Emergent mechanical thrombectomy for acute stroke using the Mindframe Capture LP system: initial single-center experience

Implantation of Large Diameter (5.5-6 mm) Derivo Embolization Devices for the Treatment of Cerebral Aneurysms

BACKGROUND

The efficacy of flow diverters is dependent upon robust wall apposition in the parent artery. Usage in large caliber cerebral vessels has therefore been limited as few implants with diameters > 5 mm exist. We present our initial experience in treating cerebral aneurysms using the 5.5 mm and 6 mm diameter implants of the Derivo embolization device (DED).

METHODS

Our prospectively maintained institutional database was reviewed to identify patients in whom a > 5 mm DED was implanted between November 2016 and February 2021. The primary efficacy outcome was complete or near-complete aneurysm occlusion at 6 months (O'Kelly-Marotta, OKM, C-D, adapted for magnetic resonance angiography). Safety outcomes included 30-day major morbidity defined as modified Rankin Score (mRS) 3-5, mortality, serious adverse events and procedural complications.

RESULTS

A total of 21 large diameter DEDs were deployed in 18 patients (age 59.5 ± 14.1 years), harboring 19 unruptured aneurysms. Of the aneurysms 14 (73.7%) were saccular in morphology (sac diameter 10.9 ± 5.5 mm, neck diameter 6.8 ± 3.1 mm), 3 (15.8%) aneurysms were dissecting, 1 (5.3%) iatrogenic pseudoaneurysm and 1 (5.3%) fusiform. Aneurysm locations were: ICA (internal carotid artery) (n = 17); (7 cavernous, 4 paraophthalmic, 2 paraclinoid, 1 petrous, 2 communicating, 1 cervical); vertebrobasilar (n = 2). Adjunct stenting to optimize proximal wall apposition was undertaken in 5 (27.8%) patients. At 6 months 75% of patients followed-up met the primary efficacy endpoint (OKM C-D). There were no serious adverse events, 30-day major morbidity (mRS 3-5) or mortality.

CONCLUSION

Implantation of large diameter (5.5 mm and 6 mm) DEDs into capacious cerebral vessels to treat a range of complex aneurysms is safe and technically feasible but may require adjunct stenting to optimize proximal wall apposition. Short-term efficacy of this device subset is comparable to previous DED and other flow diverter studies. Long-term follow-up and comparative studies are required for further assessment.

Effectiveness of very low profile thrombectomy device in primary distal medium vessel occlusion, as rescue therapy after incomplete proximal recanalization or following iatrogenic thromboembolic events

Background

Recent progress with smaller retrievers has expanded the ability to reach distal brain arteries. We herein report recanalization, bleeding complications and short-term clinical outcomes with the smallest currently known low profile thrombectomy device in patients with primary or secondary distal medium vessel occlusion (DMVO).

Methods

We performed a retrospective analysis of 115 patients receiving mechanical thrombectomy (MT) in DMVO using the extended Thrombolysis in Cerebral Infarction (eTICI), European Cooperative Acute Stroke Study (ECASS) II classification, The National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) scores at admission and discharge to evaluate outcomes. Patients were stratified into three groups: (1) primary isolated distal occlusion (n=34), (2) secondary distal occlusion after MT of a proximal vessel occlusion (n=71), or (3) during endovascular treatment of aneurysms or arteriovenous malformations (AVMs) (n=10).

Results

Successful distal recanalization, defined as an eTICI score of 2b67, 2c and 3, was achieved in 74.7% (86/115) of patients. More specifically, it was 70.5% (24/34), 73.2% (52/71), and 100% (10/10) of primary DMVO, secondary DMVO after proximal MT, and rescue MT during aneurysm or AVM embolization, respectively. Symptomatic intraparenchymal bleeding occurred in 6.9% (eight patients). In-hospital mortality occurred in 18.1% (19/105) of patients with stroke. The most common cause of death was large infarct, old age, and therapy limitation.

Conclusion

Direct or rescue MT of DMVO using a very low profile thrombectomy device is associated with a high rate of successful recanalization and a reasonable rate of symptomatic hemorrhagic complication, despite a risk of 18.1% hospital mortality in elderly patients. Further trials are needed to confirm our results and assess long-term clinical outcomes.

Mechanical Thrombectomy of Distal Occlusions Using a Direct Aspiration First Pass Technique Compared with New Generation of Mini-0.017 Microcatheter Compatible-Stent Retrievers: A Meta-Analysis

BACKGROUND

There are no current evidence-based recommendations on mechanical thrombectomy (MT) in M2 or other distal occlusions. The objective of this paper was to investigate clinical and radiologic outcomes of MT in distal locations using the new generation of mini-0.017 microcatheter compatible-stent retrievers (SRs) compared with a direct aspiration first pass technique (ADAPT) MT.

METHODS

A systematic search was performed for studies published from January 2016 to March 2019. According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies that reported clinical and radiologic outcomes of patients undergoing MT using new generation of SRs or ADAPT in distal locations. The cumulative prevalence was estimated for each outcome. Heterogeneity of the data was assessed by the Higgins index (I²), and a random-effects model was applied.

RESULTS

Fifteen studies and 494 patients were included; 7 studies reported on patients treated with a new SR and 8 studies analyzed patients treated with ADAPT. The rate of thrombolysis in cerebral infarction score 2b-3 after MT for distal occlusions was 80.6% (383 of 494; 95% confidence interval [CI], 74.8%-86.3%; I² = 64.4%). Successful recanalization was comparable after SR use with low-profile devices and ADAPT (176 of 226; 82%; 95% CI, 72.6%-1.5%; I² = 70.5% vs. 207 of 268; 79.4%; 95% CI, 71.8%-86.9%; I² = 60.8%, respectively; P = 0.4). The rate of the modified Rankin scale score of 0-2 at 3 months was higher in the ADAPT group (160 of 251; 68.9%; 95% CI, 51.8%-85.9%; I² = 92.2%) than the SR group (92 of 177; 58.7%; 95% CI, 37.3%-80%; I² = 58.7%; P = 0.01). The mortality rate was lower among the ADAPT group (20 of 251; 5.4%; 95% CI, 1.4%-9%; I² = 63%) than the SR group (16 of 108; 13%; 95% CI, 6%-19%; I² = 13%; P = 0.008).

CONCLUSIONS

MT in distal locations using the new generation of SR yields comparable results compared with ADAPT in terms of recanalization; however, the use of SR is associated with lower functional independence and higher mortality rate.

Mechanical Thrombectomy: Emerging Technologies and Techniques

BACKGROUND

The treatment of acute ischemic stroke due to large vessel occlusion (LVO) has revolutionized in the last decade. We sought to compile the most relevant literature published about the evolution in treating this disabling and fatal disease.

METHODS

A literature review of recent studies describing early treatment options like intravenous tissue plasminogen activator to the latest mechanical thrombectomy (MT) techniques was performed. We described in a chronological order the evolution of LVO treatment.

RESULTS

Recanalization rates with newer techniques and MT devices approach a 90% of effectiveness. Timely interventions have also resulted in better clinical outcomes with approximately 50% of patient achieving functional independence at 90 days. At least 14 new third generation thrombectomy devices are currently being evaluated in in vitro and clinical studies.

CONCLUSIONS

The treatment of LVO with MT is feasible and safe. MT is standard of care in treating acute ischemic stroke due to LVO.

Reperfusion therapy in acute ischemic stroke: dawn of a new era?

Following the success of recent endovascular trials, endovascular therapy has emerged as an exciting addition to the arsenal of clinical management of patients with acute ischemic stroke (AIS). In this paper, we present an extensive overview of intravenous and endovascular reperfusion strategies, recent advances in AIS neurointervention, limitations of various treatment paradigms, and provide insights on imaging-guided reperfusion therapies. A roadmap for imaging guided reperfusion treatment workflow in AIS is also proposed. Both systemic thrombolysis and endovascular treatment have been incorporated into the standard of care in stroke therapy. Further research on advanced imaging-based approaches to select appropriate patients, may widen the time-window for patient selection and would contribute immensely to early thrombolytic strategies, better recanalization rates, and improved clinical outcomes.

Novel and emerging technologies for endovascular thrombectomy

Endovascular thrombectomy device improvements in recent years have served a pivotal role in improving the success and safety of the thrombectomy procedure. As the intervention gains widespread use, developers have focused on maximizing the reperfusion rates and reducing procedural complications associated with these devices. This has led to a boom in device development. This review will cover novel and emerging technologies developed for endovascular thrombectomy.

Catch Plus thrombectomy device in acute stroke: initial evaluation

OBJECTIVE

To report our initial experience with the Catch Plus thrombectomy device (CPD) in patients with acute ischemic stroke (AIS).

MATERIALS AND METHODS

We retrospectively evaluated the procedural variables as well as the clinical and angiographic outcomes of patients with acute occlusion of a major intracranial artery in the anterior circulation who were treated with CPD at our center. Baseline characteristics (gender, age, comorbidities, cardiovascular risk factors, National Institutes of Health Stroke Scale (NIHSS) score, and vessel occlusion sites) of these patients were recorded. Thrombolysis in Cerebral Infarction (TICI) score, incidence of symptomatic and asymptomatic bleeding, and 90 day modified Rankin Scale (mRS) scores were evaluated as indicators of outcome.

RESULTS

38 patients with a mean age of 67.5 years were treated with CPD. Mean time from symptom onset to procedure initiation was 226.7 min. Recanalization (TICI 2b-3) was achieved in 27 patients (71.1%). The median NIHSS score on admission was 20. Rates of symptomatic and asymptomatic intracerebral hemorrhage were 7.9% and 13.2%, respectively. The 90 day clinical follow-up data were available for 37 patients. The 90 day mortality rate was 18.9%, and the 90 day clinically acceptable functional outcome (mRS score ≤2) rate was 43.2% (mRS score 0-3, 54.1%). Very distal thrombectomy involving the cortical arteries was performed on four patients without complications.

CONCLUSIONS

Our initial experience suggests that mechanical thrombectomy with the CPD improves 90 day outcomes of patients with AIS by facilitating effective recanalization.