Groin complications in endovascular mechanical thrombectomy for acute ischemic stroke: a 10-year single center experience

BOBBY balloon guide catheter thrombectomy in large-vessel occlusion stroke: Initial experience

BACKGROUND AND PURPOSE

Nonrandomized studies have found Balloon Guide Catheter (BGC) use to improve technical and functional outcomes in patients undergoing mechanical thrombectomy (MT).

MATERIALS AND METHODS

We performed a retrospective analysis on prospectively collected data of consecutive ischemic stroke patients undergoing MT at our institution (December 2020-October 2021). Interventions where BOBBY BGC (BBGC, MicroVentionTM, Aliso Viejo, CA) was used were identified. Baseline demographics and clinico-radiographic characteristics were retrospectively collected and analysed using descriptive statistics.

RESULTS

A total of 43 patients received BBGC-MT (male: female = 26:17, median age 72 years [IQR 62-82]). The most common occlusion site was the middle cerebral artery (MCA) (60.4%). Over half (51.2%) received intravenous thrombolytics. The BBGC tracked well over tortuous aortic arches (type II 34.8%, type III 16.3%), with median arteriotomy-to-perfusion time of 29 min (IQR 20-46). Thromboaspiration was used as first-line MT technique in 69.7% cases, with 1 (IQR 1-2) median MT pass achieving modified TICI (thrombolysis in cerebral ischemia) scores of 3 and 2b/3 in 74.4% and 95.3% respectively. Our overall first pass effect (FPE, defined as mTICI 3 after firs-pass) and modified FPE (defined as, mTICI 2b/3 after first-pass) rates were 51.1% and 79.1% respectively, with rates of 92.3% and 100% respectively when stentretriever and thromboaspiration were combined. The median reduction in National Institutes of Health Stroke Scale (NIHSS) was 9 (IQR 4-15, p < 0.0001), with a median 90-day modified Rankin Score (mRS) of 1.5 (IQR 0-2).

CONCLUSIONS

BOBBY BGC use resulted in a high first-pass effect rate and may contribute towards improved functional outcomes.

Mechanical thrombectomy using the retrograde semi-retrieval technique for patients with underlying intracranial atherosclerotic stenosis

Background

The retrograde semi-retrieval technique (RESET) has been described as a modified technique for endovascular thrombectomy (EVT) whose safety and efficacy for intracranial atherosclerosis stenosis (ICAS) patients remain uncertain. This article presents our single-center experience, comparing RESET vs. non-RESET in ICAS patients.

Materials and methods

We analyzed 327 consecutive ICAS patients who underwent EVT at Tianjin Huanhu Hospital from January 2018 and December 2022. Patients were categorized into two groups: RESET and non-RESET. The primary outcome was the first-pass effect (FPE). Secondary outcomes included successful reperfusion, functional independence at 90 days, mortality, and symptomatic intracranial hemorrhage (sICH).

Results

RESET was significantly associated with FPE [adjusted odds ratio (aOR) 2.00, 95% confidence interval (CI) 1.03-3.87, p = 0.040]. RESET was not significantly associated with successful reperfusion (aOR 1.5, CI 0.55-4.06, p = 0.425), an mRS of 0-2 at 90 days (aOR 1.36, CI 0.83-2.21, p = 0.223), sICH (aOR 0.39, CI 0.12-1.23, p = 0.108), and mortality (aOR 0.49, CI 0.16-1.44, p = 0.193). After propensity score matching, the results were consistent with the primary analysis.

Conclusion

Compared to non-RESET, patients treated with RESET showed increased FPE incidence and significantly decreased puncture-to-reperfusion time. RESET was proven to be safe and effective in enhancing reperfusion for LVO patients receiving EVT with underlying ICAS.

Off-Label Use of the 8-F Angio-Seal for Closure of Greater than 8-F Common Femoral Arterial Access: A Systematic Review and Meta-Analysis

PURPOSE

To evaluate the safety of >8-F access closures using 8-F Angio-Seal.

MATERIALS AND METHODS

An electronic search was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines using Web of Science, Embase, Scopus, and PubMed databases from inception until January 17, 2022. Actionable and nonactionable bleeding events were defined in conjugation with the Bleeding Academic Research Consortium definition. Prevalence rates with corresponding 95% CIs were calculated using R software version 4.2.2. Eight articles, with 422 patients, were included in the analysis.

RESULTS

The overall groin adverse event rate was 5.92% (95% CI, 3.01-11.34). The most commonly reported adverse events were any bleeding (5.74%; 95% CI, 3.23-10.00) (nonactionable bleeding, 0.96% [95% CI, 0.10-8.30]; actionable bleeding, 2.30% [95% CI, 0.89-5.84]), pseudoaneurysm (1.18%; 95% CI, 0.49-2.81), and groin hematoma (1.28%; 95% CI, 0.23-6.79). The least commonly reported adverse events were device failure and vessel occlusion/stenosis, with rates 0.29% (95% CI, 0.01-7.41) and 0.45% (95% CI, 0.02-7.74), respectively. No studies recorded events regarding the following adverse events: mortality, infection, deep venous thrombosis, and retroperitoneal hematoma. Moreover, the results showed significant differences, based on the sheath size used, in actionable bleeding (P = .04) and the rate of need for surgical repair (P < .01).

CONCLUSIONS

Common femoral artery access of >8-F can be effectively closed with the Angio-Seal with comparable outcomes to those of <8 F; however, larger access approaching 14 F is associated with a significant increase in morbidity. Further safety is needed, especially for the larger access sizes.

Predictors of Transfemoral Access Site Complications in Neuroendovascular Procedures: A large Single-Center Cohort Study

OBJECTIVE

The transfemoral (TF) route has historically been the preferred access site for endovascular procedures. However, despite its widespread use, TF procedures may confer morbidity as a result of access site complications. The aim of this study is to provide the rate and predictors of TF access site complications for neuroendovascular procedures.

METHODS

This is a single center retrospective study of TF neuroendovascular procedures performed between 2017 and 2022. The incidence of complications and associated risk factors were analyzed across a large cohort of patients.

RESULTS

The study comprised of 2043 patients undergoing transfemoral neuroendovascular procedures. The composite rate of access site complications was 8.6 % (n = 176). These complications were divided into groin hematoma formation (n = 118, 5.78 %), retroperitoneal hematoma (n = 14, 0.69 %), pseudoaneurysm formation (n = 40, 1.96 %), and femoral artery occlusion (n = 4, 0.19 %). The cross-over to trans radial access rate was 1.1 % (n = 22). On univariate analysis, increasing age (OR=1.0, p = 0.06) coronary artery disease (OR=1.7, p = 0.05) peripheral vascular disease (OR=1.9, p = 0.07), emergent mechanical thrombectomy procedures (OR=2.1, p < 0.001) and increasing sheath size (OR=1.3, p < 0.001) were associated with higher TF access site complications. On multivariate analysis, larger sheath size was an independent risk factor for TF access site complications (OR=1.8, p = 0.02).

CONCLUSION

Several pertinent factors contribute towards the incidence of TF access site complications. Factors associated with TF access site complications include patient demographics (older age) and clinical risk factors (vascular disease), as well as periprocedural factors (sheath size).

Safety and efficacy of the SeparGateTM balloon-guiding catheter in neurointerventional surgery: A prospective, multicenter, single-arm clinical trial

Objective

To evaluate the safety and efficacy of the SeparGate™ balloon-guiding catheter (BGC) for blocking flow and delivering devices in neurointerventional surgery.

Method

This prospective multicenter single-arm trial enrolled patients who received BGC adjuvant therapy to provide temporary blood flow arrest of the supra-aortic arch arteries and their branch vessels in interventional therapy. The primary endpoint was immediate procedural success rate in flow arrest, device delivery, and withdrawal. The efficacy endpoints were intraoperative product performance, including rigidity, smoothness, fracture resistance of the catheter wall, catheter push performance, compatibility and radiopaque display, integrity, adhesion thrombus after withdrawal and balloon rupture. The safety endpoints were adverse and serious adverse events associated with the test device and serious adverse events resulting in death or serious health deterioration.

Result

A total of 129 patients were included; of them, 128 were analyzed in the full analysis set (FAS) and per protocol set (PPS). Immediate procedural success was achieved in 97.7% of patients with FAS and PPS. The lower bound of the 95% confidence interval was 94.6%, higher than the preset efficacy margin of 94%. Device-related adverse events occurred in 2 (1.6%) cases. One was mild adverse event of vasospasm, which resolved spontaneously. The other was serious adverse event of dissection aggravation, which was treated with stenting angioplasty. No device defects were observed.

Conclusion

In neurointerventional surgery, the SeparGate™ BGC can be used to temporarily block the flow of the supra-aortic arch arteries and their branch vessels and guide the interventional device to the target vascular position.

Transradial versus Transfemoral Approaches in Diagnostic and Therapeutic Neuroendovascular Interventions: A Meta-Analysis of Current Literature

BACKGROUND

The adoption of the transradial approach (TRA) has been increasing in popularity as a primary method to conduct both diagnostic and therapeutic interventions. As this technique gains broader acceptance and use within the neuroendovascular community, comparing its complication profile with a better-established alternative technique, the transfemoral approach (TFA), becomes more important. This study aimed to evaluate the safety of TRA compared with TFA in patients undergoing diagnostic, therapeutic, and combined neuroendovascular procedures.

METHODS

A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A literature search of PubMed and other databases was conducted for studies from all available dates. To compare TRA and TFA, we performed an indirect meta-analysis between studies that mentioned the complications of the procedures.

RESULTS

Our search yielded 532 studies, of which 108 met full inclusion criteria. A total of 54,083 patients (9137 undergoing TRA and 44,946 undergoing TFA) were included. Access site complication rate was lower in TRA (1.62%) compared with TFA (3.31%) (P < 0.01). Neurological complication rate was lower in TRA (1.64%) compared with TFA (3.82%) (P = 0.02 and P < 0.01, respectively). Vascular spasm rate was higher in TRA (3.65%) compared with TFA (0.88%) (P < 0.01). Wound infection complication rate was higher in TRA (0.32%) compared with TFA (0.2%) (P < 0.01).

CONCLUSIONS

Patients undergoing TFA are significantly more likely to experience access site complications and neurological complications compared with patients undergoing TRA. Patients undergoing TRA are more likely to experience complications such as wound infections and vascular spasm.

Clinical and Procedural Outcomes with or without Balloon Guide Catheters during Endovascular Thrombectomy in Acute Ischemic Stroke: A Systematic Review and Meta-analysis with First-line Technique Subgroup Analysis

BACKGROUND

Balloon guide catheters are increasingly used to improve clot retrieval by temporarily stopping proximal blood flow during endovascular thrombectomy.

PURPOSE

Our aim was to provide a summary of the literature comparing the procedural and clinical outcomes of endovascular thrombectomy with or without balloon guide catheters, depending on the first-line technique used.

DATA SOURCES

We used PubMed/MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews.

STUDY SELECTION

We chose studies that compared using balloon guide catheters with not using them.

DATA ANALYSIS

Random effects meta-analysis was performed to compare the procedural outcomes measured as the first-pass effect, successful reperfusion, number of passes, procedural duration, arterial puncture to reperfusion time, distal emboli, and clinical outcomes.

DATA SYNTHESIS

Overall, a meta-analysis of 16 studies (5507 patients, 50.8% treated with balloon guide catheters and 49.2% without them) shows that the use of balloon guide catheters increases the odds of achieving a first-pass effect (OR = 1.92; 95% CI, 1.34-2.76; P < .001), successful reperfusion (OR = 1.85; 95% CI, 1.42-2.40; P < .001), and good functional outcome (OR =1.48; 95% CI, 1.27-1.73; P < .001). Balloon guide catheters reduce the number of passes (mean difference = -0.35; 95% CI, -0.65 to -0.04; P = .02), procedural time (mean difference = -19.73; 95% CI, -34.63 to -4.83; P = .009), incidence of distal or new territory emboli (OR = 0.5; 95% CI, 0.26-0.98; P = .04), and mortality (OR = 0.72; 95% CI, 0.62-0.85; P < .001). Similar benefits of balloon guide catheters are observed when the first-line technique was a stent retriever or contact aspiration, but not for a combined approach.

LIMITATIONS

The analysis was based on nonrandomized trials with a moderate risk of bias.

CONCLUSIONS

Current literature suggests improved clinical and procedural outcomes associated with the use of balloon guide catheters during endovascular thrombectomy, especially when using the first-line stent retriever.

Balloon guide catheters: use, reject, or randomize?

Thrombectomy devices played an important role in the success of endovascular treatment trials over the past five years. A balloon guide catheter (BGC) is an adjunctive device used to arrest and reverse flow by inflating the balloon at its tip, which allows for flow reversal in intracranial arteries during retrieval of thrombectomy devices by applying concomitant aspiration through its lumen. Thereby, it can decrease the risk of clot fragmentation and distal embolization. Despite the numerous benchtop and clinical observational studies showing the superiority of BGC to conventional guide catheters in improving reperfusion quality and clinical outcome, its use is still low in clinical practice. The reasons behind this reluctance might be related to technical and cost issues. Therefore, high level evidence data, i.e., a randomized clinical trial, are needed to increase its implementation in thrombectomy procedures. Nonetheless, several obstacles and challenges can prevent the completion of such a trial, and efforts are needed to overcome them. We provide an overview of the current opinions about BGCs in the neurointerventional community and discuss the feasibility and challenges of a possible randomized trial to answer the question "should a BGC be routinely used in endovascular treatment of acute ischemic stroke?"

Comparison of Balloon Guide Catheters and Standard Guide Catheters for Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

BACKGROUND

Balloon guide catheters (BGCs) are designed to induce flow arrest during mechanical thrombectomy procedures for acute ischemic stroke due to large-vessel occlusion and have been associated with improved clinical and angiographic outcomes. We conducted a systematic review and meta-analysis evaluating the relative technical and clinical outcomes associated with BGC versus non-BGC approaches.

METHODS

A systematic review of clinical literature using the PubMed database was undertaken to identify multiarm studies published between 2010 and 2021 reporting the use of BGC versus non-BGC approaches for stroke treatment. Data collected included complete recanalization (thrombolysis in cerebral infarction, TICI), first-pass effect TICI 3, puncture-to recanalization time, number of endovascular attempts, distal embolization, symptomatic intracerebral hemorrhage, 90-day modified Rankin Scale score 0-2, and 90-day mortality. Subgroup analyses assessed the impact of treatment device (stent-retrievers, contact aspiration, combination therapy, and not specified/other). A random effects model was fit for each outcome measure.

RESULTS

Fifteen studies were included. Compared with non-BGC approaches, patients treated with BGCs had greater odds of TICI 3 (odds ratio [OR] 1.57; 95% confidence interval [95% CI] 1.08-2.29) and first-pass effect TICI 3 (OR 3.63; 95% CI 2.34-5.62), reduced puncture-to-revascularization time (mean difference -7.8; 95% CI -13.3 to -2.2), fewer endovascular attempts (mean difference -0.47; 95% CI -0.68 to -0.26), reduced odds of distal emboli (OR 0.34; 95% CI 0.17-0.71) and symptomatic intracerebral hemorrhage (OR 0.66; 95% CI 0.51-0.86), greater odds of 90-day modified Rankin Scale score 0-2 (OR 1.51; 95% CI 1.27-1.79), and reduced odds of mortality (OR 0.69; 95% CI 0.57-0.82).

CONCLUSIONS

BGCs yield superior technical and clinical outcomes while reducing patient complications.

Access-site complications in ultrasound-guided endovascular thrombectomy: a single-institution retrospective cohort study

OBJECTIVE

Mechanical endovascular thrombectomy (EVT) is an increasingly relied-on treatment for clot retrieval in the context of ischemic strokes, which otherwise are associated with significant morbidity and mortality. Despite several known risks associated with this procedure, there is a high degree of technical heterogeneity across both centers and operators. The most common procedural complications occur at the point of transfemoral access (the common femoral artery), and include access-site hematomas, dissections, and pseudoaneurysms. Other interventional fields have previously popularized the use of ultrasound to enhance the anatomical localization of structures relevant to vascular access and thereby reducing access-site complications. In this study, the authors aimed to describe the ultrasound-guided EVT technique performed at a large, quaternary neurovascular referral center, and to characterize the effects of ultrasound guidance on access-site complications.

METHODS

A retrospective chart review of all patients treated with EVT at a single center between January 2013 and August 2020 was performed. Patients in this cohort were treated using a universal, unique, ultrasound-guided, single-wall puncture technique, which bears several theoretical advantages over the standard technique of arterial puncture via palpation.

RESULTS

There were 479 patients treated with EVT within the study period. Twenty patients in the cohort were identified as having experienced some form of access-site complication. Eight (1.67%) of these patients experienced minor access-site complications, all of which were groin hematomas and none of which were clinically significant, as defined by requiring surgical or interventional management or transfusion. The remaining 12 patients experienced arterial dissection (n = 5), arterial pseudoaneurysm (n = 4), retroperitoneal hematoma (n = 2), or arterial occlusion (n = 1), with only 1.04% (5/479) requiring surgical or interventional management or transfusion.

CONCLUSIONS

The authors found an overall reduction in total access-site complications as well as minor access-site complications in the study cohort compared with previously published randomized controlled trials and observational studies in the recent literature. The findings suggested that there may be a role for routine use of ultrasound-guided puncture techniques in EVT to decrease rates of complications.

Clinical impact of EVT with failed reperfusion in patients with acute ischemic stroke: results from the ESCAPE and ESCAPE-NA1 trials

BACKGROUND AND PURPOSE

Endovascular treatment (EVT) is a powerful treatment for large vessel occlusion (LVO) stroke if reperfusion can be achieved, while in cases with failed reperfusion, EVT may cause harm, as procedure-related complications may occur. We hypothesized that EVT with failed recanalization does not result in worse outcomes compared to best medical management and compared clinical outcomes of LVO stroke patients who underwent EVT with failed reperfusion to those who were treated with best medical management.

METHODS

We included patients with failed reperfusion from the control (EVT-only) arm of the ESCAPE-NA1 trial and the EVT arm of the ESCAPE trial and patients of the ESCAPE control arm who were treated with best medical management. Failed reperfusion following EVT was defined as modified thrombolysis in cerebral infarction score 0-2a. Proportions of good outcome (modified Rankin scale 0-2) were compared between patients who did and did not undergo EVT, and adjusted effect size estimates for EVT on outcomes were obtained.

RESULTS

We included 260 patients (110 failed EVT and 150 non-EVT patients). Proportions of good outcome were 38/110 (34.6%) with failed EVT vs.43/147 (29.3%) without EVT (adjusted odds ratio[aOR]: 1.48 [95%CI: 0.81-2.68]). Mortality and proportions of sICH in the failed EVT group vs. patients treated with best medical management were 26/110 (23.6%) vs. 28/147 (19.1%), aOR: 1.12 (95%CI: 0.56-2.24), and 7/110 (6.4%) vs. 4/150 (2.7%), aOR: 2.34 (95%CI: 0.00-22.97).

CONCLUSION

Clinical outcomes of EVT patients with failed reperfusion did not differ significantly from patients treated with best medical management.

Use of 8Fr angio-seal for closure of femoral arteriotomy following use of 8Fr and 9Fr sheaths in patients undergoing mechanical thrombectomy for acute ischaemic stroke

BACKGROUND

Little is known about the safety of off-label use of an 8Fr Angio-Seal VIP for large-bore arteriotomies in patients treated with mechanical thrombectomy (MT) and intravenous thrombolysis (IVT) for acute ischaemic stroke (AIS). We aimed to identify differences in the groin complication rate using an 8Fr Angio-Seal VIP for common femoral arteriotomy closures following the use of 8Fr and 9Fr sheaths.

METHODS

All AIS patients who underwent MT at our tertiary neuroscience unit between January 2018 and March 2020 were retrospectively reviewed.

RESULTS

161 patients were included in the study, of whom 56 and 105 patients underwent an arteriotomy using an 8Fr sheath (36 of them receiving IVT) and a 9Fr sheath (57 of them receiving IVT). Overall, 17 groin complications were identified (10.5%) in 5 patients (8.9%) who had had 8Fr sheaths inserted and 12 patients (11.4%) who had had 9Fr sheaths inserted. Major complications were identified in only 2 patients (1.2%), one patient in each of the 8Fr and 9Fr cohorts suffering a pseudoaneurysm requiring intervention. No retroperitoneal haematoma, infection, acute limb ischaemia or ipsilateral DVT was identified. No significant difference in groin complications was observed between the 8Fr and 9Fr femoral arteriotomy cohorts or between the MT patients that did or did not receive adjunctive IVT.

CONCLUSION

In the setting of MT with IVT, off-label use of an 8Fr Angio-Seal VIP for closure of a femoral arteriotomy following use of a 9Fr sheath has a similar safety profile to the licensed use of an 8Fr Angio-Seal VIP for closure of a femoral arteriotomy following use of an 8Fr sheath or smaller.

Balloon guide catheter improvements in thrombectomy outcomes persist despite advances in intracranial aspiration technology

BACKGROUND

First-pass effect (FPE) has been established as a key metric for technical success and strongly correlates with better clinical outcomes. Most data supporting improved outcomes with the use of a balloon guide catheter (BGC) predate the advent of last-generation large-bore intracranial aspiration catheters. We aim to evaluate the impact of BGC in FPE and clinical outcomes in a large cohort of patients treated with contemporary technology.

METHODS

Patients were recruited from the prospectively ongoing ROSSETTI registry. This registry includes all consecutive patients with anterior circulation large-vessel occlusion (LVO) from 10 comprehensive stroke centers in Spain. Demographic, clinical, angiographic, and clinical outcome data were compared between BGC and non-BGC groups. FPE was defined as the achievement of mTICI2c-3 after a single device pass.

RESULTS

426 patients were included out of which 271 (63.62%) used BCG. BGC-treated patients had higher FPE rate (45.8% vs 27.7%; P<0.001), higher final mTICI ≥2 c recanalization rate (76.8% vs 50.3%, respectively; P<0.001), shorter procedural time [median (IQR), 30 (19-58) vs 43 (33-71) min; P<0.001], higher NIHSS difference from admission to 24 hours [median (IQR), 8 (2-12) vs 3 (0-10); P=0.001], and lower mortality rate (17.6% vs 29.8%, P=0.026) compared with non-BGC patients. BGC use was an independent predictor of FPE (OR 2.197, 95% CI 1.436 to 3.361; P<0.001), and excellent clinical outcome at 3 months (OR 0.34, 95% CI 0.17 to 0.68; P=0.002).

CONCLUSIONS

Our results support the benefit of BGC use on angiographic and clinical outcomes in anterior circulation LVO ischemic stroke remain significant even when considering recent improvements in intracranial aspiration technology.

Safety and efficacy of Angio-Seal device for transfemoral neuroendovascular procedures: A systematic review and meta-analysis

INTRODUCTION

Angio-Seal is a commonly used device for femoral hemostasis in neuroendovascular procedures. This meta-analysis investigates of the safety and efficacy of Angio-Seal in patients undergoing endovascular neurointerventional procedures.

METHODS

A systematic review and meta-analysis on all studies evaluating the Angio-Seal device in neurointerventional procedures from inception through 2020 were performed. We studied rates of groin hematoma, retroperitoneal hematoma, pseudoaneurysm, ipsilateral DVT, and ischemic complications. Meta-analysis was performed using the random-effects model.

RESULTS

13 studies were included in our analysis. 2250 patients with 104 complications were found {4.5% (95% CI, 2.7%-6.3%)}. Of these complications, groin hematoma was the most common with a rate of 2.4% (95% CI, 1.1%-3.6%). Retroperitoneal hematoma {0.3% (95% CI, 0%-0.5%)}, pseudo-aneurysm {0.5% (95% CI, 0.2%-0.8%), and ipsilateral DVT {0.3% (95% CI, 0.1%-0.7%) were also not in negligible rate. The rate of other complications were as follows: vessel occlusion/stenosis; 0.2% (95% CI, 0%-0.4%), vascular surgery; 0.2% (95% CI, 0%-0.5%), and infection; 0.2% (95% CI, 0%-0.5%). One patient died as result of hemorrhagic complications {0.1% (95% CI, 0%-0.3%)}. Use of anticoagulant/antiplatelet therapy was found to be positively correlated with high risk of any groin complication and groin hematoma (p ≤ .05). Female gender was associated with high risk of ipsilateral DVT (p ≤ .05). Interestingly, large sheath size was associated with low risk of groin hematoma (p ≤ .05).

CONCLUSION

The safety and efficacy rate of Angio-Seal was approximately 95%. The most common complication was groin hematoma. Serious complications including retroperitoneal hematoma and femoral artery occlusion were rare.

Endovascular Stroke Interventions: Procedural Complications and Management

Endovascular mechanical thrombectomy has evolved significantly and has become the mainstay and most effective currently available treatment for acute ischemic stroke patients due to large vessel occlusion. Mechanical thrombectomy is presently performed using a stent retriever or stent-like device, an aspiration catheter, or a combination of the two. Much of the literature has focused on the benefits of endovascular mechanical thrombectomy with only limited data about procedural complications and management. Awareness of risk factors and early recognition of these complications can potentially reduce complication rates, improve management, and yield better overall outcomes. In this review, the authors present a description of intraprocedural complications and strategies to prevent and treat these complications.

Optimization of resources and modifications in acute ischemic stroke care in response to the global COVID-19 pandemic

Background

The COVID-19 pandemic has presented unprecedented challenges to healthcare organizations worldwide. A steadily rising number of patients requiring intensive care, a large proportion from racial and ethnic minorities, demands creative solutions to provide high-quality care while ensuring healthcare worker safety in the face of limited resources. Boston Medical Center has been particularly affected due to the underserved patient population we care for and the increased risk of ischemic stroke in patients with COVID-19 infection.

Methods

We present protocol modifications developed to manage patients with acute ischemic stroke in a safe and effective manner while prioritizing judicious use of personal protective equipment and intensive care unit resources.

Conclusion

We feel this information will benefit other organizations facing similar obstacles in caring for the most vulnerable patient populations during this ongoing public health crisis.

Access-Site Complications in Transfemoral Neuroendovascular Procedures: A Systematic Review of Incidence Rates and Management Strategies

BACKGROUND

The femoral artery is the most common access route for cerebral angiography and neurointerventional procedures. Complications of the transfemoral approach include groin hemorrhages and hematomas, retroperitoneal hematomas, pseudoaneurysms, arteriovenous fistulas, peripheral artery occlusions, femoral nerve injuries, and access-site infections. Incidence rates vary among different randomized and nonrandomized trials, and the literature lacks a comprehensive review of this subject.

OBJECTIVE

To gather data from 16 randomized clinical trials (RCT) and 17 nonrandomized cohort studies regarding femoral access-site complications for a review paper. We also briefly discuss management strategies for these complications based on the most recent literature.

METHODS

A PubMed indexed search for all neuroendovascular clinical trials, retrospective studies, and prospective studies that reported femoral artery access-site complications in neurointerventional procedures.

RESULTS

The overall access-site complication rate in RCTs is 5.13%, while in in non-RCTs, the rate is 2.78%. The most common complication in both groups is groin hematoma followed by access-site hemorrhage and femoral pseudoaneurysm. On the other hand, wound infection was the least common complication.

CONCLUSION

The transfemoral approach in neuroendovascular procedures holds risk for several complications. This review will allow further studies to compare access-site complications between the transfemoral approach and other alternative access sites, mainly the transradial approach, which is gaining a lot of interest nowadays.

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

Background

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

Design

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

Discussion

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

Trial registration

ChiCTR1800014459.

Role of Balloon Guide Catheter in Modern Endovascular Thrombectomy

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

GUide sheath Advancement and aspiRation in the Distal petrocavernous internal carotid artery (GUARD) Technique during Thrombectomy Improves Reperfusion and Clinical Outcomes

BACKGROUND AND PURPOSE

Adjunctive techniques to stent retriever thrombectomy include balloon-guide catheters and/or distal access catheters for aspiration. We describe a novel technique using a flexible, 6 French 088 distal guide sheath advanced past the skull base to augment mechanical thrombectomy. We studied the relative safety and efficacy of this technique in the setting of a combined stent retriever-distal access catheter aspiration thrombectomy protocol.

MATERIALS AND METHODS

We performed a retrospective case-control study of intracranial internal carotid artery or M1-M2 middle cerebral artery occlusions requiring mechanical thrombectomy. Patients were divided into 2 groups based on thrombectomy techniques: conventional stent retriever with distal access catheter aspiration without (standard) and with adjunctive GUide sheath Advancement and aspiRation in the Distal petrocavernous internal carotid artery (GUARD). Using propensity score matching, we compared procedural safety, reperfusion efficacy using the modified Thrombolysis in Cerebral Infarction scale and clinical outcomes with the modified Rankin Scale.

RESULTS

In comparing the GUARD (45 patients) versus standard (45 matched case controls) groups, there were no significant differences in demographics, NIHSS presentations, IV rtPA use, median onset-to-groin puncture times, procedural complications, symptomatic intracranial hemorrhage, or mortality. The GUARD group demonstrated significantly higher successful mTICI ≥2b reperfusion rates (98% versus 80%, P = .015) and improved functional mRS ≤2 outcomes (67% versus 43%, P = .04), with independent effects of the GUARD technique confirmed in a multivariable logistic regression model.

CONCLUSIONS

The GUARD technique during mechanical thrombectomy with combined stent retrieval-distal access catheter aspiration is safe and effective in improving reperfusion and clinical outcomes.

The Effects of Balloon-Guide Catheters on Outcomes after Mechanical Thrombectomy in Acute Ischemic Strokes : A Meta-Analysis

Objective

Mechanical thrombectomies with balloon-guide catheters (BGC) are thought to improve successful recanalization rates and to decrease the incidence of distal emboli compared to thrombectomies without BGC. We aimed to assess the effects of BGC on the outcomes of mechanical thrombectomy in acute ischemic strokes.

Methods

Studies from PubMed, EMBASE, and the Cochrane library database from January 2010 to February 2018 were reviewed. Random effect model for meta-analysis was used. Analyses such as meta-regression and the “trim-and-fill” method were additionally carried out.

Results

A total of seven articles involving 2223 patients were analyzed. Mechanical thrombectomy with BGC was associated with higher rates of successful recanalization (odds ratio [OR], 1.632; 95% confidence interval [CI], 1.293–2.059). BGC did not significantly decrease distal emboli, both before (OR, 0.404; 95% CI, 0.108–1.505) and after correcting for bias (adjusted OR, 1.165; 95% CI, 0.310–4.382). Good outcomes were observed more frequently in the BGC group (OR, 1.886; 95% CI, 1.564–2.273). Symptomatic intracranial hemorrhage and mortality did not differ significantly with BGC use.

Conclusion

Our meta-analysis demonstrates that BGC enhance recanalization rates. However, BGC use did not decrease distal emboli after mechanical thrombectomies. This should be interpreted with caution due to possible publication bias and heterogeneity. Additional meta-analyses based on individual patient data are needed to clarify the role of BGC in mechanical thrombectomies.

Safety profile of an 8F femoral arteriotomy closure using the Angio-Seal device in thrombolysed acute stroke patients undergoing thrombectomy

Background The relationship between bridging thrombolysis and femoral access site complications after mechanical thrombectomy remains contested. Use of a closure device could minimise bleeding complications. This study aimed to elucidate the rate of access site complications in a cohort of patients treated using an 8F groin sheath with subsequent closure using the Angio-Seal to assess safety and the impact of bridging thrombolysis on access site complication rate. Methods All patients with large vessel occlusive stroke treated between 2014 and 2017 with thrombectomy with or without bridging thrombolysis were reviewed. A prospectively acquired departmental database was used to obtain baseline data, and the radiology information and haematology reporting systems were used to record imaging or transfusion relating to subsequent access site complications. Results Seventy-five patients treated with thrombectomy alone were compared to 70 patients treated with prior intravenous thrombolysis. All had an 8F femoral sheath placed for arterial access, and all underwent attempted haemostasis with an 8F Angio-Seal. Two patients (1.14%) suffered Angio-Seal device failure necessitating manual pressure. One patient (0.6%) suffered a small femoral pseudo-aneurysm. No retroperitoneal haemorrhage, haematoma requiring transfusion, ipsilateral deep-vein thrombosis or ipsilateral acute limb ischaemia was encountered. There was no significant difference in the rate of haemorrhagic, ischaemic or infective complications between those treated with bridging thrombolysis or thrombectomy alone. Conclusion Use of the Angio-Seal closure device for 8F femoral access is safe in acute stroke patients. Intravenous thrombolysis prior to endovascular thrombectomy does not significantly alter femoral access site complication rate if this approach is used.

Complications of endovascular treatment for acute ischemic stroke: Prevention and management

Endovascular mechanical thrombectomy (MT) for the treatment of acute stroke due to large vessel occlusion has evolved significantly with the publication of multiple positive thrombectomy trials. MT is now a recommended treatment for acute ischemic stroke. Mechanical thrombectomy is associated with a number of intra-procedural or post-operative complications, which need to be minimized and effectively managed to maximize the benefits of thrombectomy. Procedural complications include: access-site problems (vessel/nerve injury, access-site hematoma and groin infection); device-related complications (vasospasm, arterial perforation and dissection, device detachment/misplacement); symptomatic intracerebral hemorrhage; subarachnoid hemorrhage; embolization to new or target vessel territory. Other complications include: anesthetic/contrast-related, post-operative hemorrhage, extra-cranial hemorrhage and pseudoaneurysm. Some complications are life-threatening and many lead to increased length of stay in intensive care and stroke units. Complications increase costs and delay the commencement of rehabilitation. Some may be preventable; the impact of others can be minimized with early detection and appropriate management. Both neurointerventionists and stroke specialists need to be aware of the risk factors, strategies for prevention, and management of these complications. With the increasing use of mechanical thrombectomy for the treatment of acute ischemic stroke, incidence and outcome of complications will need to be carefully monitored by stroke teams. In this narrative review, we examine the frequency of complications of MT in the treatment of acute ischemic stroke with an emphasis on periprocedural complications. Overall, from recent randomized controlled trials, the risk of complications with sequelae for patient from mechanical thrombectomy is ∼15%. We discuss the management of complications and identify areas with limited evidence, which need further research. Search strategy and selection criteria Relevant evidence was found by searches of Medline and Cochrane Library, reference list, cross-referencing and main journal content pages. Search terms included "brain ischemia", "acute ischemic stroke", "cerebral infarction" AND "mechanical thrombectomy", "endovascular therapy", "endovascular treatment", "endovascular embolectomy", "intra-arterial" AND "randomized controlled trial", "non-randomised trials", "observational studies" AND "complications", "procedural complications", "peri-procedural complications", "device-related complications", "management", "treatment", "outcome". The search included only human studies, and was limited to studies published in English between January 2014 and November 2016. The final reference list was selected on the basis of relevance to the topics covered in the Review. Guidelines for management of acute ischaemic stroke by the American Heart Association, the European Stroke Organisation, multi-disciplinary guidelines and the National Institute for Health and Care Excellence (NICE) were also reviewed.

Impact of balloon guide catheter on technical and clinical outcomes: a systematic review and meta-analysis

Background and purpose

Flow arrest with balloon guide catheters (BGCs) is becoming increasingly recognized as critical to optimizing patient outcomes for mechanical thrombectomy. We performed a systematic review and meta-analysis of the literature for studies that compared angiographic and clinical outcomes for patients who underwent mechanical thrombectomy with and without BGCs.

Materials and methods

In April 2017 a literature search on BGC and mechanical thrombectomy for stroke was performed. All studies included patients treated with and without BGCs using modern techniques (ie, stent retrievers). Using random effects meta-analysis, we evaluated the following outcomes: first-pass recanalization, Thrombolysis In Cerebral Infarction (TICI) 3 recanalization, TICI 2b/3 recanalization, favorable outcome (modified Rankin Scale (mRS) 0–2), mortality, and mean number of passes and procedure time.

Results

Five non-randomized studies of 2022 patients were included (1083 BGC group and 939 non-BGC group). Compared with the non-BGC group, patients treated with BGCs had higher odds of first-pass recanalization (OR 2.05, 95% CI 1.65 to 2.55), TICI 3 (OR 2.13, 95% CI 1.43 to 3.17), TICI 2b/3 (OR 1.54, 95% CI 1.21 to 1.97), and mRS 0–2 (OR 1.84, 95% CI 1.52 to 2.22). BGC-treated patients also had lower odds of mortality (OR 0.52, 95% CI 0.37 to 0.73) compared with non-BGC patients. The mean number of passes was significantly lower for BGC-treated patients (weighted mean difference −0.34, 95% CI−0.47 to −0.22). Mean procedure time was also significantly shorter for BGC-treated patients (weighted mean difference −7.7 min, 95% CI−9.0to −6.4).

Conclusions

Non-randomized studies suggest that BGC use during mechanical thrombectomy for acute ischemic stroke is associated with superior clinical and angiographic outcomes. Further randomized trials are needed to confirm the results of this study.

Mechanical Thrombectomy in Patients with Acute Ischemic Stroke and Lower NIHSS Scores: Recanalization Rates, Periprocedural Complications, and Clinical Outcome

BACKGROUND AND PURPOSE

Mechanical thrombectomy, in addition to intravenous thrombolysis, has become standard in acute ischemic stroke treatment in patients with large-vessel occlusion in the anterior circulation. However, previous randomized controlled stroke trials were not focused on patients with mild-to-moderate symptoms. Thus, there are limited data for patient selection, prediction of clinical outcome, and occurrence of complications in this patient population. The purpose of this analysis was to assess clinical and interventional data in patients treated with mechanical thrombectomy in case of ischemic stroke with mild-to-moderate symptoms.

MATERIALS AND METHODS

We performed a retrospective analysis of a prospectively collected stroke data base. Inclusion criteria were anterior circulation ischemic stroke treated with mechanical thrombectomy at our institution between September 2010 and October 2015 with an NIHSS score of ≤8.

RESULTS

Of 484 patients, we identified 33 (6.8%) with the following characteristics: median NIHSS = 5 (interquartile range, 4-7), median onset-to-groin puncture time = 320 minutes (interquartile range, 237-528 minutes). Recanalization (TICI = 2b-3) was achieved in 26 (78.7%) patients. Two cases of symptomatic intracranial hemorrhage were observed. Favorable (mRS 0-2) and moderate (mRS 0-3) clinical outcome at 90 days was achieved in 21 (63.6%) and 30 (90.9%) patients, respectively.

CONCLUSIONS

The clinical outcome of patients undergoing mechanical thrombectomy for acute ischemic stroke with mild stroke due to large-vessel occlusion appears to be predominately favorable, even in a prolonged time window. However, although infrequent, angiographic complications could impair clinical outcome. Future randomized controlled trials should assess the benefit compared with the best medical treatment.