kim
- Neurointerventional Radiology, California Pacific Medical Center, San Francisco, CA, USA.,Neurointerventional Radiology, Mills-Peninsula Medical Center, Burlingame, CA, USA
| | - Joey D English
- Neurointerventional Radiology, California Pacific Medical Center, San Francisco, CA, USA.,Neurointerventional Radiology, Mills-Peninsula Medical Center, Burlingame, CA, USA
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Patki P, Simon S, Manning KB, Costanzo F. Computational analysis of effects of clot length on Acute ischemic stroke recanalization under different cyclic aspiration loading conditions. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2023; 39:e3667. [PMID: 36511815 PMCID: PMC9960186 DOI: 10.1002/cnm.3667] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 11/16/2022] [Accepted: 12/04/2022] [Indexed: 06/17/2023]
Abstract
Acute ischemic stroke, the second leading cause of death worldwide, results from occlusion of a cerebral artery by a blood clot. Application of cyclic aspiration using an aspiration catheter is a current therapy for the removal of lodged clots. In this study, we perform finite element simulations to analyze deformation of long clots, having length to radius ratio of 2-10, which corresponds to clot-length of 2.85-14.25 mm, under peak-to-peak cyclic aspiration pressures of 10-50 mmHg, and frequencies of 0.5, 1, and 2 Hz. Our computational system comprises of a nonlinear viscoelastic solid clot, a hyperelastic artery, and a nonlinear viscoelastic cohesive zone, the latter modeling the clot-artery interface. We observe that clots having length-to-radius ratio approximately greater than two separate from the inner arterial surface somewhere between the axial and distal ends, irrespective of the cyclic aspiration loading conditions. The stress distribution within the clot shows large tensile stresses in the clot interior, indicating the possibility of simultaneous fragmentation of the clot. Thus, this study shows us the various failure mechanisms simultaneously present in the clot during cyclic aspiration. Similarly, the stress distribution within the artery implies a possibility of endothelial damage to the arterial wall near the end where the aspiration pressure is applied. This framework provides a foundation for further investigation to clot fracture and adhesion characterization.
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Affiliation(s)
- Priyanka Patki
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, Pennsylvania, USA
| | - Scott Simon
- Department of Neurosurgery, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
- Department of Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Keefe B. Manning
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, Pennsylvania, USA
- Department of Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Francesco Costanzo
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, Pennsylvania, USA
- Center for Neural Engineering, The Pennsylvania State University, University Park, Pennsylvania, USA
- Department of Engineering Science and Mechanics, The Pennsylvania State University, University Park, Pennsylvania, USA
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Comparison of mechanical thrombectomy techniques in an in vitro stroke model: How to obtain a first pass recanalization? J Neuroradiol 2022; 50:438-443. [PMID: 36526015 DOI: 10.1016/j.neurad.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 12/12/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Since mechanical thrombectomy (MT) has proven to be effective in the treatment of acute ischemic stroke (AIS), significant research has been dedicated to establishing procedural techniques offering best rate of first pass effect (FPE). In this study, we compared the efficacy of different techniques in vitro to achieve the first pass recanalisation (FPR). METHODS In vitro MT procedures were performed using a realistic silicone model of the human cerebral vasculature. The MT with stent retriever (SR) were performed with manual co-aspiration through the respective access catheter and intermediate catheter (IC), with Solumbra or partial retrieval techniques into the IC. Two SRs (Solitaire and EmboTrap) were selected to retrieve both red blood cells (RBC) rich and fibrin-rich clots. FPR rates were recorded for each case. RESULTS Overall, 144 MT were performed. FPR rates using the partial retrieval and Solumbra technique were of 100% and 87%, respectively (p = 0.01). The rate of FPR was of 92% using the balloon-guide catheter (BGC) compared to 64% with the guide catheter (GC) (p = 0.0001). With an IC, no differences were found between using a BGC or a GC (87.9% vs 89,6%, p = 0.75). No significant difference was observed between the Embotrap and the Solitaire device for the rate of FPR (82% and 74%, respectively; p = 0.23). CONCLUSIONS In this study, FPR rates were higher with the use of an IC associated with the partial retrieval technique, regardless the guide catheter, the SR, or the clot composition. The less effective technique was the association of GC and SR, without an IC.
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Bernava G, Brina O, Reymond P, Rosi A, Hofmeister J, Yilmaz H, Muster M, Kulcsar Z, Lovblad KO, Machi P. In vitro evaluation of how the presence of the stent retriever and microcatheter influences aspiration parameters in thrombectomy according to their position inside the aspiration catheter. Interv Neuroradiol 2022:15910199221135040. [PMID: 36348632 DOI: 10.1177/15910199221135040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Several variations of the combined thrombectomy technique for acute ischemic stroke using a stent retriever and aspiration catheter have been described. The aim of our study was to assess how the presence of the microcatheter and stent retriever affect the basic aspiration parameters, namely, flow rate and aspiration force, depending on their position within the aspiration catheter. METHODS Two experimental set-ups were designed to assess changes in flow rate and aspiration force according to the position of the stent retriever and microcatheter within the aspiration catheter. RESULTS The transition of the stent retriever and microcatheter from the distal to proximal position resulted in a progressive increase in the flow rate, but with no impact on aspiration force. Additionally, the size of the stent retriever had no significant effect on flow rate changes and the reduction in flow rate was related to the microcatheter diameter. Negative pressure generated inside the aspiration catheter impacted on its distal segment located beyond the radiopaque marker, thus leading to its partial collapse. As a consequence, the measured aspiration force was lower than the theoretical aspiration force level for all tested aspiration catheters. CONCLUSIONS In our experimental model, the position of the stent retriever and microcatheter within the aspirator catheter affected the flow rate, but not the aspiration force. Negative pressure generated within the aspiration catheter appeared to determine a partial collapse of the distal segment that resulted in a less effective aspiration force than the theoretical aspiration force level.
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Affiliation(s)
- Gianmarco Bernava
- Division of Neuroradiology, Geneva University Hospitals, Geneva, Switzerland
| | - Olivier Brina
- Division of Neuroradiology, Geneva University Hospitals, Geneva, Switzerland
| | - Philippe Reymond
- Division of Neuroradiology, Geneva University Hospitals, Geneva, Switzerland
| | - Andrea Rosi
- Division of Neuroradiology, Geneva University Hospitals, Geneva, Switzerland
| | - Jeremy Hofmeister
- Division of Neuroradiology, Geneva University Hospitals, Geneva, Switzerland
| | - Hasan Yilmaz
- Division of Neuroradiology, Geneva University Hospitals, Geneva, Switzerland
| | - Michel Muster
- Division of Neuroradiology, Geneva University Hospitals, Geneva, Switzerland
| | - Zsolt Kulcsar
- Division of Neuroradiology, University Hospital of Zurich, Zurich, Switzerland
| | - Karl-Olof Lovblad
- Division of Neuroradiology, Geneva University Hospitals, Geneva, Switzerland
| | - Paolo Machi
- Division of Neuroradiology, Geneva University Hospitals, Geneva, Switzerland
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Johnson S, Dwivedi A, Mirza M, McCarthy R, Gilvarry M. A Review of the Advancements in the in-vitro Modelling of Acute Ischemic Stroke and Its Treatment. FRONTIERS IN MEDICAL TECHNOLOGY 2022; 4:879074. [PMID: 35756535 PMCID: PMC9214215 DOI: 10.3389/fmedt.2022.879074] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/29/2022] [Indexed: 11/13/2022] Open
Abstract
In-vitro neurovascular models of large vessel occlusions (LVOs) causing acute ischemic stroke (AIS) are used extensively for pre-clinical testing of new treatment devices. They enable physicians and engineers to examine device performance and the response of the occlusion to further advance design solutions for current unmet clinical needs. These models also enable physicians to train on basic skills, to try out new devices and new procedural approaches, and for the stroke team to practice workflows together in the comfort of a controlled environment in a non-clinical setting. Removal of the occlusive clot in its entirety is the primary goal of the endovascular treatment of LVOs via mechanical thrombectomy (MT) and the medical treatment via thrombolysis. In MT, recanalization after just one pass is associated with better clinical outcomes than procedures that take multiple passes to achieve the same level of recanalization, commonly known as first pass effect (FPE). To achieve this, physicians and engineers are continually investigating new devices and treatment approaches. To distinguish between treatment devices in the pre-clinical setting, test models must also be optimized and expanded become more nuanced and to represent challenging patient cohorts that could be improved through new technology or better techniques. The aim of this paper is to provide a perspective review of the recent advancements in the in-vitro modeling of stroke and to outline how these models need to advance further in future. This review provides an overview of the various in-vitro models used for the modeling of AIS and compares the advantages and limitations of each. In-vitro models remain an extremely useful tool in the evaluation and design of treatment devices, and great strides have been made to improve replication of physiological conditions. However, further advancement is still required to represent the expanding indications for thrombectomy and thrombolysis, and the generation of new thrombectomy devices, to ensure that smaller treatment effects are captured.
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Affiliation(s)
- Sarah Johnson
- Cerenovus (Johnson & Johnson), Galway Neuro Technology Centre, Galway, Ireland
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He H, Liu YS, Liang HB, Li Y, Liu JR. Outcomes of Mechanical Thrombectomy for Acute Ischemic Stroke When Multiple Passes Are Required and Associated Risk Factors. Eur Neurol 2022; 85:300-307. [PMID: 35504260 DOI: 10.1159/000522559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 02/04/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION This study aimed to evaluate the outcomes of mechanical thrombectomy for acute ischemic stroke when multiple passes are required and to identify the associated risk factors. METHODS Consecutive patients with acute ischemic stroke treated with mechanical thrombectomy at the Neurology Department of Ninth People's Hospital and the Neurosurgery Department of Xinhua Hospital of Shanghai Jiao Tong University School of Medicine from 2013 to 2018 were included. Patients were divided into 2 groups: those who received ≤2 passes and those who received >2 passes. Outcomes of the 2 groups were compared. Multivariate linear regression was used to determine factors associated with the need for >2 passes. All patient data were reviewed retrospectively. RESULTS A total of 122 patients were included, of whom 83 patients required ≤2 passes and 39 patients required >2 passes. After adjusting for sex, atrial fibrillation history, smoking history, and involvement of middle cerebral artery and internal cerebral artery, the National Institutes of Health Stroke Scale (NIHSS) score was associated with a 1.08-times greater risk of >2 passes (95% confidence interval [CI]: 1.01-1.17), and internal carotid artery with a 5.13-times greater risk of >2 passes (95% CI: 1.02-25.69). Having more than 2 passes was associated with significantly higher 7-day (25.6% vs. 6%), 90-day mortality rates (34.2% vs. 16%) and a significantly lower recanalization rate (66.7% vs. 89.2%). CONCLUSION Needing more than 2 passes during mechanical thrombectomy is associated with poorer outcomes. Higher preprocedural NIHSS scores and internal carotid artery thrombi are associated with more than 2 passes.
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Affiliation(s)
- Hong He
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yi-Sheng Liu
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hai-Bing Liang
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yi Li
- Department of Neuosurgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Department of Neuosurgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jian-Ren Liu
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Pressman E, Sommer KN, Waqas M, Siddiqui AH, Ionita CN, Mokin M. Comparison of stent retriever thrombectomy using 3-dimensional patient-specific models of intracranial circulation with actual middle cerebral artery occlusion thrombectomy cases. J Neuroimaging 2022; 32:436-441. [PMID: 34958701 PMCID: PMC9899120 DOI: 10.1111/jon.12961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 12/05/2021] [Accepted: 12/06/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND PURPOSE Stent retriever (SR) thrombectomy is commonly used for the treatment of emergent large vessel occlusion (ELVO) in acute ischemic stroke. Clot imaging parameters such as clot length, diameter, distance to the internal carotid artery terminus, and vessel angle where the SR is deployed may predict the likelihood of achieving first pass effect (FPE). Most of the proposed factors that seem to affect recanalization success have been studied individually, and conflicting data derived from clinical versus in vitro studies using 3-dimensional printed models of intracranial circulation currently exist. METHODS Using patient-specific 3-dimensional phantoms of the cervical and intracranial circulation, we simulated middle cerebral arteries (MCA) M1 and M2 occlusions treated with SR thrombectomy using Solitaire (Medtronic) or Trevo (Styker). Our primary outcome was FPE, defined as Thrombolysis in Cerebral Infarction score of 2c-3 achieved after a single thrombectomy attempt. We also performed retrospective analysis of same clot imaging characteristics of consecutive cases of MCA occlusion and its association with FPE matching the 3-dimensional in vitro experiments. Analysis was conducted using IBM SPSS Statistics Version 25 (IBM Corp., Armonk, NY). Chi-square tests and bivariate logistic regressions were the main statistical tests used in analysis. A p-value of less than .05 was considered to indicate statistical significance. Ninety-five confidence intervals (95% CI) were generated. RESULTS We compared 41 thrombectomy experiments performed using patient-specific 3-dimensional in vitro models with a retrospective cohort of 41 patients treated with SR thrombectomy. We found that in the in vitro cohort, higher MCA angulation was associated with a lower likelihood of FPE (odds ratio [OR] = 0.967, 95% CI = 0.944-0.991, p = .008). Meanwhile in the in vivo cohort, higher MCA angulation was associated with a higher likelihood of FPE (OR = 1.039, 95% CI = 1.003-1.077, p = .033). Neither clot length nor location of clot (M1 vs. M2) was associated with a difference in FPE rates in either cohort. DISCUSSION Comparison of SR thrombectomy performed during actual MCA occlusion cases versus patient-specific 3-dimensional replicas revealed MCA angulation as an independent predictor of procedure success or failure. However, the opposite direction of effect was observed between the two studied environments, indicating potential limitations of studying SR thrombectomy using 3-dimensional models of LVO.
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Affiliation(s)
- Elliot Pressman
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida 33620
| | - Kelsey N Sommer
- Department of Biomedical Engineering, University at Buffalo NY 14228,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo NY 14208
| | - Mohammad Waqas
- Department of Neurosurgery, University at Buffalo, Buffalo, NY 14208
| | - Adnan H Siddiqui
- Department of Biomedical Engineering, University at Buffalo NY 14228,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo NY 14208,Department of Neurosurgery, University at Buffalo, Buffalo, NY 14208
| | - Ciprian N Ionita
- Department of Biomedical Engineering, University at Buffalo NY 14228,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo NY 14208
| | - Maxim Mokin
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida 33620
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Sommer KN, Bhurwani MMS, Iyer V, Ionita CN. Comparison of fluid dynamics changes due to physical activity in 3D printed patient specific coronary phantoms with the Windkessel equivalent model of coronary flow. 3D Print Med 2022; 8:10. [PMID: 35389117 PMCID: PMC8988414 DOI: 10.1186/s41205-022-00138-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 03/29/2022] [Indexed: 11/11/2022] Open
Abstract
Background 3D printing (3DP) used to replicate the geometry of normal and abnormal vascular pathologies has been demonstrated in many publications; however, reproduction of hemodynamic changes due to physical activities, such as rest versus moderate exercise, need to be investigated. We developed a new design for patient specific coronary phantoms, which allow adjustable physiological variables such as coronary distal resistance and coronary compliance in patients with coronary artery disease. The new design was tested in precise benchtop experiments and compared with a theoretical Windkessel electrical circuit equivalent, that models coronary flow and pressure using arterial resistance and compliance. Methods Five phantoms from patients who underwent clinically indicated elective invasive coronary angiography were built from CCTA scans using multi-material 3D printing. Each phantom was used in a controlled flow system where patient specific flow conditions were simulated by a programmable cardiac pump. To simulate the arteriole and capillary beds flow resistance and the compliance for various physical activities, we designed a three-chamber outlet system which controls the outflow dynamics of each coronary tree. Benchtop pressure measurements were recorded using sensors embedded in each of the main coronary arteries. Using the Windkessel model, patient specific flow equivalent electrical circuit models were designed for each coronary tree branch, and flow in each artery was determined for known inflow conditions. Local flow resistances were calculated through Poiseuille’s Law derived from the radii and lengths of the coronary arteries using CT angiography based multi-planar reconstructions. The coronary stenosis flow rates from the benchtop and the electrical models were compared to the localized flow rates calculated from invasive pressure measurements recorded in the angio-suites. Results The average Pearson correlations of the localized flow rates at the location of the stenosis between each of the models (Benchtop/Electrical, Benchtop/Angio, Electrical/Angio) are 0.970, 0.981, and 0.958 respectively. Conclusions 3D printed coronary phantoms can be used to replicate the human arterial anatomy as well as blood flow conditions. It displays high levels of correlation when compared to hemodynamics calculated in electrically-equivalent coronary Windkessel models as well as invasive angio-suite pressure measurements.
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Affiliation(s)
- Kelsey N Sommer
- Department of Biomedical Engineering, University at Buffalo, Buffalo, NY, USA. .,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA. .,QAS.AI Incorporated, Buffalo, NY, 14203, USA.
| | - Mohammad Mahdi Shiraz Bhurwani
- Department of Biomedical Engineering, University at Buffalo, Buffalo, NY, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA
| | - Vijay Iyer
- University at Buffalo Cardiology, University at Buffalo Jacobs School of Medicine, Buffalo, NY, USA
| | - Ciprian N Ionita
- Department of Biomedical Engineering, University at Buffalo, Buffalo, NY, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA.,QAS.AI Incorporated, Buffalo, NY, 14203, USA
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12
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Sweid A, Sajja KC, Mouchtouris N, Weinberg JH, Shivashankar K, Saad H, Abbas R, El Naamani K, Ramesh S, Schaefer J, Saiegh FA, Jabbour P, Herial NA, Zarzour H, Tjoumakaris S, Romo V, Rosenwasser RH, Gooch MR. Rescue stenting for acute ischemic stroke with Refractory Emergent Large vessel occlusion in the modern thrombectomy era. Clin Neurol Neurosurg 2022; 215:107183. [DOI: 10.1016/j.clineuro.2022.107183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 01/20/2022] [Accepted: 02/19/2022] [Indexed: 11/03/2022]
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13
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Gong M, Zhou Y, He X, Chen L, Zhao B, Kong J, Su H, Gu J. Mechanical revascularization using Solitaire AB device for acute limb ischemia secondary to popliteal and infrapopliteal embolic occlusion. Digit Health 2022; 8:20552076221084467. [PMID: 35340902 PMCID: PMC8943301 DOI: 10.1177/20552076221084467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 02/14/2022] [Indexed: 11/28/2022] Open
Abstract
Objective Acute limb ischemia is one of the most common arterial emergencies. The data of mechanical revascularization using Solitaire AB device coupled with thromboaspiration for the treatment of popliteal and infrapopliteal acute limb ischemia are limited. The aim of this study was to review the preliminary safety and effectiveness. Methods We performed a single-center retrospective review of patients with popliteal and infrapopliteal acute limb ischemia treated with Solitaire AB device coupled with thromboaspiration from February 2019 to May 2020. Adjunctive balloon angioplasty was performed to correct coexisting atherosclerotic stenosis. Technical success was defined as successful deployment of the Solitaire AB device across the occlusive segment and successful retrieval without the use of adjunctive catheter-directed thrombolysis or balloon angioplasty. Clinical success was defined as the relief of symptoms related to acute limb ischemia. Follow-up outcomes were also reviewed. Results There were 15 consecutive patients who underwent 16 Solitaire AB devices. Technical success was achieved in 11 (73.3%) patients. Of the unsuccessful patients, double-stent retrievers were employed in 1 (6.7%) patient. Two patients who encountered residual clots in distal small arteries underwent adjunctive catheter-directed thrombolysis. An adjunctive balloon angioplasty was required in 1 (6.7%) patient. All patients had notable acute limb ischemia symptom relief after the procedures. Clinical success was achieved in 14 (93.3%) patients. Besides one patient encountered minor amputation, the major amputation was prevented in all patients. No device-related complications or distal embolization events were recorded during the procedures. At the follow-up of 12 months, all surviving patients remained symptom-free, the patency was achieved in 12 (80%) patients and the limb salvage was 100%. Conclusions Preliminary outcomes suggest that mechanical revascularization using Solitaire AB device coupled with manual thromboaspiration appears to be a rapid, safe, and effective modality that appears to reduce the requirement for catheter-directed thrombolysis. Advances in knowledge These findings may add a promising recanalization therapy for acute embolic occlusion of the acute limb ischemia secondary to popliteal and infrapopliteal arteries.
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Affiliation(s)
- Maofeng Gong
- Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu PR China
| | - Yangyi Zhou
- Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu PR China
| | - Xu He
- Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu PR China
| | - Liang Chen
- Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu PR China
| | - Boxiang Zhao
- Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu PR China
| | - Jie Kong
- Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu PR China
| | - Haobo Su
- Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu PR China
| | - Jianping Gu
- Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu PR China
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14
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Preclinical modeling of mechanical thrombectomy. J Biomech 2021; 130:110894. [PMID: 34915309 DOI: 10.1016/j.jbiomech.2021.110894] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 11/16/2021] [Accepted: 11/18/2021] [Indexed: 11/21/2022]
Abstract
Mechanical thrombectomy to treat large vessel occlusions (LVO) causing a stroke is one of the most effective treatments in medicine, with a number needed to treat to improve clinical outcomes as low as 2.6. As the name implies, it is a mechanical solution to a blocked artery and modeling these mechanics preclinically for device design, regulatory clearance and high-fidelity physician training made clinical applications possible. In vitro simulation of LVO is extensively used to characterize device performance in representative vascular anatomies with physiologically accurate hemodynamics. Embolus analogues, validated against clots extracted from patients, provide a realistic simulated use experience. In vitro experimentation produces quantitative results such as particle analysis of distal emboli generated during the procedure, as well as pressure and flow throughout the experiment. Animal modeling, used mostly for regulatory review, allows estimation of device safety. Other than one recent development, nearly all animal modeling does not incorporate the desired target organ, the brain, but rather is performed in the extracranial circulation. Computational modeling of the procedure remains at the earliest stages but represents an enormous opportunity to rapidly characterize and iterate new thrombectomy concepts as well as optimize procedure workflow. No preclinical model is a perfect surrogate; however, models available can answer important questions during device development and have to date been successful in delivering efficacious and safe devices producing excellent clinical outcomes. This review reflects on the developments of preclinical modeling of mechanical thrombectomy with particular focus on clinical translation, as well as articulate existing gaps requiring additional research.
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15
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Yadong S, Haobo S, Liang C, Hao H, Zhaoxuan L, Jianping G. Endovascular Revascularization as Primary Treatment for Acute Embolic Mesenteric Ischemia: Stent Thrombectomy plus Aspiration versus Aspiration Alone. J Vasc Interv Radiol 2021; 33:295-303. [PMID: 34915163 DOI: 10.1016/j.jvir.2021.12.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 11/05/2021] [Accepted: 12/04/2021] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE This study aimed to investigate the outcomes of stent thrombectomy combined with aspiration versus aspiration alone in acute mesenteric ischemia (AMI). METHODS This was a single-center, retrospective cohort study. Between 1 May 2012 and 1 January 2021, 41 patients (mean age, 73.8±7.9 years) with AMI who underwent stent thrombectomy plus aspiration (Group 1, n=14) or aspiration alone (Group 2, n=27) were included. Patients' treatment regimens, clinical and follow-up outcomes were reviewed and analyzed. The group differences were compared using a Chi square test, Fisher's exact test, independent t test, or Mann-Whitney U test. The cumulative survival rate was calculated using a Kaplan-Meier curve. RESULTS The overall clinical success rate was 78.0% (32/41), and no significant difference was found between Group 1 and Group 2 (78.6% vs. 77.8%, p = 1.00). Whereas Group 1 was associated with a higher complete clearance rate (78.6% vs. 44.4%, p = 0.04), less adjunctive local thrombolysis (14.3% vs. 48.1%, p = 0.03), and shorter length of hospital stay (5.7±4.7 vs. 10.7±9.0 days, p = 0.03). The estimated survival rate at 1 month, 3 months, 6 months, 1 year, and 2 years was 73.2%, 72.5%, 71.4%, 65.3%, and 59.8%, respectively. No significant difference was found in survival rate between the groups (log-rank, p = 0.96). The recurrence rate for Group 1 and Group 2 were 8.3% (1/12) and 4.0% (1/25), respectively. CONCLUSIONS Compared with aspiration alone, additional stent thrombectomy showed superiorities in higher complete clearance rate, reduced adjunctive thrombolysis, and shorter length of hospital stay.
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Affiliation(s)
- Shi Yadong
- The Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, No. 68 Changle Road, Nanjing 210006, China
| | - Su Haobo
- The Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, No. 68 Changle Road, Nanjing 210006, China
| | - Chen Liang
- The Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, No. 68 Changle Road, Nanjing 210006, China
| | - Huang Hao
- The Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, No. 68 Changle Road, Nanjing 210006, China
| | - Lu Zhaoxuan
- The Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, No. 68 Changle Road, Nanjing 210006, China
| | - Gu Jianping
- The Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, No. 68 Changle Road, Nanjing 210006, China.
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16
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Luraghi G, Cahalane RME, van de Ven E, Overschie SCM, Gijsen FJH, Akyildiz AC. In vitro and in silico modeling of endovascular stroke treatments for acute ischemic stroke. J Biomech 2021; 127:110693. [PMID: 34450517 DOI: 10.1016/j.jbiomech.2021.110693] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 07/06/2021] [Accepted: 08/09/2021] [Indexed: 12/25/2022]
Abstract
Acute ischemic stroke occurs when a thrombus obstructs a cerebral artery, leading to sub-optimal blood perfusion to brain tissue. A recently developed, preventive treatment is the endovascular stroke treatment (EVT), which is a minimally invasive procedure, involving the use of stent-retrievers and/or aspiration catheters. Despite its increasing use, many critical factors of EVT are not well understood. In this respect, in vitro, and in silico studies have the great potential to help us deepen our understanding of the procedure, perform further device and procedural optimization, and help in clinical training. This review paper provides an overview of the previous in vitro and in silico evaluations of EVT treatments, with a special emphasis on the four main aspects of the adopted experimental and numerical set-ups: vessel, thrombus, device, and procedural settings.
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Affiliation(s)
- Giulia Luraghi
- Department of Biomechanical Engineering, Delft University of Technology, Delft, the Netherlands; Department of Chemistry, Materials and Chemical Engineering "Giulio Natta", Politecnico di Milano, Milan, Italy.
| | - Rachel M E Cahalane
- Department of Biomedical Engineering, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Emma van de Ven
- Department of Biomechanical Engineering, Delft University of Technology, Delft, the Netherlands
| | - Serena C M Overschie
- Department of Biomechanical Engineering, Delft University of Technology, Delft, the Netherlands
| | - Frank J H Gijsen
- Department of Biomechanical Engineering, Delft University of Technology, Delft, the Netherlands; Department of Biomedical Engineering, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Ali C Akyildiz
- Department of Biomechanical Engineering, Delft University of Technology, Delft, the Netherlands; Department of Biomedical Engineering, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands
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17
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Ospel JM, van der Lugt A, Gounis M, Goyal M, Majoie CBLM. A clinical perspective on endovascular stroke treatment biomechanics. J Biomech 2021; 127:110694. [PMID: 34419825 DOI: 10.1016/j.jbiomech.2021.110694] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/27/2021] [Accepted: 08/09/2021] [Indexed: 12/27/2022]
Abstract
Acute ischemic stroke (AIS) is caused by blockage of an arterial blood vessel in the brain by a thrombus, which interrupts oxygen supply to the brain parenchyma. The goal of endovascular stroke treatment (mechanical thrombectomy) is to restore blood flow as quickly and completely as possible. There are numerous factors that influence endovascular treatment success. They can be broadly grouped into a) factors related to blood vessels, b) factors related to the thrombus, c) factors related to endovascular treatment technique and tools and d) operator-related factors. While blood vessel and tgthro thrombus-related factors are mostly non-modifiable in the acute setting, operator and technique-related factors can be modified, and extensive research is currently being done to investigate the complex interplay of all these variables, and to optimize the modifiable factors to the maximum possible extent. In this review, we will describe these factors and how they interact with each other in detail, and outline some of their practical implications. We will conclude with a short summary and outlook on future directions for optimizing endovascular treatment success.
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Affiliation(s)
- Johanna M Ospel
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada; Department of Neuroradiology, University Hospital Basel, Basel, Switzerland; Department of Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada.
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
| | - Matthew Gounis
- Department of Radiology, University of Massachusetts Medical School, Worcester, United States
| | - Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada; Department of Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
| | - Charles B L M Majoie
- Department of Radiology & Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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18
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Liu Y, Abbasi M, Arturo Larco JL, Kadirvel R, Kallmes DF, Brinjikji W, Savastano L. Preclinical testing platforms for mechanical thrombectomy in stroke: a review on phantoms, in-vivo animal, and cadaveric models. J Neurointerv Surg 2021; 13:816-822. [PMID: 33722966 PMCID: PMC8364863 DOI: 10.1136/neurintsurg-2020-017133] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 02/18/2021] [Accepted: 02/19/2021] [Indexed: 11/03/2022]
Abstract
Preclinical testing platforms have been instrumental in the research and development of thrombectomy devices. However, there is no single model which fully captures the complexity of cerebrovascular anatomy, physiology, and the dynamic artery-clot-device interaction. This article provides a critical review of phantoms, in-vivo animal, and human cadaveric models used for thrombectomy testing and provides insights into the strengths and limitations of each platform. Articles published in the past 10 years that reported thrombectomy testing platforms were identified. Characteristics of each test platform, such as intracranial anatomy, artery tortuosity, vessel friction, flow conditions, device-vessel interaction, and visualization, were captured and benchmarked against human cerebral vessels involved in large-vessel occlusion stroke. Thrombectomy phantoms have been constructed from silicone, direct 3D-printed polymers, and glass. These phantoms represent oversimplified patient-specific cerebrovascular geometry but enable adequate visualization of devices and clots under appropriate flow conditions. They do not realistically mimic the artery-clot interaction. For the animal models, arteries from swine, canines, and rabbits have been reported. These models can reasonably replicate the artery-clot-device interaction and have the unique value of evaluating the safety of thrombectomy devices. However, the vasculature geometries are substantially less complex and flow conditions are different from human cerebral arteries. Cadaveric models are the most accurate vascular representations but with limited access and challenges in reproducibility of testing conditions. Multiple test platforms should be likely used for comprehensive evaluation of thrombectomy devices. Interpretation of the testing results should take into consideration platform-specific limitations.
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Affiliation(s)
- Yang Liu
- Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mehdi Abbasi
- Radiology, Mayo Clinic, Rochester, Minnesota, USA
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19
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Al-Bayati AR, Haussen DC, Mohammaden MH, Pisani L, Bhatt N, Liberato B, Frankel MR, Nogueira RG. Blind exchange technique to facilitate large-bore aspiration catheter navigation during stroke thrombectomy. Clin Neurol Neurosurg 2021; 208:106873. [PMID: 34388597 DOI: 10.1016/j.clineuro.2021.106873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 07/23/2021] [Accepted: 08/02/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Optimizing mechanical thrombectomy (MT) techniques is an essential facet of our developing field. Herein, we describe the "Blind exchange" (BE) technique; an alternative fashion of efficiently performing stent-retriever (SR) coupled with contact aspiration thrombectomy (aspiration-retriever technique for stroke-ARTS). METHODS A prospectively collected MT database was reviewed from July 2018-February 2020. We included all consecutive patients with anterior circulation large vessel occlusions in whom BE technique was performed. According to the response of the retriever, the decision to add an aspiration catheter (AC) for ARTS was made. The microcatheter was then fully retracted and the AC tracked over the deployed SR wire in a BE fashion. The primary outcome was technical success and safety measures included procedural-related complications. RESULTS One hundred nineteen patients were identified, mean age was 66.7 ± 15.8 years and 57(47.9%) were males. Twenty-six patients (21.8%) had intracranial ICA occlusion and 93(78.2%) had MCA-M1 segment occlusion. The median ASPECTS was 7(IQR;8-9), baseline NIHSS score was 18(IQR;14-21), and procedure time was 36(IQR;25-57) minutes. IV-tPA was used in 26(21.8%) of cases. Successful reperfusion (eTICI2b-3) was achieved in 100% of cases including full reperfusion (eTICI3) in 67(56.3%) of cases. The AC was successfully navigated into the target lesion without any complications in all cases. Symptomatic intracranial hemorrhage occurred in 4.2% of patients. The rates of 90-day mRS0-2 and mortality were 44.3% and 12.5%, respectively. CONCLUSION BE is a safe and feasible alternative technique of navigating large bore AC into the intracranial vasculature while performing ARTS.
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Affiliation(s)
- Alhamza R Al-Bayati
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, 80 Jesse Hill Drive SE, Room 8D108A, Atlanta, GA 30303, 700, United States.
| | - Diogo C Haussen
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, 80 Jesse Hill Drive SE, Room 8D108A, Atlanta, GA 30303, 700, United States.
| | - Mahmoud H Mohammaden
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, 80 Jesse Hill Drive SE, Room 8D108A, Atlanta, GA 30303, 700, United States.
| | - Leonardo Pisani
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, 80 Jesse Hill Drive SE, Room 8D108A, Atlanta, GA 30303, 700, United States.
| | - Nirav Bhatt
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, 80 Jesse Hill Drive SE, Room 8D108A, Atlanta, GA 30303, 700, United States.
| | - Bernardo Liberato
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, 80 Jesse Hill Drive SE, Room 8D108A, Atlanta, GA 30303, 700, United States.
| | - Michael R Frankel
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, 80 Jesse Hill Drive SE, Room 8D108A, Atlanta, GA 30303, 700, United States.
| | - Raul G Nogueira
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, 80 Jesse Hill Drive SE, Room 8D108A, Atlanta, GA 30303, 700, United States.
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Paccione E, Ionita CN. Challenges in hemodynamics assessment in complex neurovascular geometries using computational fluid dynamics and benchtop flow simulation in 3D printed patient specific phantoms. PROCEEDINGS OF SPIE--THE INTERNATIONAL SOCIETY FOR OPTICAL ENGINEERING 2021; 11600. [PMID: 33814673 DOI: 10.1117/12.2582169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Purpose Complex hemodynamics assessments, as those related to carotid stenosis, are not always easily straightforward due to multifaceted challenges presented by the collateral flow in the Circle of Willis (CoW) and brain flow autoregulation. Advanced computational and benchtop methods to investigate hemodynamics aspects related to such complex flows are often used, however both have limitations and could lead to results which may diverge. In this study we investigated these aspects by performing correlated computational fluid dynamics (CFD) simulations and benchtop experiments in patient specific 3D printed phantoms. Materials and Methods To investigate the flow in patients with carotid stenosis, we built two patient specific phantoms which contained the arterial lesion of interest, all main arteries leading to the brain, the CoW and main arteries branching from it. Each phantom was connected to a generic aortic arch. A programmable pump was connected and flow parameters were measured proximal and distal to the lesion and the contralateral arteries. The patient 3D geometry was used to perform a set of CFD simulations where inflow boundary conditions matched the experimental ones. Flow conditions were recorded at the same locations as the experimental setup. Further exploration into the translation from experimental to CFD was also performed by customizing vascular segmentation and physically manipulating arterial compliance properties. Results We initially observed significant differences between the CFD recordings and the experimental setup. Most of the differences were due to changes in phantom geometry when subjected to physiological pressures and simplistic outflow boundary conditions in the CFD simulations which do not account for pulsatility and nonlinear phenomena. Further work confirms the need for dynamic mesh behavior within CFD simulations attempting to computationally mimic 3D-printed benchtop experiments. Additionally, CFD simulation may benefit from considering geometry specific to a 3D-printed vascular phantom.
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Affiliation(s)
- Eric Paccione
- University Dept. of Biomedical Engineering, University at Buffalo, Buffalo, NY
| | - Ciprian N Ionita
- University Dept. of Biomedical Engineering, University at Buffalo, Buffalo, NY.,Canon Stroke and Vascular Research Center, Buffalo, NY
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21
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Sommer KN, Bhurwani MMS, Mokin M, Ionita CN. Evaluation of challenges and limitations of mechanical thrombectomy using 3D printed neurovascular phantoms. PROCEEDINGS OF SPIE--THE INTERNATIONAL SOCIETY FOR OPTICAL ENGINEERING 2021; 11601:116010B. [PMID: 34334874 PMCID: PMC8323489 DOI: 10.1117/12.2580962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The mechanical thrombectomy (MT) efficacy, for large vessel occlusion (LVO) treatment in patients with stroke, could be improved if better teaching and practicing surgical tools were available. We propose a novel approach that uses 3D printing (3DP) to generate patient anatomical vascular variants for simulation of diverse clinical scenarios of LVO treated with MT. 3DP phantoms were connected to a flow loop with physiologically relevant flow conditions, including input flow rate and fluid temperature. A simulated blood clot was introduced into the model and placed in the Middle Cerebral Artery region. Clot location, composition (hard or soft clot), length, and arterial angulation were varied and MTs were simulated using stent retrievers. Device placement relative to the clot and the outcome of the thrombectomy were recorded for each situation. Angiograms were captured before and after LVO simulation and after the MT. Recanalization outcome was evaluated using the Thrombolysis in Cerebral Infarction (TICI) scale. Forty-two 3DP neurovascular phantom benchtop experiments were performed. Clot mechanical properties, hard versus soft, had the highest impact on the MT outcome, with 18/42 proving to be successful with full or partial clot retrieval. Other factors such as device manufacturer and the tortuosity of the 3DP model correlated weakly with the MT outcome. We demonstrated that 3DP can become a comprehensive tool for teaching and practicing various surgical procedures for MT in LVO patients. This platform can help vascular surgeons understand the endovascular devices limitations and patient vascular geometry challenges, to allow surgical approach optimization.
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Affiliation(s)
- Kelsey N Sommer
- Department of Biomedical Engineering, University at Buffalo NY 14228,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo NY 14208
| | - Mohammad Mahdi Shiraz Bhurwani
- Department of Biomedical Engineering, University at Buffalo NY 14228,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo NY 14208
| | - Maxim Mokin
- Department of Neurosurgery, University of South Florida, Tampa, Florida 33620
| | - Ciprian N Ionita
- Department of Biomedical Engineering, University at Buffalo NY 14228,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo NY 14208
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22
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Waqas M, Mokin M, Lim J, Vakharia K, Springer ME, Meess KM, Ducharme RW, Ionita CN, Nagesh SVS, Gutierrez LC, Snyder KV, Davies JM, Levy EI, Siddiqui AH. Design and Physical Properties of 3-Dimensional Printed Models Used for Neurointervention: A Systematic Review of the Literature. Neurosurgery 2021; 87:E445-E453. [PMID: 32392300 DOI: 10.1093/neuros/nyaa134] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 03/11/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Three-dimensional (3D) printing has revolutionized training, education, and device testing. Understanding the design and physical properties of 3D-printed models is important. OBJECTIVE To systematically review the design, physical properties, accuracy, and experimental outcomes of 3D-printed vascular models used in neurointervention. METHODS We conducted a systematic review of the literature between January 1, 2000 and September 30, 2018. Public/Publisher MEDLINE (PubMed), Web of Science, Compendex, Cochrane, and Inspec databases were searched using Medical Subject Heading terms for design and physical attributes of 3D-printed models for neurointervention. Information on design and physical properties like compliance, lubricity, flow system, accuracy, and outcome measures were collected. RESULTS A total of 23 articles were included. Nine studies described 3D-printed models for stroke intervention. Tango Plus (Stratasys) was the most common material used to develop these models. Four studies described a population-representative geometry model. All other studies reported patient-specific vascular geometry. Eight studies reported complete reconstruction of the circle of Willis, anterior, and posterior circulation. Four studies reported a model with extracranial vasculature. One prototype study reported compliance and lubricity. Reported circulation systems included manual flushing, programmable pistons, peristaltic, and pulsatile pumps. Outcomes included thrombolysis in cerebral infarction, post-thrombectomy flow restoration, surgical performance, and qualitative feedback. CONCLUSION Variations exist in the material, design, and extent of reconstruction of vasculature of 3D-printed models. There is a need for objective characterization of 3D-printed vascular models. We propose the development of population representative 3D-printed models for skill improvement or device testing.
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Affiliation(s)
- Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Maxim Mokin
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida
| | - Jaims Lim
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Kunal Vakharia
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | | | | | | | - Ciprian N Ionita
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York
| | - Swetadri Vasan Setlur Nagesh
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York
| | - Liza C Gutierrez
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York
| | - Kenneth V Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Jason M Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Jacobs Institute, Buffalo, New York.,Department of Bioinformatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Jacobs Institute, Buffalo, New York.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Jacobs Institute, Buffalo, New York.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
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23
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Abstract
Endovascular therapy (EVT) has become the standard treatment for large-vessel occlusion (LVO) acute ischemic stroke (AIS). EVT is now indicated in patients up to 24h from their last known well, provided that the patient meets specific clinical and imaging criteria. Improvements in thrombectomy devices, techniques, and operator experience have allowed successful EVT of ICA terminus, M1-MCA occlusions as well as proximal M2-MCA, basilar artery occlusions, and revascularization of tandem lesions. Mechanical thrombectomy failures still occur due to several factors, however, highlighting the need for further device and technical improvements. An ongoing debate exists regarding the need for pre-EVT thrombolytic agents, thrombectomy techniques, distal occlusions, anesthesia methods, the role of advanced neuroimaging, the treatment of patients with larger infarct core, and those presenting with milder stroke symptoms. Many of these questions are the subject of current or upcoming clinical trials. This review aims to provide an outline and discussion about the established recommendations and emerging topics regarding EVT for LVO AIS.
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Affiliation(s)
- Fabio Settecase
- Neuroradiology Division, Department of Radiology, University of British Columbia, Vancouver, BC, Canada; Diagnostic and Interventional Neuroradiology Division, Department of Radiology, Vancouver General Hospital, Vancouver, BC, Canada; Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, United States.
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24
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Nawka MT, Hanning U, Guerreiro H, Flottmann F, Van Horn N, Buhk JH, Fiehler J, Frölich AM. Feasibility of a customizable training environment for neurointerventional skills assessment. PLoS One 2020; 15:e0238952. [PMID: 32941466 PMCID: PMC7498089 DOI: 10.1371/journal.pone.0238952] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 08/26/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To meet increasing demands to train neuroendovascular techniques, we developed a dedicated simulator applying individualized three-dimensional intracranial aneurysm models ('HANNES'; Hamburg Anatomic Neurointerventional Endovascular Simulator). We hypothesized that HANNES provides a realistic and reproducible training environment to practice coil embolization and to exemplify disparities between neurointerventionalists, thus objectively benchmarking operators at different levels of experience. METHODS Six physicians with different degrees of neurointerventional procedural experience were recruited into a standardized training protocol comprising catheterization of two internal carotid artery (ICA) aneurysms and one basilar tip aneurysm, followed by introduction of one framing coil into each aneurysm and finally complete coil embolization of one determined ICA aneurysm. The level of difficulty increased with every aneurysm. Fluoroscopy was recorded and assessed for procedural characteristics and adverse events. RESULTS Physicians were divided into inexperienced and experienced operators, depending on their experience with microcatheter handling. Mean overall catheterization times increased with difficulty of the aneurysm model. Inexperienced operators showed longer catheterization times (median; IQR: 47; 30-84s) than experienced operators (21; 13-58s, p = 0.011) and became significantly faster during the course of the attempts (rho = -0.493, p = 0.009) than the experienced physicians (rho = -0.318, p = 0.106). Number of dangerous maneuvers throughout all attempts was significantly higher for inexperienced operators (median; IQR: 1.0; 0.0-1.5) as compared to experienced operators (0.0; 0.0-1.0, p = 0.014). CONCLUSION HANNES represents a modular neurointerventional training environment for practicing aneurysm coil embolization in vitro. Objective procedural metrics correlate with operator experience, suggesting that the system could be useful for assessing operator proficiency.
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Affiliation(s)
- Marie Teresa Nawka
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helena Guerreiro
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Noel Van Horn
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan-Hendrik Buhk
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Maximilian Frölich
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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25
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Scullen T, Nerva JD, Amenta PS, Dumont AS. Commentary: Design and Physical Properties of 3-Dimensional Printed Models Used for Neurointervention: A Systematic Review of the Literature. Neurosurgery 2020; 87:E454-E455. [PMID: 32453826 DOI: 10.1093/neuros/nyaa217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 03/28/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Tyler Scullen
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
| | - John D Nerva
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
| | - Peter S Amenta
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
| | - Aaron S Dumont
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
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26
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Fitzgerald S, Ryan D, Thornton J, Nogueira RG. Preclinical evaluation of Millipede 088 intracranial aspiration catheter in cadaver and in vitro thrombectomy models. J Neurointerv Surg 2020; 13:447-452. [PMID: 32606100 PMCID: PMC8053321 DOI: 10.1136/neurintsurg-2020-016218] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/03/2020] [Accepted: 06/04/2020] [Indexed: 11/30/2022]
Abstract
Background Larger bore aspiration catheters are expected to significantly improve the speed and completeness of acute stroke revascularization. Objective To evaluate the navigability and clot retrieval performance of a novel 8Fr aspiration catheter, Millipede 088 (Perfuze Ltd), using fresh-frozen cadavers and an in vitro thrombectomy model, respectively. Methods Cadaveric study: Transfemoral catheterization of the intracranial arteries was performed in six cadavers, allowing evaluation of navigation to 12 middle cerebral arteries (MCAs) and six basilar arteries. Commercially available 6Fr aspiration catheters (SOFIA Plus, Microvention) were used as controls. In vitro study: Three human blood clot phenotypes were created; red blood cell-rich, mixed, and fibrin/platelets-rich. Two clot sizes, resulting in occlusion of the internal carotid artery (ICA) and MCA-M1 were investigated. Endpoints were first-pass effect (FPE), first-pass complete ingestion, and second-pass recanalization. Results Cadaveric study: Both the Millipede 088 and SOFIA Plus devices reached the distal MCA-M1 and the basilar artery in 10/12 and 2/2 of the navigation attempts, respectively. In the two instances of unsuccessful navigation, neither device was able to cross the ophthalmic artery. In vitro study: In 10 mm long M1 occlusions, Millipede 088 achieved 100% FPE versus 40% for 6Fr devices (p>0.001). In 20 mm long ICA occlusions, Millipede 088 achieved 100% removal success within two passes in each clot phenotype compared with an average of 27% for 6Fr devices (p>0.001). Conclusions Navigation of the Millipede 088 catheter to the MCA-M1 and basilar artery is feasible in a cadaver model. Millipede 088 demonstrates superiority over 6Fr aspiration catheters for three representative clot phenotypes at the most common sites of occlusion in an in vitro vasculature model.
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Affiliation(s)
- Seán Fitzgerald
- Department of Physiology, National University of Ireland Galway, Galway, Ireland
| | - David Ryan
- Department of Mechanical Engineering, National University of Ireland Galway, Galway, Ireland
| | - John Thornton
- Interventional Neuroradiology Service, Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - Raul G Nogueira
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia, USA.,Department of Neurology, Emory University, Atlanta, Georgia, USA
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27
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Yi HJ, Lee DH, Sung JH. Comparison of FlowGate 2 and Merci as balloon guide catheters used in mechanical thrombectomies for stroke intervention. Exp Ther Med 2020; 20:1129-1136. [PMID: 32765661 DOI: 10.3892/etm.2020.8757] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 01/10/2020] [Indexed: 12/25/2022] Open
Abstract
The present study reports on the usefulness of FlowGate2 (FG2) as a novel balloon guide catheter (BGC) for mechanical thrombectomy (MT) treatment. MT using a BGC device was performed on 255 patients at the authors' institution (St. Vincent's hospital, Suwon, Korea and Hangang Sacred Heart Hospital, Seoul, Korea) between January 2014 and September 2018. A total of 235 patients underwent successful application of BGCs and were divided into two groups; an FG2 and a Merci group, and a comparative analysis was performed. The failure rate in the FG2 group (2.5%) was significantly lower than that in the Merci group (10.8%; P=0.016). Occurrence of distal emboli was significantly lower in the FG2 group (4.7%) than in the Merci group (7.3%; P=0.012). According to subgroup analysis of the BGC and the intermediate catheter, the incidence rate of the distal emboli in the FG2 with an intermediate catheter (2.3%) was significantly lower than that of the Merci with an intermediate catheter (6.6%; P=0.038). The ratio of thrombolysis in cerebral infarction (TICI) 3 recanalization in the first pass was higher in the FG2 group than in the Merci group, in both total (44.7 vs. 34.7%; P=0.033) and subgroup patients (46.5 vs. 34.4%; P=0.029). In the multivariate analysis, use of an intermediate catheter [odds ratio (OR), 0.75; 95% confidence interval (CI), 0.66-0.94; P=0.029] and FG2 application (OR, 0.59; 95% CI, 0.25-0.93; P=0.020) were the predictive factors for fewer distal emboli. In summary, FG2 BGC enables an effective MT with less application failures and occurrence of distal emboli, and higher TICI 3 recanalization at the first stent passage, compared with Merci BGC.
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Affiliation(s)
- Ho Jun Yi
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Gyeonggi-do 16247, Republic of Korea.,Department of Neurosurgery, Hangang Sacred Heart Hospital, College of Medicine, Hallym University, Seoul 07247, Republic of Korea
| | - Dong Hoon Lee
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Gyeonggi-do 16247, Republic of Korea
| | - Jae Hoon Sung
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Gyeonggi-do 16247, Republic of Korea
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28
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Soize S, Pierot L, Mirza M, Gunning G, Gilvarry M, Gawlitza M, Vivien D, Zuber M, Touzé E. Fast Stent Retrieval Improves Recanalization Rates of Thrombectomy: Experimental Study on Different Thrombi. AJNR Am J Neuroradiol 2020; 41:1049-1053. [PMID: 32409312 DOI: 10.3174/ajnr.a6559] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 03/02/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE About 20% of patients with acute ischemic stroke due to large-artery occlusion do not achieve recanalization with mechanical thrombectomy. We aimed to determine whether the speed of retrieval of the stent retriever influences the efficacy in removing different clot types. MATERIALS AND METHODS Sixty mechanical thrombectomies were performed using an in vitro pulsatile cerebrovascular circulation model with controlled pressure and flow rate. Experiments were dichotomized into fast and slow retrieval using a wedging technique, in which the stent retriever and distal catheter are retrieved together. We used 3 different clot types: erythrocyte-rich, fibrin-rich, and friable clots. Primary end points were complete (TICI 3) and successful (TICI 2b-3) recanalizations. Secondary measures were distal and new territory embolizations. RESULTS Fast retrieval was more frequently associated with complete (RR = 1.83; 95% CI, 1.12-2.99) and successful recanalization (RR = 1.50; 95% CI, 1.03-2.19) than slow retrieval, without a difference in distal embolization (RR = 0.75; 95% CI, 0.29-1.90). There were no emboli in a new territory. The advantage of fast retrieval over slow retrieval differed according to the clot composition, with a stronger effect with fibrin-rich clots with regard to complete (RR = 4.00; 95% CI, 1.11-14.35; Pint = .04) and successful (Pint = .10) recanalization. CONCLUSIONS In our experimental model, a fast removal improved recanalization rates of mechanical thrombectomy, especially in the case of fibrin-rich clots. An in vivo confirmation is warranted to see whether our findings can have an impact in clinical practice.
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Affiliation(s)
- S Soize
- From the Department of Neuroradiology (S.S., L.P., M. Gawlitza), Hôpital Maison Blanche, Champagne-Ardenne University, Reims, France .,Unité Mixte de Recherche (UMR)-S 1237 Physiopathology and Imaging of Neurological Disorders (S.S., D.V., E.T.), National Institute for Health and Medical Research, Normandie University, Université Caen Normandie, Cyceron, Caen, France
| | - L Pierot
- From the Department of Neuroradiology (S.S., L.P., M. Gawlitza), Hôpital Maison Blanche, Champagne-Ardenne University, Reims, France
| | - M Mirza
- Neuravi/Cerenovus (M.M., G.G., M. Gilvarry), Galway, Ireland
| | - G Gunning
- Neuravi/Cerenovus (M.M., G.G., M. Gilvarry), Galway, Ireland
| | - M Gilvarry
- Neuravi/Cerenovus (M.M., G.G., M. Gilvarry), Galway, Ireland
| | - M Gawlitza
- From the Department of Neuroradiology (S.S., L.P., M. Gawlitza), Hôpital Maison Blanche, Champagne-Ardenne University, Reims, France
| | - D Vivien
- Unité Mixte de Recherche (UMR)-S 1237 Physiopathology and Imaging of Neurological Disorders (S.S., D.V., E.T.), National Institute for Health and Medical Research, Normandie University, Université Caen Normandie, Cyceron, Caen, France
| | - M Zuber
- Department of Neurology (M.Z.), Hôpital Saint-Joseph, Paris Descartes University, Paris, France
| | - E Touzé
- Unité Mixte de Recherche (UMR)-S 1237 Physiopathology and Imaging of Neurological Disorders (S.S., D.V., E.T.), National Institute for Health and Medical Research, Normandie University, Université Caen Normandie, Cyceron, Caen, France
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29
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Soto JM, Reed LK, Benardete EA. Successful endovascular removal of a chondroblastic osteosarcoma embolus within the left middle cerebral artery. Proc (Bayl Univ Med Cent) 2020; 33:451-452. [PMID: 32675984 DOI: 10.1080/08998280.2020.1747326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 03/18/2020] [Accepted: 03/23/2020] [Indexed: 12/21/2022] Open
Abstract
A 57-year-old woman with metastatic chondroblastic osteosarcoma developed sudden-onset right-sided weakness and aphasia. She was found to have an occluded left middle cerebral artery (M1 segment) and underwent endovascular stroke intervention with return to a normal neurological exam within 24 h. Histologic analysis of the embolus was consistent with chondroblastic osteosarcoma.
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Affiliation(s)
- Jose M Soto
- Department of Neurosurgery, Baylor Scott and White HealthTempleTexas
| | - Laura K Reed
- Department of Neurosurgery, Baylor Scott and White HealthTempleTexas
| | - Ethan A Benardete
- Department of Neurosurgery, Baylor Scott and White HealthTempleTexas
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30
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Imaging Clot Characteristics in Stroke and its Possible Implication on Treatment. Clin Neuroradiol 2019; 30:27-35. [DOI: 10.1007/s00062-019-00841-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 09/17/2019] [Indexed: 12/11/2022]
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31
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Chueh JY, Kang DH, Kim BM, Gounis MJ. Role of Balloon Guide Catheter in Modern Endovascular Thrombectomy. J Korean Neurosurg Soc 2019; 63:14-25. [PMID: 31591997 PMCID: PMC6952736 DOI: 10.3340/jkns.2019.0114] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 06/21/2019] [Indexed: 01/09/2023] Open
Abstract
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.
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Affiliation(s)
- Ju-Yu Chueh
- Department of Radiology, New England Center for Stroke Research, University of Massachusetts Medical School, Worcester, MA, USA
| | - Dong-Hun Kang
- Department of Neurosurgery and Radiology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Byung Moon Kim
- Department of Radiology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Matthew J Gounis
- Department of Radiology, New England Center for Stroke Research, University of Massachusetts Medical School, Worcester, MA, USA
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32
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Talayero C, Romero G, Pearce G, Wong J. Numerical modelling of blood clot extraction by aspiration thrombectomy. Evaluation of aspiration catheter geometry. J Biomech 2019; 94:193-201. [PMID: 31420154 DOI: 10.1016/j.jbiomech.2019.07.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 07/27/2019] [Accepted: 07/29/2019] [Indexed: 11/18/2022]
Abstract
Aspiration thrombectomy is one of the most effective systems for blood clot removal and vessel recanalization. We present the results of a study involving the modelling and extraction of blood clots in the arteries of the human body using the following computer tools: Bond-Graph methodology for the fluid domain and Multi-Body Simulation for the mechanical domain. The modelling for the mechanical domain focuses on the clot and the distal end section of an aspiration device. Our final model considers an elastic characterization of the blood clot with progressive detachment from the vessel wall. We conclude that the results of such modelling could potentially improve the effectiveness of blood clot removal by reducing the risk of clot fragmentation. Such modelling could also potentially provide an adjunct technique in improving recanalization of arteries over a range of given parameters (mechanical properties of the vessel, mechanical properties of the blood clot, blood clot length, suction pressure, catheter - clot distance, catheter shape, catheter diameter and vessel occlusion).
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Affiliation(s)
- Carlos Talayero
- Department of Mechanical Engineering, Universidad Politécnica de Madrid, Madrid, Spain.
| | - Gregorio Romero
- Department of Mechanical Engineering, Universidad Politécnica de Madrid, Madrid, Spain.
| | - Gillian Pearce
- Department of Mechanical Engineering, School of Engineering, University of Birmingham, Birmingham, United Kingdom
| | - Julian Wong
- Department of Cardiac, Thoracic & Vascular Surgery, National University Heart Centre Singapore, Singapore
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33
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McCarthy DJ, Sur S, Fortunel A, Snelling B, Luther E, Yavagal D, Peterson E, Starke RM. Predictors of Balloon Guide Catheter Assistance Success in Stent-retrieval Thrombectomy for an Anterior Circulation Acute Ischemic Stroke. Cureus 2019; 11:e5350. [PMID: 31602354 PMCID: PMC6779151 DOI: 10.7759/cureus.5350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction Mechanical thrombectomy has become the standard treatment for large vessel occlusion (LVO) in acute ischemic stroke (AIS) in well-selected patients. Although many devices and strategies exist, the use of a balloon-tip guide catheter (BGC) with stent-retriever (SR) may hold several advantages. We aim to assess the efficacy and identify predictors of technical success of this unique approach. Methods From our prospectively maintained database, we identified consecutive cases in which a BGC was used for stent-retriever thrombectomy in anterior circulation LVO between 2015 and 2016. Baseline and procedural characteristics were captured and analyzed. Predictors of technical and clinical outcomes were identified by multivariable logistic regression analysis. Results Ninety-three patients with AIS-LVO were treated with BGC-assisted mechanical thrombectomy. The mean age was 71 years old (SD 14), with 49.5% male (n=46). Pre-operative IV-tPA was administered in 55.9% (n=52) of cases. The most common location of occlusive thrombus was M1 (64.5%, n=60). Successful recanalization (mTICI=2b-3) was achieved in 86.0% (n=80) of cases while complete revascularization (mTICI-3) was achieved in 56.5% (n=52). There was a first-pass success rate of 52.7% (n=49). At discharge, 38.7% of the patients were functionally independent (mRS≤2). Multivariate analysis revealed that the middle cerebral artery location was strongly predictive of first-pass success, resulting in mTICI =2b revascularization (OR 7.10, p=0.018). Additionally, female gender (OR 2.85, p=0.042) and decreasing mTICI were associated with a poor clinical outcome (mRS≥4; OR 1.76, p=0.008). Conclusions BGC assistance in stent retrieval thrombectomy is safe and effective for AIS due to anterior circulation LVO. Further investigation is required to elucidate the optimal treatment strategy based on patient and disease characteristics.
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Affiliation(s)
- David J McCarthy
- Neurosurgery, University of Miami Miller School of Medicine, Miami, USA
| | - Samir Sur
- Neurosurgery, University of Miami Miller School of Medicine, Miami, USA
| | - Adisson Fortunel
- Neurosurgery, University of Miami Miller School of Medicine, Miami, USA
| | - Brian Snelling
- Neurosurgery, Boca Raton Regional Hospital, Boca Raton, USA
| | - Evan Luther
- Neurosurgery, University of Miami Miller School of Medicine, Miami, USA
| | - Dileep Yavagal
- Neuroendovascular Surgery, University of Miami Miller School of Medicine, Miami, USA
| | - Eric Peterson
- Neurosurgery, University of Miami Miller School of Medicine, Miami, USA
| | - Robert M Starke
- Neurosurgery, University of Miami Miller School of Medicine, Miami, USA
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Kim SH, Choi JH, Kang MJ, Cha JK, Kim DH, Nah HW, Park HS, Kim SH, Huh JT. Efficacy of Combining Proximal Balloon Guiding Catheter and Distal Access Catheter in Thrombectomy with Stent Retriever for Anterior Circulation Ischemic Stroke. J Korean Neurosurg Soc 2019; 62:405-413. [PMID: 31290296 PMCID: PMC6616992 DOI: 10.3340/jkns.2019.0007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 04/24/2019] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE We evaluated efficacy of combining proximal balloon guiding catheter (antegrade flow arrest) and distal access catheter (aspiration at the site of occlusion) in thrombectomy for anterior circulation ischemic stroke. METHODS We retrospectively analyzed 116 patients who underwent mechanical thrombectomy with stent retriever. The patients were divided by the techniques adopted, the combined technique (proximal balloon guiding catheter and large bore distal access catheter) group (n=57, 49.1%) and the conventional (guiding catheter with stent retriever) technique group (n=59, 50.9%). We evaluated baseline characteristics (epidemiologic data, clinical and imaging characteristics) and procedure details (the number of retrieval attempts, procedure time), as well as angiographic (thrombolysis in cerebral infarction (TICI) score, distal thrombus migration) and clinical outcome (National Institutes of Health Stroke Scale at discharge, modified Rankin Scale [mRS] at 3 months) of them. RESULTS The number of retrieval attempts was lower (p=0.002) and the first-pass successful reperfusion rate was higher (56.1% vs. 28.8%; p=0.003) in the combined technique group. And the rate of final result of TICI score 3 was higher (68.4% vs. 28.8%; p<0.01) and distal thrombus migration rate was also lower (15.8% vs. 40.7%; p=0.021) in the combined technique group. Early strong neurologic improvement (improvement of National Institutes of Health Stroke Scale ≥11 or National Institutes of Health Stroke Scale ≤1 at discharge) rate (57.9% vs. 36.2%; p=0.02) and favorable clinical outcome (mRS at 3 months ≤2) rate (59.6% vs. 33.9%; p=0.005) were also better in the combined technique group. CONCLUSION The combined technique needs lesser attempts, decreases distal migration, increases TICI 3 reperfusion and achieves better clinical outcomes.
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Affiliation(s)
- Sang Hwa Kim
- Busan-Ulsan Regional Cardiocerebrovascular Center, Dong-A University Hospital, Busan, Korea.,Department of Neurosurgery, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Jae Hyung Choi
- Busan-Ulsan Regional Cardiocerebrovascular Center, Dong-A University Hospital, Busan, Korea.,Department of Neurosurgery, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Myung Jin Kang
- Busan-Ulsan Regional Cardiocerebrovascular Center, Dong-A University Hospital, Busan, Korea.,Department of Radiology, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Jae Kwan Cha
- Busan-Ulsan Regional Cardiocerebrovascular Center, Dong-A University Hospital, Busan, Korea.,Department of Neurology, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Dae Hyun Kim
- Busan-Ulsan Regional Cardiocerebrovascular Center, Dong-A University Hospital, Busan, Korea.,Department of Neurology, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Hyun Wook Nah
- Busan-Ulsan Regional Cardiocerebrovascular Center, Dong-A University Hospital, Busan, Korea.,Department of Neurology, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Hyun Seok Park
- Busan-Ulsan Regional Cardiocerebrovascular Center, Dong-A University Hospital, Busan, Korea.,Department of Neurosurgery, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Sang Hyun Kim
- Busan-Ulsan Regional Cardiocerebrovascular Center, Dong-A University Hospital, Busan, Korea.,Department of Radiology, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Jae Taeck Huh
- Busan-Ulsan Regional Cardiocerebrovascular Center, Dong-A University Hospital, Busan, Korea.,Department of Neurosurgery, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
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Girdhar G, Epstein E, Nguyen K, Gregg C, Kumar T, Wainwright J, Liu AY, Linfante I. Longer 6-mm Diameter Stent Retrievers Are Effective for Achieving Higher First Pass Success with Fibrin-Rich Clots. INTERVENTIONAL NEUROLOGY 2019; 8:187-195. [PMID: 32508901 DOI: 10.1159/000499974] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 03/28/2019] [Indexed: 11/19/2022]
Abstract
First pass success (FPS) can be defined as in vitro retrieval of clot in a single pass during mechanical thrombectomy (MT) for acute large vessel occlusion (LVO). Despite advancements in MT technology, retrieval of fibrin-rich clots remains a challenge. Therefore, the effect of stent retriever length on FPS for fibrin-rich clots was investigated by using SolitaireTM 6 × 40 versus 6 × 30 mm devices with a balloon guide catheter (BGC) or distal access catheter (DAC) and sheath, in an in vitro model of anterior circulation neurovascular anatomy. Additionally, vascular safety of the SolitaireTM 6 × 40 versus 6 × 30 mm devices was evaluated in a porcine model for differences in: luminal thrombus, inflammation, endothelial coverage, fibrin deposits, smooth muscle cell loss, elastic lamina and adventitia disruption, intimal hyperplasia, and lumen reduction, at 0, 30, and 90 days post-treatment. In vitro overall FPS was measured as: SolitaireTM 6 × 40 (95%) and SolitaireTM 6 × 30 (67%). FPS for clot location in middle cerebral artery was: (a) BGC (6 × 40 mm: 100%; 6 × 30 mm: 100%; n = 8); (b) DAC with 088 sheath (6 × 40 mm: 83%; 6 × 30 mm: 33%; n = 12). FPS for clot location in internal carotid artery was: (a) BGC (6 × 40 mm: 100%; 6 × 30 mm: 80%; n = 11); (b) DAC with 088 sheath (6 × 40 mm: 100%; 6 × 30 mm: 67%; n = 10). Stent length had a significant effect (Fisher's exact test; p < 0.05) on FPS. In vivo evaluation in the porcine model showed no difference in vascular safety parameters between the SolitaireTM 6 × 40 and 6 × 30 mm devices (p > 0.05) at all time points in the study. Longer stent retrievers may be safe and effective in improving FPS for fibrin-rich clots in in vitro and in vivo models of LVO.
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Affiliation(s)
- Gaurav Girdhar
- Department of R&D, Neurovascular, Medtronic, Irvine, California, USA
| | - Evan Epstein
- Department of R&D, Neurovascular, Medtronic, Irvine, California, USA
| | - Kevin Nguyen
- Department of R&D, Neurovascular, Medtronic, Irvine, California, USA
| | - Chelsea Gregg
- Department of R&D, Neurovascular, Medtronic, Irvine, California, USA
| | - Tejashri Kumar
- Department of R&D, Neurovascular, Medtronic, Irvine, California, USA
| | - John Wainwright
- Department of R&D, Neurovascular, Medtronic, Irvine, California, USA
| | - Amon Y Liu
- AYL Consulting LLC, Redwood City, California, USA
| | - Italo Linfante
- Interventional Neuroradiology and Endovascular Neurosurgery, Miami Cardiac and Vascular Institute, Baptist Hospital, Miami, Florida, USA
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Brehm A, Maus V, Tsogkas I, Colla R, Hesse AC, Gera RG, Psychogios MN. Stent-retriever assisted vacuum-locked extraction (SAVE) versus a direct aspiration first pass technique (ADAPT) for acute stroke: data from the real-world. BMC Neurol 2019; 19:65. [PMID: 30987600 PMCID: PMC6466709 DOI: 10.1186/s12883-019-1291-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 03/31/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Embolectomy is the standard of care in acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). Aim of this study was to compare two techniques: A Direct Aspiration First Pass Technique (ADAPT) and Stent-retriever Assisted Vacuum-locked Extraction (SAVE) stratified by the occluded vessel. METHODS One hundred seventy-one patients (71 male) treated between January 2014 and September 2017 with AIS due to LVO of the anterior circulation (55 carotid T, 94 M1, 22 M2) were included. Treatment techniques were divided into two categories: ADAPT and SAVE. Primary endpoints were successful reperfusion (mTICI ≥2b), near-perfect reperfusion (mTICI ≥2c) and groin puncture to reperfusion time. Secondary endpoints were the number of device-passes, first-pass reperfusion, the frequency of emboli to new territory (ENT), clinical outcome at 90 days, and the frequency of symptomatic intracranial hemorrhage (sICH). Analysis was performed on an intention to treat basis. RESULTS Overall, SAVE resulted in significant higher rates of successful reperfusion (mTICI≥2b) compared to ADAPT (93.5% vs 75.0%; p = 0.006). After stratification for the occluded vessel only the carotid T remained significant with higher rates of near-perfect reperfusion (mTICI≥2c) (55.2% vs 15.4%; p = 0.025), while for successful reperfusion a trend remained (93.1% vs 65.4%; p = 0.10). Groin to reperfusion times were not significantly different. Secondary analysis revealed higher rates of first-pass successful reperfusion (59.6% vs 33.3%; p = 0.019), higher rates of first-pass near-perfect reperfusion in the carotid T (35.4% vs 16.7%; p = 0.038) and a lower number of device-passes overall (median 1 IQR 1-2 vs 2 IQR 2-3; p < 0.001) and in the carotid T (median 2 IQR 1.3 vs 3 IQR 2-5; p < 0.001) for SAVE. Clinical outcome and safety parameters were comparable between groups. CONCLUSIONS Embolectomy using SAVE appears superior to ADAPT, especially for carotid T occlusions with regard to reperfusion success.
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Affiliation(s)
- Alex Brehm
- Department of Neuroradiology, University Medical Center Goettingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany
| | - Volker Maus
- Department of Neuroradiology, University Medical Center Goettingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany
| | - Ioannis Tsogkas
- Department of Neuroradiology, University Medical Center Goettingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany
| | - Ruben Colla
- Department of Neuroradiology, University Medical Center Goettingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany
| | - Amélie Carolina Hesse
- Department of Neuroradiology, University Medical Center Goettingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany
| | - Roland Gerard Gera
- Department of Medical Statistics, University Medical Center Goettingen, Humboldtallee 32, 37073 Göttingen, Germany
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, University Medical Center Goettingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany
- Department of Neuroradiology, Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Basel, Switzerland
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Mechanical Thrombectomy Using the Solitaire AB Device for Acute Embolic Mesenteric Ischemia. J Vasc Interv Radiol 2019; 30:43-48. [DOI: 10.1016/j.jvir.2018.08.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 07/07/2018] [Accepted: 08/05/2018] [Indexed: 12/24/2022] Open
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Mokin M, Waqas M, Setlur Nagesh SV, Karkhanis NV, Levy EI, Ionita CN, Siddiqui AH. Assessment of distal access catheter performance during neuroendovascular procedures: measuring force in three-dimensional patient specific phantoms. J Neurointerv Surg 2018; 11:619-622. [PMID: 30514736 DOI: 10.1136/neurintsurg-2018-014468] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 11/09/2018] [Accepted: 11/14/2018] [Indexed: 01/03/2023]
Abstract
BACKGROUND The amount of force applied on a device is an important measure to evaluate the endovascular and surgical device manipulations. The measure has not been evaluated for neuroenodvascular procedures. PURPOSE We aimed to study the use of force measure as a novel approach to test distal access catheter (DAC) performance during catheterization of cervical and intracranial vessels using patient specific 3-dimentional (3D) phantoms. METHODS Using patient specific 3D phantoms of the cervical and intracranial circulation, we recorded measure of force required to deliver three types of DACs beyond the ophthalmic segment of the internal carotid artery. Six different combinations of DAC-microcatheter-guidewire were tested. We intentionally included what we considered suboptimal combinations of DACs, microcatheters, and guidewires during our experiments to test the feasibility of measuring force under different conditions. A six axis force sensor was secured to the DAC with an adjustable torque used to track axially directed push and pull forces required to navigate the DAC to the target site. RESULTS In a total of 55 experiments, we found a significant difference in the amount of force used between different DACs (mean force for DAC A, 1.887±0.531N; for DAC B, 2.153±1.280 N; and for DAC C, 1.194±0.521 N, P=0.007). There was also a significant difference in force measures among the six different catheter systems (P=0.035). CONCLUSIONS Significant difference in the amount of force used between different DACs and catheter systems were recorded. Use of force measure in neuroendovascular procedures on 3D printed phantoms is feasible.
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Affiliation(s)
- Maxim Mokin
- Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Swetadri Vasan Setlur Nagesh
- Canon Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Nitant Vivek Karkhanis
- Canon Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York, USA.,Department of Biomedical Engineering, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Ciprian N Ionita
- Canon Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York, USA.,Department of Biomedical Engineering, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA
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Aydin K, Barburoglu M, Oztop Cakmak O, Yesilot N, Vanli ENY, Akpek S. Crossing Y-Solitaire thrombectomy as a rescue treatment for refractory acute occlusions of the middle cerebral artery. J Neurointerv Surg 2018; 11:246-250. [DOI: 10.1136/neurintsurg-2018-014288] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 08/14/2018] [Accepted: 08/16/2018] [Indexed: 12/13/2022]
Abstract
BackgroundMechanical thrombectomy using a stent retriever has become the standard of care for acute large-vessel occlusions in the anterior circulation. Clots that are refractory to single stent retriever thrombectomy remain a challenge for neurointerventionalists.ObjectiveTo assess the efficacy and safety of double stent retriever (crossing Y-Solitaire) thrombectomy as a rescue treatment for acute middle cerebral artery (MCA) occlusions that are refractory to single stent retriever thrombectomy.MethodsWe retrospectively reviewed the databases of our hospitals to identify patients who presented with an acute MCA occlusion and were treated with crossing Y-Solitaire thrombectomy. The angiographic (Thrombolysis in Cerebral Infarction (TICI) scale) and clinical outcomes (National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) scores) and complications were assessed.ResultsTen patients were included in the study. The median initial NIHSS score and Alberta Stroke Program Early CT Score (ASPECTS) were 19.0 and 9.6, respectively. Crossing Y-Solitaire thrombectomy was performed as a rescue technique after unsuccessful single Solitaire thrombectomy passes in all cases. Successful recanalization (TICI 2b/3) was achieved in 8 (80%) patients. We observed asymptomatic reperfusion hemorrhages in 2 (20%) patients. No procedural related complications were seen other than reversible vasospasms in 5 (50%) patients. Sixty percent of the patients had a mRS score of between 2 and 0 at 90 days after the procedure. There was no mortality.ConclusionCrossing Y-Solitaire thrombectomy seems to be an effective and safe alternative rescue technique to treat refractory MCA bifurcation occlusions that are refractory to standard thrombectomy procedures.
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40
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Nguyen TN, Zaidat OO. Balloon Guide Catheter in Large-Vessel Occlusion Stroke Therapy. Radiology 2018; 284:607-608. [PMID: 28723284 DOI: 10.1148/radiol.2017170375] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Thanh N Nguyen
- Departments of Neurology, Neurosurgery, and Radiology, 72 E Concord St, C-3, Boston Medical Center, Boston, MA 02118
| | - Osama O Zaidat
- Departments of Neurology, Neurosurgery, and Radiology, 72 E Concord St, C-3, Boston Medical Center, Boston, MA 02118
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Sonig A, Setlur Nagesh SV, Fennell VS, Gandhi S, Rangel-Castilla L, Ionita CN, Snyder KV, Hopkins LN, Bednarek DR, Rudin S, Siddiqui AH, Levy EI. A Patient Dose-Reduction Technique for Neuroendovascular Image-Guided Interventions: Image-Quality Comparison Study. AJNR Am J Neuroradiol 2018; 39:734-741. [PMID: 29449282 DOI: 10.3174/ajnr.a5552] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 12/06/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The ROI-dose-reduced intervention technique represents an extension of ROI fluoroscopy combining x-ray entrance skin dose reduction with spatially different recursive temporal filtering to reduce excessive image noise in the dose-reduced periphery in real-time. The aim of our study was to compare the image quality of simulated neurointerventions with regular and reduced radiation doses using a standard flat panel detector system. MATERIALS AND METHODS Ten 3D-printed intracranial aneurysm models were generated on the basis of a single patient vasculature derived from intracranial DSA and CTA. The incident dose to each model was reduced using a 0.7-mm-thick copper attenuator with a circular ROI hole (10-mm diameter) in the middle mounted inside the Infinix C-arm. Each model was treated twice with a primary coiling intervention using ROI-dose-reduced intervention and regular-dose intervention protocols. Eighty images acquired at various intervention stages were shown twice to 2 neurointerventionalists who independently scored imaging qualities (visibility of aneurysm-parent vessel morphology, associated vessels, and/or devices used). Dose-reduction measurements were performed using an ionization chamber. RESULTS A total integral dose reduction of 62% per frame was achieved. The mean scores for regular-dose intervention and ROI dose-reduced intervention images did not differ significantly, suggesting similar image quality. Overall intrarater agreement for all scored criteria was substantial (Kendall τ = 0.62887; P < .001). Overall interrater agreement for all criteria was fair (κ = 0.2816; 95% CI, 0.2060-0.3571). CONCLUSIONS Substantial dose reduction (62%) with a live peripheral image was achieved without compromising feature visibility during neuroendovascular interventions.
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Affiliation(s)
- A Sonig
- From the Departments of Neurosurgery (A.S., V.S.F., L.R.-C., C.N.I., K.V.S., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Department of Neurosurgery (A.S., V.S.F., S.G., L.R.-C., K.V.S., L.N.H., S.R., A.H.S., E.I.L.), Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - S V Setlur Nagesh
- Toshiba Stroke and Vascular Research Center (S.V.S.N., C.N.I., L.N.H., D.R.B., S.R., A.H.S., E.I.L.)
| | - V S Fennell
- From the Departments of Neurosurgery (A.S., V.S.F., L.R.-C., C.N.I., K.V.S., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Department of Neurosurgery (A.S., V.S.F., S.G., L.R.-C., K.V.S., L.N.H., S.R., A.H.S., E.I.L.), Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - S Gandhi
- Neurology (S.G., K.V.S.), Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurosurgery (A.S., V.S.F., S.G., L.R.-C., K.V.S., L.N.H., S.R., A.H.S., E.I.L.), Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Buffalo Neuroimaging Analysis Center (S.G.), Buffalo, New York
| | - L Rangel-Castilla
- From the Departments of Neurosurgery (A.S., V.S.F., L.R.-C., C.N.I., K.V.S., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Department of Neurosurgery (A.S., V.S.F., S.G., L.R.-C., K.V.S., L.N.H., S.R., A.H.S., E.I.L.), Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - C N Ionita
- From the Departments of Neurosurgery (A.S., V.S.F., L.R.-C., C.N.I., K.V.S., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Toshiba Stroke and Vascular Research Center (S.V.S.N., C.N.I., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Department of Biomedical Engineering (C.N.I., S.R.)
| | - K V Snyder
- From the Departments of Neurosurgery (A.S., V.S.F., L.R.-C., C.N.I., K.V.S., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Radiology (K.V.S., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Neurology (S.G., K.V.S.), Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurosurgery (A.S., V.S.F., S.G., L.R.-C., K.V.S., L.N.H., S.R., A.H.S., E.I.L.), Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - L N Hopkins
- From the Departments of Neurosurgery (A.S., V.S.F., L.R.-C., C.N.I., K.V.S., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Radiology (K.V.S., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Department of Neurosurgery (A.S., V.S.F., S.G., L.R.-C., K.V.S., L.N.H., S.R., A.H.S., E.I.L.), Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Toshiba Stroke and Vascular Research Center (S.V.S.N., C.N.I., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Jacobs Institute (L.N.H., A.H.S.), Buffalo, New York
| | - D R Bednarek
- From the Departments of Neurosurgery (A.S., V.S.F., L.R.-C., C.N.I., K.V.S., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Radiology (K.V.S., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Toshiba Stroke and Vascular Research Center (S.V.S.N., C.N.I., L.N.H., D.R.B., S.R., A.H.S., E.I.L.)
| | - S Rudin
- From the Departments of Neurosurgery (A.S., V.S.F., L.R.-C., C.N.I., K.V.S., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Radiology (K.V.S., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Department of Neurosurgery (A.S., V.S.F., S.G., L.R.-C., K.V.S., L.N.H., S.R., A.H.S., E.I.L.), Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Toshiba Stroke and Vascular Research Center (S.V.S.N., C.N.I., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Department of Biomedical Engineering (C.N.I., S.R.).,Department of Mechanical and Aerospace Engineering (S.R.).,Department of Electrical Engineering (S.R.), University at Buffalo, State University of New York, Buffalo, New York
| | - A H Siddiqui
- From the Departments of Neurosurgery (A.S., V.S.F., L.R.-C., C.N.I., K.V.S., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Radiology (K.V.S., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Department of Neurosurgery (A.S., V.S.F., S.G., L.R.-C., K.V.S., L.N.H., S.R., A.H.S., E.I.L.), Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Toshiba Stroke and Vascular Research Center (S.V.S.N., C.N.I., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Jacobs Institute (L.N.H., A.H.S.), Buffalo, New York
| | - E I Levy
- From the Departments of Neurosurgery (A.S., V.S.F., L.R.-C., C.N.I., K.V.S., L.N.H., D.R.B., S.R., A.H.S., E.I.L.) .,Radiology (K.V.S., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Department of Neurosurgery (A.S., V.S.F., S.G., L.R.-C., K.V.S., L.N.H., S.R., A.H.S., E.I.L.), Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Toshiba Stroke and Vascular Research Center (S.V.S.N., C.N.I., L.N.H., D.R.B., S.R., A.H.S., E.I.L.)
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Fennell VS, Setlur Nagesh SV, Meess KM, Gutierrez L, James RH, Springer ME, Siddiqui AH. What to do about fibrin rich ‘tough clots’? Comparing the Solitaire stent retriever with a novel geometric clot extractor in an in vitro stroke model. J Neurointerv Surg 2018; 10:907-910. [DOI: 10.1136/neurintsurg-2017-013507] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 12/07/2017] [Accepted: 12/07/2017] [Indexed: 11/03/2022]
Abstract
BackgroundDespite advances in revascularization tools for large vessel occlusion presenting as acute ischemic stroke, a significant subset of clots remain recalcitrant to current strategies. We assessed the effectiveness of a novel thrombectomy device that was specifically designed to retrieve resistant fibrin rich clots, the geometric clot extractor (GCE; Neuravi, Galway, Ireland), in an in vitro cerebrovascular occlusion stroke model.MethodsAfter introducing fibrin rich clot analogues into the middle cerebral artery of the model, we compared the rates of recanalization between GCE and Solitaire flow restoration stent retriever (SR; Medtronic, Minneapolis, Minnesota, USA; control group) cases. A maximum of three passes of each device was allowed. If the SR failed to recanalize the vessel after three passes, one pass of the GCE was allowed (rescue cases).ResultsIn a total of 26 thrombectomy cases (13 GCE, 13 SR), successful recanalization (Thrombolysis in Cerebral Infarction score of 2b or 3) was achieved 100% of the time in the GCE cases with an average of 2.13 passes per case. This rate was significantly higher compared with the Solitaire recanalization rate (7.7%, P<0.0001) with an average of three passes per case. After SR failure (in 92% of cases), successful one pass GCE rescue recanalization was achieved 66% of the time (P<0.005).ConclusionApplication of the GCE in this experimental stroke model to retrieve typically recalcitrant fibrin rich clots resulted in higher successful recanalization rates than the SR.
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Malisch TW, Zaidat OO, Castonguay AC, Marden FA, Gupta R, Sun CHJ, Martin CO, Holloway WE, Mueller-Kronast N, English J, Linfante I, Dabus G, Bozorgchami H, Xavier A, Rai AT, Froehler M, Badruddin A, Nguyen TN, Taqi MA, Abraham MG, Janardhan V, Shaltoni H, Novakovic R, Yoo AJ, Abou-Chebl A, Chen PR, Britz GW, Kaushal R, Nanda A, Nogueira RG. Clinical and Angiographic Outcomes with the Combined Local Aspiration and Retriever in the North American Solitaire Stent-Retriever Acute Stroke (NASA) Registry. INTERVENTIONAL NEUROLOGY 2017; 7:26-35. [PMID: 29628942 DOI: 10.1159/000480353] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background Various techniques are used to enhance the results of mechanical thrombectomy with stent-retrievers, including proximal arrest with balloon guide catheter (BGC), conventional large bore proximal catheter (CGC), or in combination with local aspiration through a large-bore catheter positioned at the clot interface (Aspiration-Retriever Technique for Stroke [ARTS]). We evaluated the impact of ARTS in the North American Solitaire Acute Stroke (NASA) registry. Summary Data on the use of the aspiration technique were available for 285 anterior circulation patients, of which 29 underwent ARTS technique, 131 CGC, and 125 BGC. Baseline demographics were comparable, except that ARTS patients are less likely to have hypertension or atrial fibrillation. The ARTS group had more ICA occlusions (41.4 vs. 22% in the BGC, p = 0.04 and 26% in CGC, p = 0.1) and less MCA/M1 occlusions (44.8 vs. 68% in BGC and 62% in CGC). Time from arterial puncture to reperfusion or end of procedure with ARTS was shorter than with CGC (54 vs. 91 min, p = 0.001) and was comparable to the BGC time (54 vs. 67, p = 0.11). Final degree of reperfusion was comparable among the groups (TICI [modified Thrombolysis in Cerebral Infarction] score 2b or higher was 72 vs. 70% for CGC vs. 78% for BGC). Procedural complications, mortality, and good clinical outcome at 90 days were similar between the groups. Key Messages The ARTS mechanical thrombectomy in acute ischemic stroke patients appears to yield better results as compared to the use of CGCs with no significant difference when compared to BGC. This early ARTS technique NASA registry data are limited by the earlier generation distal large bore catheters and small sample size. Future studies should focus on the comparison of ARTS and BGC techniques.
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Affiliation(s)
- Tim W Malisch
- Department of Radiology, Alexian Brothers Medical Center, Elk Grove Village, Illinois, USA
| | - Osama O Zaidat
- St Vincent Mercy Hospital, Toledo, Ohio, USA.,Neuroscience Center, Well Star Health System, Atlanta, Georgia, USA
| | | | - Franklin A Marden
- Department of Radiology, Alexian Brothers Medical Center, Elk Grove Village, Illinois, USA
| | - Rishi Gupta
- St Vincent Mercy Hospital, Toledo, Ohio, USA.,Neuroscience Center, Well Star Health System, Atlanta, Georgia, USA
| | - Chung-Huan J Sun
- St Vincent Mercy Hospital, Toledo, Ohio, USA.,Neuroscience Center, Well Star Health System, Atlanta, Georgia, USA
| | | | | | | | - Joey English
- California Pacific Medical Center, San Francisco, California, USA
| | - Italo Linfante
- Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, Florida, USA
| | - Guilherme Dabus
- Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, Florida, USA
| | | | - Andrew Xavier
- Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Ansaar T Rai
- Department of Radiology, West Virginia University Hospital, Morgantown, West Virginia, USA
| | - Michael Froehler
- Department of Neurology, Neurosurgery, Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Thanh N Nguyen
- Department of Neurology, Neurosurgery, Radiology, Boston Medical Center, Boston, Massachusetts, USA
| | - M Asif Taqi
- Desert Regional Medical Center, Palm Springs, California, USA
| | | | | | - Hashem Shaltoni
- University of Texas Health Science Center, Houston, Texas, USA
| | - Robin Novakovic
- Department of Radiology, Neurology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Albert J Yoo
- Division of Diagnostic and Interventional Neuroradiology, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Peng Roc Chen
- Department of Neurosurgery, University of Texas, Houston, Texas, USA
| | - Gavin W Britz
- Department of Neurosurgery, Methodist Neurological Institute, Houston, Texas, USA
| | | | | | - Raul G Nogueira
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
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44
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Hesse AC, Behme D, Kemmling A, Zapf A, Große Hokamp N, Frischmuth I, Maier I, Liman J, Tsogkas I, Buhk JH, Tran J, Fiehler J, Mpotsaris A, Schramm P, Berlis A, Knauth M, Psychogios MN. Comparing different thrombectomy techniques in five large-volume centers: a 'real world' observational study. J Neurointerv Surg 2017; 10:525-529. [PMID: 28963362 DOI: 10.1136/neurintsurg-2017-013394] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 09/07/2017] [Accepted: 09/12/2017] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND PURPOSE Thrombectomy has become the standard of care for acute ischaemic stroke due to large vessel occlusion. Aim of this study was to compare the radiological outcomes and time metrics of the various thrombectomy techniques. METHODS In this retrospective, multicenter study we analysed the data of 450 patients with occlusion of the anterior circulation, treated in five high-volume center from 2013 to 2016. The treatment techniques were divided in three categories: first-pass use of a large-bore aspiration-catheter; first-pass use of a stent-retriever; and primary combined approach (PCA) of an aspiration-catheter and stent-retriever. Primary endpoints were successful reperfusion and groin to reperfusion time. Secondary endpoints were the number of attempts and occurrence of emboli in new territory (ENT). The primary analysis was based on the intention to treat groups (ITT). RESULTS The ITT-analysis showed significantly higher reperfusion rates, with 86% of successful reperfusion in the PCA-group compared with 73% in the aspiration group and 65% in the stent-retriever group. There was no significant difference in groin to reperfusion time regarding the used technique. The secondary analysis showed an impact of the technique on the number of attempts and the occurrence of ENTs. Lowest ENT rates and attempts were reported with the combined approach. CONCLUSIONS The combined first-pass deployment of a stent-retriever and an aspiration-catheter was the most effective technique for reperfusion of anterior circulation large vessel occlusion. Our results correlate with the latest single-centrere studies, reporting very high reperfusion rates with PCA variations.
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Affiliation(s)
- Amélie Carolina Hesse
- Institute for Diagnostic and Interventional Neuroradiology, University Medical Center Goettingen, Goettingen, Germany
| | - Daniel Behme
- Institute for Diagnostic and Interventional Neuroradiology, University Medical Center Goettingen, Goettingen, Germany
| | - André Kemmling
- Institute of Neuroradiology, University Medical Center Schleswig-Holstein, Luebeck, Germany
| | - Antonia Zapf
- Department of Medical Statistics, University Medical Center Goettingen, Goettingen, Germany
| | - Nils Große Hokamp
- Institute of Diagnostic and Interventional Radiology, University Hospital Cologne, Cologne, Germany
| | - Isabelle Frischmuth
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center, Hamburg-Eppendorf, Hamburg, Germany
| | - Ilko Maier
- Department of Neurology, University Medical Center Goettingen, Goettingen, Germany
| | - Jan Liman
- Department of Neurology, University Medical Center Goettingen, Goettingen, Germany
| | - Ioannis Tsogkas
- Institute for Diagnostic and Interventional Neuroradiology, University Medical Center Goettingen, Goettingen, Germany
| | - Jan-Hendrik Buhk
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center, Hamburg-Eppendorf, Hamburg, Germany
| | - Julia Tran
- Institute for Diagnostic and Interventional Neuroradiology, University Medical Center Goettingen, Goettingen, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center, Hamburg-Eppendorf, Hamburg, Germany
| | - Anastasios Mpotsaris
- Institute of Diagnostic and Interventional Radiology, University Hospital Cologne, Cologne, Germany
| | - Peter Schramm
- Institute of Neuroradiology, University Medical Center Schleswig-Holstein, Luebeck, Germany
| | - Ansgar Berlis
- Department of Neuroradiology, Hospital Augsburg, Augsburg, Germany
| | - Michael Knauth
- Institute for Diagnostic and Interventional Neuroradiology, University Medical Center Goettingen, Goettingen, Germany
| | - Marios-Nikos Psychogios
- Institute for Diagnostic and Interventional Neuroradiology, University Medical Center Goettingen, Goettingen, Germany
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45
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De Meyer SF, Andersson T, Baxter B, Bendszus M, Brouwer P, Brinjikji W, Campbell BC, Costalat V, Dávalos A, Demchuk A, Dippel D, Fiehler J, Fischer U, Gilvarry M, Gounis MJ, Gralla J, Jansen O, Jovin T, Kallmes D, Khatri P, Lees KR, López-Cancio E, Majoie C, Marquering H, Narata AP, Nogueira R, Ringleb P, Siddiqui A, Szikora I, Vale D, von Kummer R, Yoo AJ, Hacke W, Liebeskind DS. Analyses of thrombi in acute ischemic stroke: A consensus statement on current knowledge and future directions. Int J Stroke 2017; 12:606-614. [PMID: 28534706 DOI: 10.1177/1747493017709671] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Limited data exist on clot composition and detailed characteristics of arterial thrombi associated with large vessel occlusion in acute ischemic stroke. Advances in endovascular thrombectomy and related imaging modalities have created a unique opportunity to analyze thrombi removed from cerebral arteries. Insights into thrombus composition, etiology, physical properties and neurovascular interactions may lead to future advancements in acute ischemic stroke treatment and improved clinical outcomes. Advances in imaging techniques may enhance clot characterization and inform therapeutic decision-making prior to treatment and reveal stroke etiology to guide secondary prevention. Current imaging techniques can provide some information about thrombi, but there remains much to evaluate about relationships that may exist among thrombus composition, occlusion characteristics and treatment outcomes. Improved pathophysiological characterization of clot types, their properties and how these properties change over time, together with clinical correlates from ongoing studies, may facilitate revascularization with thrombolysis and thrombectomy. Interdisciplinary approaches covering clinical, engineering and scientific aspects of thrombus research will be key to advancing the understanding of thrombi and improving acute ischemic stroke therapy. This consensus statement integrates recent research on clots and thrombi retrieved from cerebral arteries and provides a rationale for further analyses, including current opportunities and limitations.
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Affiliation(s)
- Simon F De Meyer
- 1 Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Tommy Andersson
- 2 Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,3 Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden.,4 Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium
| | - Blaise Baxter
- 5 Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga
| | - Martin Bendszus
- 6 Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Patrick Brouwer
- 3 Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Waleed Brinjikji
- 7 Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Bruce Cv Campbell
- 8 Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Grattan Street, Parkville, VIC 3050, Australia
| | - Vincent Costalat
- 9 Interventional and Diagnostic Neuroradiology, Montpellier University Hospital, Montpellier, France
| | - Antoni Dávalos
- 10 Acute Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain
| | - Andrew Demchuk
- 11 Department of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada
| | - Diederik Dippel
- 12 Department of Neurology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Jens Fiehler
- 13 Department of Neuroradiology, University Medical Center, Hamburg, Germany
| | - Urs Fischer
- 14 Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael Gilvarry
- 15 Neuravi Thromboembolic Initiative, Neuravi Ltd, Galway, Ireland
| | - Matthew J Gounis
- 16 Division of Neuroimaging and Intervention and New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Jan Gralla
- 17 Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Olav Jansen
- 18 Department of Radiology and Neuroradiology, UKSH, Kiel, Germany
| | - Tudor Jovin
- 19 Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David Kallmes
- 7 Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Pooja Khatri
- 20 Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Kennedy R Lees
- 21 Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland, UK
| | - Elena López-Cancio
- 10 Acute Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain
| | - Charles Majoie
- 22 Department of Radiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Henk Marquering
- 22 Department of Radiology, Academic Medical Center, Amsterdam, the Netherlands.,23 Department of Biomedical Engineering and Physics, Academic Medical Center, Amsterdam, the Netherlands
| | | | - Raul Nogueira
- 25 Department of Neurology, Emory University, Atlanta, Georgia, USA
| | - Peter Ringleb
- 26 Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Adnan Siddiqui
- 27 Department of Neurosurgery, University of Buffalo, Buffalo, New York, USA
| | - István Szikora
- 28 Department of Neuroradiology, National Institute of Neurosciences, Budapest, Hungary
| | - David Vale
- 15 Neuravi Thromboembolic Initiative, Neuravi Ltd, Galway, Ireland
| | | | | | - Werner Hacke
- 31 Department of Neurology, University Hospital Heidelberg, Ruprecht-Karls University, Heidelberg, Germany
| | - David S Liebeskind
- 32 Neurovascular Imaging Research Core and UCLA Stroke Center, University of California, Los Angeles, California, USA
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46
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Yoo AJ, Andersson T. Thrombectomy in Acute Ischemic Stroke: Challenges to Procedural Success. J Stroke 2017; 19:121-130. [PMID: 28592779 PMCID: PMC5466290 DOI: 10.5853/jos.2017.00752] [Citation(s) in RCA: 133] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Revised: 05/24/2017] [Accepted: 05/24/2017] [Indexed: 02/06/2023] Open
Abstract
The overwhelming clinical benefit of intra-arterial stroke therapy owes to the major advance in revascularization brought on by the current generation of thrombectomy devices. Nevertheless, there remains a sizeable proportion of patients for whom substantial reperfusion cannot be achieved or is achieved too late. This article addresses the persistent challenges that face neurointerventionists and reviews technical refinements that may help to mitigate these obstacles to procedural success. Insights from in vitro modeling and clinical research are organized around a conceptual framework that examines the interaction between the device, the thrombus and the vessel wall.
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Affiliation(s)
| | - Tommy Andersson
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium
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47
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Shepard L, Sommer K, Izzo R, Podgorsak A, Wilson M, Said Z, Rybicki FJ, Mitsouras D, Rudin S, Angel E, Ionita CN. Initial Simulated FFR Investigation Using Flow Measurements in Patient-specific 3D Printed Coronary Phantoms. PROCEEDINGS OF SPIE--THE INTERNATIONAL SOCIETY FOR OPTICAL ENGINEERING 2017. [PMID: 28649159 DOI: 10.1117/12.2253889] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE Accurate patient-specific phantoms for device testing or endovascular treatment planning can be 3D printed. We expand the applicability of this approach for cardiovascular disease, in particular, for CT-geometry derived benchtop measurements of Fractional Flow Reserve, the reference standard for determination of significant individual coronary artery atherosclerotic lesions. MATERIALS AND METHODS Coronary CT Angiography (CTA) images during a single heartbeat were acquired with a 320×0.5mm detector row scanner (Toshiba Aquilion ONE). These coronary CTA images were used to create 4 patient-specific cardiovascular models with various grades of stenosis: severe, <75% (n=1); moderate, 50-70% (n=1); and mild, <50% (n=2). DICOM volumetric images were segmented using a 3D workstation (Vitrea, Vital Images); the output was used to generate STL files (using AutoDesk Meshmixer), and further processed to create 3D printable geometries for flow experiments. Multi-material printed models (Stratasys Connex3) were connected to a programmable pulsatile pump, and the pressure was measured proximal and distal to the stenosis using pressure transducers. Compliance chambers were used before and after the model to modulate the pressure wave. A flow sensor was used to ensure flow rates within physiological reported values. RESULTS 3D model based FFR measurements correlated well with stenosis severity. FFR measurements for each stenosis grade were: 0.8 severe, 0.7 moderate and 0.88 mild. CONCLUSIONS 3D printed models of patient-specific coronary arteries allows for accurate benchtop diagnosis of FFR. This approach can be used as a future diagnostic tool or for testing CT image-based FFR methods.
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Affiliation(s)
- Lauren Shepard
- University Dept. of Biomedical Engineering, University at Buffalo, Buffalo, NY.,Toshiba Stroke and Vascular Research Center, Buffalo, NY
| | - Kelsey Sommer
- University Dept. of Biomedical Engineering, University at Buffalo, Buffalo, NY.,Toshiba Stroke and Vascular Research Center, Buffalo, NY
| | - Richard Izzo
- University Dept. of Biomedical Engineering, University at Buffalo, Buffalo, NY.,Toshiba Stroke and Vascular Research Center, Buffalo, NY.,The Jacobs Institute, Buffalo, NY
| | - Alexander Podgorsak
- University Dept. of Biomedical Engineering, University at Buffalo, Buffalo, NY.,Toshiba Stroke and Vascular Research Center, Buffalo, NY
| | - Michael Wilson
- Interventional Cardiology, University at Buffalo Medicine, UBMD, Buffalo, NY
| | - Zaid Said
- Interventional Cardiology, University at Buffalo Medicine, UBMD, Buffalo, NY
| | - Frank J Rybicki
- The Ottawa Hospital Research Institute and the Department of Radiology, University of Ottawa, Ottawa, ON, CA
| | | | - Stephen Rudin
- University Dept. of Biomedical Engineering, University at Buffalo, Buffalo, NY.,Toshiba Stroke and Vascular Research Center, Buffalo, NY
| | - Erin Angel
- Toshiba American Medical Systems, Tustin, CA
| | - Ciprian N Ionita
- University Dept. of Biomedical Engineering, University at Buffalo, Buffalo, NY.,Toshiba Stroke and Vascular Research Center, Buffalo, NY
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48
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Meess KM, Izzo RL, Dryjski ML, Curl RE, Harris LM, Springer M, Siddiqui AH, Rudin S, Ionita CN. 3D Printed Abdominal Aortic Aneurysm Phantom for Image Guided Surgical Planning with a Patient Specific Fenestrated Endovascular Graft System. PROCEEDINGS OF SPIE--THE INTERNATIONAL SOCIETY FOR OPTICAL ENGINEERING 2017. [PMID: 28638171 DOI: 10.1117/12.2253902] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Following new trends in precision medicine, Juxatarenal Abdominal Aortic Aneurysm (JAAA) treatment has been enabled by using patient-specific fenestrated endovascular grafts. The X-ray guided procedure requires precise orientation of multiple modular endografts within the arteries confirmed via radiopaque markers. Patient-specific 3D printed phantoms could familiarize physicians with complex procedures and new devices in a risk-free simulation environment to avoid periprocedural complications and improve training. Using the Vascular Modeling Toolkit (VMTK), 3D Data from a CTA imaging of a patient scheduled for Fenestrated EndoVascular Aortic Repair (FEVAR) was segmented to isolate the aortic lumen, thrombus, and calcifications. A stereolithographic mesh (STL) was generated and then modified in Autodesk MeshMixer for fabrication via a Stratasys Eden 260 printer in a flexible photopolymer to simulate arterial compliance. Fluoroscopic guided simulation of the patient-specific FEVAR procedure was performed by interventionists using all demonstration endografts and accessory devices. Analysis compared treatment strategy between the planned procedure, the simulation procedure, and the patient procedure using a derived scoring scheme. RESULTS With training on the patient-specific 3D printed AAA phantom, the clinical team optimized their procedural strategy. Anatomical landmarks and all devices were visible under x-ray during the simulation mimicking the clinical environment. The actual patient procedure went without complications. CONCLUSIONS With advances in 3D printing, fabrication of patient specific AAA phantoms is possible. Simulation with 3D printed phantoms shows potential to inform clinical interventional procedures in addition to CTA diagnostic imaging.
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Affiliation(s)
- Karen M Meess
- The Jacobs Institute, Buffalo, NY 14203.,CUBRC Inc., Buffalo, NY 14225.,Department of Biomedical Engineering, University at Buffalo, Buffalo, NY 14228.,Toshiba Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY 14203
| | - Richard L Izzo
- The Jacobs Institute, Buffalo, NY 14203.,Department of Biomedical Engineering, University at Buffalo, Buffalo, NY 14228.,Toshiba Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY 14203
| | - Maciej L Dryjski
- Department of Vascular Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY 14203
| | - Richard E Curl
- Department of Vascular Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY 14203
| | - Linda M Harris
- Department of Vascular Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY 14203
| | | | - Adnan H Siddiqui
- The Jacobs Institute, Buffalo, NY 14203.,Toshiba Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY 14203.,Department of Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY 14203
| | - Stephen Rudin
- Department of Biomedical Engineering, University at Buffalo, Buffalo, NY 14228.,Toshiba Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY 14203.,Department of Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY 14203.,Department of Radiology, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY 14203
| | - Ciprian N Ionita
- Department of Biomedical Engineering, University at Buffalo, Buffalo, NY 14228.,Toshiba Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY 14203
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49
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Sommer K, Izzo RL, Shepard L, Podgorsak AR, Rudin S, Siddiqui AH, Wilson MF, Angel E, Said Z, Springer M, Ionita CN. Design Optimization for Accurate Flow Simulations in 3D Printed Vascular Phantoms Derived from Computed Tomography Angiography. PROCEEDINGS OF SPIE--THE INTERNATIONAL SOCIETY FOR OPTICAL ENGINEERING 2017; 10138. [PMID: 28663663 DOI: 10.1117/12.2253711] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
3D printing has been used to create complex arterial phantoms to advance device testing and physiological condition evaluation. Stereolithographic (STL) files of patient-specific cardiovascular anatomy are acquired to build cardiac vasculature through advanced mesh-manipulation techniques. Management of distal branches in the arterial tree is important to make such phantoms practicable. We investigated methods to manage the distal arterial flow resistance and pressure thus creating physiologically and geometrically accurate phantoms that can be used for simulations of image-guided interventional procedures with new devices. Patient specific CT data were imported into a Vital Imaging workstation, segmented, and exported as STL files. Using a mesh-manipulation program (Meshmixer) we created flow models of the coronary tree. Distal arteries were connected to a compliance chamber. The phantom was then printed using a Stratasys Connex3 multimaterial printer: the vessel in TangoPlus and the fluid flow simulation chamber in Vero. The model was connected to a programmable pump and pressure sensors measured flow characteristics through the phantoms. Physiological flow simulations for patient-specific vasculature were done for six cardiac models (three different vasculatures comparing two new designs). For the coronary phantom we obtained physiologically relevant waves which oscillated between 80 and 120 mmHg and a flow rate of ~125 ml/min, within the literature reported values. The pressure wave was similar with those acquired in human patients. Thus we demonstrated that 3D printed phantoms can be used not only to reproduce the correct patient anatomy for device testing in image-guided interventions, but also for physiological simulations. This has great potential to advance treatment assessment and diagnosis.
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Affiliation(s)
- Kelsey Sommer
- Department of Biomedical Engineering, University at Buffalo, Buffalo NY 14228.,Toshiba Stroke and Vascular Research Center, University at Buffalo, Buffalo NY 14208
| | - Richard L Izzo
- Department of Biomedical Engineering, University at Buffalo, Buffalo NY 14228.,Toshiba Stroke and Vascular Research Center, University at Buffalo, Buffalo NY 14208.,The Jacobs Institute, Buffalo NY 14208
| | - Lauren Shepard
- Department of Biomedical Engineering, University at Buffalo, Buffalo NY 14228.,Toshiba Stroke and Vascular Research Center, University at Buffalo, Buffalo NY 14208
| | - Alexander R Podgorsak
- Department of Biomedical Engineering, University at Buffalo, Buffalo NY 14228.,Toshiba Stroke and Vascular Research Center, University at Buffalo, Buffalo NY 14208
| | - Stephen Rudin
- Department of Biomedical Engineering, University at Buffalo, Buffalo NY 14228.,Toshiba Stroke and Vascular Research Center, University at Buffalo, Buffalo NY 14208.,University at Buffalo Neurosurgery, University at Buffalo Jacobs School of Medicine, Buffalo NY 14208
| | - Adnan H Siddiqui
- Toshiba Stroke and Vascular Research Center, University at Buffalo, Buffalo NY 14208.,University at Buffalo Neurosurgery, University at Buffalo Jacobs School of Medicine, Buffalo NY 14208
| | - Michael F Wilson
- Toshiba Stroke and Vascular Research Center, University at Buffalo, Buffalo NY 14208.,University at Buffalo Cardiology, University at Buffalo Jacobs School of Medicine, Buffalo NY 14208
| | - Erin Angel
- Toshiba America Medical Systems, Irvine CA 92618
| | - Zaid Said
- University at Buffalo Cardiology, University at Buffalo Jacobs School of Medicine, Buffalo NY 14208
| | | | - Ciprian N Ionita
- Department of Biomedical Engineering, University at Buffalo, Buffalo NY 14228.,Toshiba Stroke and Vascular Research Center, University at Buffalo, Buffalo NY 14208.,University at Buffalo Neurosurgery, University at Buffalo Jacobs School of Medicine, Buffalo NY 14208
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50
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Miura Y, Araki T, Terashima M, Tsuboi J, Saito Y, Kanamaru K, Suzuki H. Mechanical Recanalization for Acute Embolic Occlusion at the Origin of the Superior Mesenteric Artery. Vasc Endovascular Surg 2017; 51:91-94. [DOI: 10.1177/1538574416689425] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Purpose: We report a combined technique consisting of thrombectomy and thromboaspiration for the treatment of acute embolic occlusion of the superior mesenteric artery (SMA) at the origin. Case: A 90-year-old female with chronic atrial fibrillation had a sudden onset of abdominal pain and hematochezia due to acute embolic occlusion at the origin of the SMA. Computed tomographic findings showed reversible bowel wall ischemia. We performed mechanical thrombectomy using the Solitaire FR revascularization device, a self-expanding and fully retrievable stent-based thrombectomy system for acute intracranial large artery occlusion, combined with manual aspiration through a 6F guiding sheath placed at the SMA origin via a right brachial approach. Prompt and complete recanalization of the SMA was obtained without distal embolism, and intestinal necrosis was avoided. Conclusion: Combined endovascular procedures of mechanical thrombectomy using the Solitaire FR with thromboaspiration may allow prompt recanalization, clot removal, and prevention of distal embolism and therefore would be a new therapy for acute embolic occlusion at the origin of the SMA.
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Affiliation(s)
- Yoichi Miura
- Department of Neurosurgery, Suzuka Kaisei Hospital, Suzuka, Mie, Japan
| | - Tomohiro Araki
- Department of Neurosurgery, Suzuka Kaisei Hospital, Suzuka, Mie, Japan
| | - Mio Terashima
- Department of Neurosurgery, Suzuka Kaisei Hospital, Suzuka, Mie, Japan
| | - Junya Tsuboi
- Department of Gastroenterology, Suzuka Kaisei Hospital, Suzuka, Mie, Japan
| | - Yasuhiro Saito
- Department of Cardiovascular Medicine, Suzuka Kaisei Hospital, Suzuka, Mie, Japan
| | - Kenji Kanamaru
- Department of Neurosurgery, Suzuka Kaisei Hospital, Suzuka, Mie, Japan
| | - Hidenori Suzuki
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
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