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Cimflova P, Singh N, Kappelhof M, Ospel JM, Sehgal A, Kashani N, Almekhlafi MA, Demchuk AM, Berrouschot J, Dorn F, Kelly ME, Buck BH, Field TS, Dowlatshahi D, Tymianski M, Hill MD, Goyal M. Effect of incomplete reperfusion patterns on clinical outcome: insights from the ESCAPE-NA1 trial. J Neurointerv Surg 2024; 16:809-814. [PMID: 37491383 DOI: 10.1136/jnis-2023-020553] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 07/13/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Incomplete reperfusion (IR) after mechanical thrombectomy (MT) can be a consequence of residual occlusion, no-reflow phenomenon, or collateral counterpressure. Data on the impact of these phenomena on clinical outcome are limited. METHODS Patients from the ESCAPE-NA1 trial with IR (expanded Thrombolysis In Cerebral Infarction (eTICI) 2b) were compared with those with complete or near-complete reperfusion (eTICI 2c-3) on the final angiography run. Final runs were assessed for (a) an MT-accessible occlusion, or (b) a non-MT-accessible occlusion pattern. The primary clinical outcome was modified Rankin Scale (mRS) 0-2 at 90 days. Our imaging outcome was infarction in IR territory on follow-up imaging. Unadjusted and adjusted incidence rate ratios (aIRR) with 95% confidence intervals (95% CI) were obtained. RESULTS Of 1105 patients, 443 (40.1%) with IR and 506 (46.1%) with complete or near-complete reperfusion were included. An MT-accessible occlusion was identified in 147/443 patients (33.2%) and a non-MT-accessible occlusion in 296/443 (66.8%). As compared with patients with near-complete/complete reperfusion, patients with IR had significantly lower chances of achieving mRS 0-2 at 90 days (aIRR 0.82, 95% CI 0.74 to 0.91). Rates of mRS 0-2 were lower in the MT-accessible occlusion group as compared with the non-MT-accessible occlusion pattern group (aIRR 0.71, 95% CI 0.60 to 0.83, and aIRR 0.89, 95% CI 0.81 to 0.98, respectively). More patients with MT-accessible occlusion patterns developed infarcts in the non-reperfused territory as compared with patients with non-MT occlusion patterns (68.7% vs 46.3%). CONCLUSION IR was associated with worse clinical outcomes than near-complete/complete reperfusion. Two-thirds of our patients with IR had non-MT-accessible occlusion patterns which were associated with better clinical and imaging outcomes compared with those with MT-accessible occlusion patterns.
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Affiliation(s)
- Petra Cimflova
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medical Imaging and Faculty of Medicine, Masaryk University, St. Anne's University Hospital Brno, Brno, Czechia
| | - Nishita Singh
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Department of Internal Medicine - Neurology division, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Manon Kappelhof
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Johanna M Ospel
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Clinic of Radiology and Nuclear Medicine, Universitatsspital Basel, Basel, Switzerland
| | - Arshia Sehgal
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Nima Kashani
- University of Saskatchewan College of Medicine, Saskatoon, Saskatchewan, Canada
| | - Mohammed A Almekhlafi
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Hotchkis Brain Institute, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada
- Community Health Sciences, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Andrew M Demchuk
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Hotchkis Brain Institute, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Joerg Berrouschot
- Klinik für Neurologie und Neurologische Intensivmedizin, Klinikum Altenburger Land GmbH, Altenburg, Germany
| | - Franziska Dorn
- Klinik für Neuroradiologie, Universitätsklinikum Bonn, Bonn, Germany
| | - Michael E Kelly
- Department of Neurosurgery, University of Saskatchewan College of Medicine, Saskatoon, Saskatchewan, Canada
| | - Brian H Buck
- Division of Neurology, University of Alberta, Edmonton, Alberta, Canada
| | - Thalia S Field
- Division of Neurology, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Dariush Dowlatshahi
- Division of Neurology, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
| | | | - Michael D Hill
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Hotchkis Brain Institute, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada
- Community Health Sciences, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Mayank Goyal
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Hotchkis Brain Institute, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada
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Ikeda H, Kinosada M, Uezato M, Kurosaki Y, Chin M, Yamagata S. Factors related to vessel displacement due to stent retriever retraction: An in vitro study. J Neuroradiol 2024; 51:101194. [PMID: 38637231 DOI: 10.1016/j.neurad.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 03/03/2024] [Accepted: 04/05/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Thrombectomy with a stent retriever (SR) may lead to intracranial hemorrhage due to vessel displacement. We aimed to explore factors related to vessel displacement using an in vitro vessel model. METHODS A vessel model mimicking two-dimensional left internal carotid angiography findings was used in this study. Six SR types (Solitaire 3 × 40, 4 × 40, and 6 × 40; Embotrap 5 × 37; Trevo 4 × 41; and Tron 4 × 40) were fully deployed in the M2 ascending, M2 bend, or M1 horizontal portion. Subsequently, the SR was retracted, and the vessel displacement, maximum SR retraction force, and angle of the M2 bend portion were measured. A total of 180 SR retraction experiments were conducted using 6 SR types at 3 deployment positions with 10 repetitions each. RESULTS The mean maximum distance of vessel displacement for Embotrap Ⅲ 5 × 37 (6.4 ± 3.5 mm, n = 30) was significantly longer than that for the other five SR types (p = 0.029 for Solitaire 6 × 40 and p < 0.001 for the others, respectively). Vessel displacement was significantly longer in the M2 ascending portion group (5.4 ± 3.0 mm, n = 60) than in the M2 bend portion group (3.3 ± 1.6 mm, n = 60) (p < 0.001) and it was significantly longer in the M2 bend portion group than in the M1 horizontal portion group (1.1 ± 0.7 mm, n = 60) (p < 0.001). A positive correlation existed between the mean maximum SR retraction force or mean angle of the M2 bend portion due to SR retraction (i.e., vessel straightening) and the mean maximum distance of vessel displacement (r = 0.90, p < 0.001; r = 0.90, p < 0.001, respectively). CONCLUSIONS Vessel displacement varied with the SR type, size, and deployment position. Moreover, vessel displacement correlated with the SR retraction force or vessel straightening of the M2 bend portion.
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Affiliation(s)
- Hiroyuki Ikeda
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan.
| | - Masanori Kinosada
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Minami Uezato
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Yoshitaka Kurosaki
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Masaki Chin
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Sen Yamagata
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
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Ohshima T, Miyachi S. Repeated Middle Cerebral Artery Occlusion Possibly Caused by Endoluminal Injury Due to Stent Clot Retriever: A Case Report. Asian J Neurosurg 2024; 19:301-304. [PMID: 38974445 PMCID: PMC11226273 DOI: 10.1055/s-0044-1787083] [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] [Indexed: 07/09/2024] Open
Abstract
In acute ischemic stroke, various endovascular approaches have been reported with high recanalization rates and good clinical outcomes. However, the best device or technique for the first attempt at mechanical thrombectomy remains a matter of debate. We report a case in which endoluminal injury from initial stent clot retrieval possibly caused repeated middle cerebral artery occlusion. A 74-year-old man presented with left-sided hemiplegia and was diagnosed with a right internal carotid artery occlusion. He underwent endovascular thrombectomy using a stent clot retriever. Although complete recanalization was achieved in the first pass, repeated middle cerebral artery occlusion occurred. Angiography revealed an irregular inner surface and thrombus formation in the superior branch of the second segment of the right middle cerebral artery. There is a risk of endoluminal injury due to stent retrieval, especially using a large sized stent against small branches. Antiplatelet therapy may be effective for preventing recurrent occlusion. Key Messages We report a case in which endoluminal injury from initial stent clot retrieval possibly caused repeated middle cerebral artery occlusion. There is a risk of endoluminal injury due to stent retrieval, especially using a large sized stent against nonvisible small branches.
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Affiliation(s)
- Tomotaka Ohshima
- Neuroendovascular Therapy Center, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi, Japan
| | - Shigeru Miyachi
- Neuroendovascular Therapy Center, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi, Japan
- Department of Neurosurgery, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi, Japan
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Li J, Tiberi R, Bhogal P, Buhk JH, Behme D, Tomasello A, Ribo M. Impact of stent-retriever tip design on distal embolization during mechanical thrombectomy: a randomized in vitro evaluation. J Neurointerv Surg 2024; 16:285-289. [PMID: 37147003 DOI: 10.1136/jnis-2023-020382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 04/25/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND Repeated number of passes, clot fragmentation, and distal embolization during mechanical thrombectomy (MT) lead to worse clinical outcomes in acute ischemic stroke. This study aimed to assess the recanalization and embolic outcomes of different stent-retrievers (SRs): open-tip SR (Solitaire X 6×40 mm), closed-tip SR (EmboTrap II 5×33 mm), and filter-tip SR (NeVa NET 5.5×37 mm). METHODS Stiff-friable clot analogs were used to create middle cerebral artery (M1-MCA) occlusions in a benchtop model. After occlusion, experiments were randomized into one of the three treatment arms. The thrombectomy technique consisted of retrieving the SR into a balloon guide catheter under proximal flow arrest and continuous aspiration. A total of 150 single-attempt cases were performed (50 cases/treatment arm). Distal emboli (>100 µm) were collected and analyzed after each experiment. RESULTS Filter-tip SR achieved a non-significantly higher first-pass recanalization rate than open-tip SR and closed-tip SR (66% vs 48% vs 44%; P=0.064). Filter-tip SR prevented clot fragments>1 mm from embolizing distal territories in 44% of cases, compared with 16% in open-tip SR and 20% in closed-tip (P=0.003). There were no significant differences between treatment arms in terms of total emboli count (open-tip=19.2±13.1, closed-tip=19.1±10.7, filter-tip=17.2±13.0; P=0.660). Nonetheless, the number of large emboli (>1 mm) and total area of emboli were significantly lower in the filter-tip arm (n=0.88±1.2, A=2.06±1.85 mm2) than in the closed-tip arm (n=2.34±3.38, A=4.06±4.80 mm2; P<0.05). CONCLUSIONS When facing fragment-prone clots, the filter-tip SR significantly reduces the number of large clots (>1 mm) that embolize distally during an MT procedure, which in turn may increase the chances of first-pass complete recanalization.
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Affiliation(s)
- Jiahui Li
- Stroke Research, Vall d'Hebron Research Institute, Barcelona, Spain
- Stroke Unit, Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Riccardo Tiberi
- Stroke Research, Vall d'Hebron Research Institute, Barcelona, Spain
- Stroke Unit, Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Pervinder Bhogal
- Neuroradiology, The Royal London Hospital, Barts NHS Trust, London, UK
| | - Jan-Hendrik Buhk
- Neuroradiology, Asklepios Hospital Hamburg St Georg, Hamburg, Germany
| | - Daniel Behme
- Neuroradiology, University Medical Center Magdeburg, Magdeburg, Germany
| | - Alejandro Tomasello
- Stroke Research, Vall d'Hebron Research Institute, Barcelona, Spain
- Interventional Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Marc Ribo
- Stroke Research, Vall d'Hebron Research Institute, Barcelona, Spain
- Stroke Unit, Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
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Goertz L, Weiss D, Abdullayev N, Moenninghoff C, Borggrefe J, Phung TH, Haage P, Schlamann M, Dorn F, Kaschner M, Kabbasch C, Nordmeyer H. Safety and Efficacy of the Novel Low-Profile APERIO Hybrid 17 for a Treatment of Proximal and Distal Vessel Occlusion in Acute Ischemic Stroke: A Multi-Center Experience. World Neurosurg 2022; 167:e386-e396. [PMID: 35963612 DOI: 10.1016/j.wneu.2022.08.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/04/2022] [Accepted: 08/05/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVE To report our initial experience with the novel low-profile APERIO Hybrid17 Thrombectomy Device (AP17) for proximal and distal vessel occlusions in acute ischemic stroke. METHODS A multicentric retrospective analysis of patients treated with the AP17 was performed. The primary effectiveness endpoint was first-pass TICI ≥2b (Thrombolysis in cerebral infarction scale). The primary safety endpoint was the occurrence of hemorrhagic complications. Further outcome measures were number of passes, device-related complications, and 3-month functional outcome. RESULTS The AP17 was used in 71 patients (mean age: 73 years) with a median baseline National Institutes of Health Stroke Scale score of 9. Treated vessels were the carotid-T in 8 cases (11%), the M1-segment in 16 (23%), the M2-segment in 29 (41%), the anterior cerebral artery in 3 (4%), and basilar/posterior cerebral arteries in 15 (21%). The rates of first-pass and final TICI ≥2b were 75.6% and 92.7%, retrospectively, with a mean number of passes of 3 ± 2. Final TICI ≥2b rates were comparable between large and medium vessel occlusions. Symptomatic intracranial hemorrhages were recorded in 2 cases (2.8%). At 3-month clinical follow-up, a modified Rankin scale score ≤2 was achieved in 69.0% (29/42). The all-cause mortality at discharge was 17.4%. CONCLUSIONS The AP17 was associated with a reasonable safety and efficacy profile for both proximal and distal vessel occlusions. These results may contribute to establish mechanical thrombectomy for distal occlusions.
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Affiliation(s)
- Lukas Goertz
- Department of Neuroradiology, Medical Faculty and University Hospital, University of Cologne, Cologne, Germany.
| | - Daniel Weiss
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Düsseldorf, Germany
| | - Nuran Abdullayev
- Department of Neuroradiology, Medical Faculty and University Hospital, University of Cologne, Cologne, Germany
| | - Christoph Moenninghoff
- University Institute for Radiology, Neuroradiology and Nuclear Medicine, Johannes Wesling Klinikum Minden, Minden, Germany
| | - Jan Borggrefe
- University Institute for Radiology, Neuroradiology and Nuclear Medicine, Johannes Wesling Klinikum Minden, Minden, Germany
| | - Timo Huan Phung
- Institute for interventional Radiology and Neuroradiology, Neurozentrum Solingen, Radprax St. Lukas Hospital, Solingen, Germany
| | - Patrick Haage
- Department of Diagnostic and Interventional Radiology, Helios University Hospital, Wuppertal, Germany; School of Medicine, Department of Health, Witten/Herdecke University, Witten, Germany
| | - Marc Schlamann
- Department of Neuroradiology, Medical Faculty and University Hospital, University of Cologne, Cologne, Germany
| | - Franziska Dorn
- Department of Neuroradiology, Medical Faculty and University Hospital, University of Bonn, Bonn, Germany
| | - Marius Kaschner
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Düsseldorf, Germany
| | - Christoph Kabbasch
- Department of Neuroradiology, Medical Faculty and University Hospital, University of Cologne, Cologne, Germany
| | - Hannes Nordmeyer
- Institute for interventional Radiology and Neuroradiology, Neurozentrum Solingen, Radprax St. Lukas Hospital, Solingen, Germany; School of Medicine, Department of Health, Witten/Herdecke University, Witten, Germany
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Froehler MT, Good B. Safety of thrombectomy for medium vessel occlusions. Interv Neuroradiol 2022:15910199221127757. [PMID: 36120857 DOI: 10.1177/15910199221127757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Michael T Froehler
- Cerebrovascular Program, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Bryan Good
- Department of Mechanical, Aerospace, and Biomedical Engineering, 122608University of Tennessee, Knoxville, TN, USA
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Safety of Sheathless Transradial Balloon Guide Catheter Placement for Acute Stroke Thrombectomy. World Neurosurg 2022; 165:e235-e241. [PMID: 35691519 DOI: 10.1016/j.wneu.2022.06.016] [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: 03/29/2022] [Revised: 06/02/2022] [Accepted: 06/02/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Transradial access has been described for mechanical thrombectomy in acute stroke, and proximal balloon occlusion has been shown to improve recanalization and outcomes. However, sheathed access requires a larger total catheter diameter at the access site. We aimed to characterize the safety of sheathless transradial balloon guide catheter use in acute stroke intervention. METHODS Consecutive patients who underwent sheathless right-sided transradial access for thrombectomy with a balloon guide catheter were identified in a prospectively collected dataset from 2019 to 2021. Demographics, procedure details, and short-term outcomes were collected and reported with descriptive statistics. RESULTS A total of 48 patients (20 women) with a mean age of 72.3 years were identified. Of patients, 56.3% had occlusions in the left-sided circulation; 35 (72.9%) had M1 occlusions, 7 (14.6%) had M2 occlusions, and 6 (12.5%) had internal carotid artery occlusions. Tissue plasminogen activator was administered to 16 (33.3%) patients. Five (10.4%) patients underwent intraprocedural carotid stenting. The cohort had successful reperfusion after a median of 1 (interquartile range: 1, 2) pass. Median time from access to recanalization was 31 (interquartile range: 25, 53) minutes. A postprocedural Thrombolysis In Cerebral Infarction score of ≥2b was achieved in 46 (95.8%) patients. Five patients had wrist access site hematomas. All hematomas resolved with warm compresses, and no further intervention was required. CONCLUSIONS Sheathless radial access using a balloon guide catheter may be safely performed for acute ischemic stroke with excellent radiographic outcomes. Further investigation is warranted to evaluate the comparative effectiveness of sheathless compared with sheathed transradial balloon guide access.
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Luraghi G, Bridio S, Migliavacca F, Rodriguez Matas JF. Self-expandable stent for thrombus removal modeling: Solid or beam finite elements? Med Eng Phys 2022; 106:103836. [PMID: 35926960 DOI: 10.1016/j.medengphy.2022.103836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 06/09/2022] [Accepted: 06/13/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND The performance of self-expandable stents is being increasingly studied by means of finite-element analysis. As for peripheral stents, transcatheter valves and stent-grafts, there are numerous computational studies for setting up a proper model, this information is missing for stent-retrievers used in the procedure of thrombus removal in cerebral arteries. It is well known that the selection of the appropriate finite-element dimensions (topology) and formulations (typology) is a fundamental step to set up accurate and reliable computational simulations. In this context, a thorough verification analysis is here proposed, aimed at investigating how the different element typologies and topologies - available to model a stent-retriever - affect simulation results. METHOD Hexahedral and beam element formulations were analyzed first individually by virtually replicating a crimping test on the device, and then by replicating the thrombectomy procedure aiming at removing a thrombus from a cerebral vessel. In particular, three discretization refinements for each element type and different element formulations including both full and reduced integration were investigated and compared in terms of the resultant radial force of the stent and the stress field generated in the thrombus. RESULTS The sensitivity analysis on the element formulation performed with the crimping simulations allowed the identification of the optimal setting for each element family. Both setting lead to similar results in terms of stent performance in the virtual thrombectomy and should be used in future studies simulating the mechanical thrombectomy with stent-retrievers. CONCLUSIONS The carried out virtual thrombectomy procedures confirmed that the beam element formulation results were sufficiently accurate to model the radial force and the performance of the stent-retriever during the procedure. For different self-expandable stents, hexahedral formulation could be essential in stress analysis.
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Affiliation(s)
- Giulia Luraghi
- Department of Chemistry, Materials and Chemical Engineering, Politecnico di Milano, Piazza L. da Vinci 32, 20133 Milan, Italy.
| | - Sara Bridio
- Department of Chemistry, Materials and Chemical Engineering, Politecnico di Milano, Piazza L. da Vinci 32, 20133 Milan, Italy
| | - Francesco Migliavacca
- Department of Chemistry, Materials and Chemical Engineering, Politecnico di Milano, Piazza L. da Vinci 32, 20133 Milan, Italy
| | - Jose Felix Rodriguez Matas
- Department of Chemistry, Materials and Chemical Engineering, Politecnico di Milano, Piazza L. da Vinci 32, 20133 Milan, Italy
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Wang T, Ugurlu H, Yan Y, Li M, Li M, Wild AM, Yildiz E, Schneider M, Sheehan D, Hu W, Sitti M. Adaptive wireless millirobotic locomotion into distal vasculature. Nat Commun 2022; 13:4465. [PMID: 35915075 PMCID: PMC9343456 DOI: 10.1038/s41467-022-32059-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 07/14/2022] [Indexed: 11/23/2022] Open
Abstract
Microcatheters have enabled diverse minimally invasive endovascular operations and notable health benefits compared with open surgeries. However, with tortuous routes far from the arterial puncture site, the distal vascular regions remain challenging for safe catheter access. Therefore, we propose a wireless stent-shaped magnetic soft robot to be deployed, actively navigated, used for medical functions, and retrieved in the example M4 segment of the middle cerebral artery. We investigate shape-adaptively controlled locomotion in phantoms emulating the physiological conditions here, where the lumen diameter shrinks from 1.5 mm to 1 mm, the radius of curvature of the tortuous lumen gets as small as 3 mm, the lumen bifurcation angle goes up to 120°, and the pulsatile flow speed reaches up to 26 cm/s. The robot can also withstand the flow when the magnetic actuation is turned off. These locomotion capabilities are confirmed in porcine arteries ex vivo. Furthermore, variants of the robot could release the tissue plasminogen activator on-demand locally for thrombolysis and function as flow diverters, initiating promising therapies towards acute ischemic stroke, aneurysm, arteriovenous malformation, dural arteriovenous fistulas, and brain tumors. These functions should facilitate the robot’s usage in new distal endovascular operations. Accessibility into the distal vascular systems to treat various diseases remains challenging using medical catheters. Here, Wang et al. demonstrate that a stent-shaped wireless magnetic soft robot enables adaptive locomotion and medical functions into these distal vascular regions.
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Affiliation(s)
- Tianlu Wang
- Physical Intelligence Department, Max Planck Institute for Intelligent Systems, 70569, Stuttgart, Germany.,Department of Information Technology and Electrical Engineering, ETH Zurich, 8092, Zurich, Switzerland
| | - Halim Ugurlu
- Physical Intelligence Department, Max Planck Institute for Intelligent Systems, 70569, Stuttgart, Germany.,Clinic for Neuroradiology, Klinikum Stuttgart, 70174, Stuttgart, Germany.,Department of Biophysics, Aydın Adnan Menderes University, Graduate School of Health Sciences, 09010, Aydın, Turkey
| | - Yingbo Yan
- Physical Intelligence Department, Max Planck Institute for Intelligent Systems, 70569, Stuttgart, Germany
| | - Mingtong Li
- Physical Intelligence Department, Max Planck Institute for Intelligent Systems, 70569, Stuttgart, Germany
| | - Meng Li
- Physical Intelligence Department, Max Planck Institute for Intelligent Systems, 70569, Stuttgart, Germany
| | - Anna-Maria Wild
- Physical Intelligence Department, Max Planck Institute for Intelligent Systems, 70569, Stuttgart, Germany
| | - Erdost Yildiz
- Physical Intelligence Department, Max Planck Institute for Intelligent Systems, 70569, Stuttgart, Germany
| | - Martina Schneider
- Physical Intelligence Department, Max Planck Institute for Intelligent Systems, 70569, Stuttgart, Germany
| | - Devin Sheehan
- Physical Intelligence Department, Max Planck Institute for Intelligent Systems, 70569, Stuttgart, Germany
| | - Wenqi Hu
- Physical Intelligence Department, Max Planck Institute for Intelligent Systems, 70569, Stuttgart, Germany.
| | - Metin Sitti
- Physical Intelligence Department, Max Planck Institute for Intelligent Systems, 70569, Stuttgart, Germany. .,Department of Information Technology and Electrical Engineering, ETH Zurich, 8092, Zurich, Switzerland. .,School of Medicine and College of Engineering, Koç University, 34450, Istanbul, Turkey.
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10
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Hernández D, Cuevas JL, Gramegna LL, Requena M, Piñana C, de Dios M, Coscojuela P, Esteves M, Li J, Gil A, Ribó M, Tomasello A. Increased Number of Passes and Double Stent Retriever Technique Induces Cumulative Injury on Arterial Wall After Mechanical Thrombectomy in a Swine Model. Transl Stroke Res 2022; 14:425-433. [PMID: 35672562 DOI: 10.1007/s12975-022-01044-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/25/2022] [Accepted: 05/30/2022] [Indexed: 11/27/2022]
Abstract
The number of stentriever passes during endovascular thrombectomy impacts clinical outcomes in acute ischemic stroke. Previous studies suggest that the simultaneous double stent retriever technique (DSRT) could improve the efficacy and reduce the number of passes. We aim to analyze the degree of vessel wall injury according to the number of passes and technique (single vs. simultaneous devices). Histological changes were evaluated in renal arteries (RAs) of swine models after thrombectomy (1, 2, or 3 passes) with single stent (SSRT) and DSRT. Thrombectomy passes were performed in 12 RA: 3 samples from each artery were studied by optical microscopy to assess a vascular damage score. All thirty-six samples showed endothelial denudation and different degrees of damage in the deepest layers of the arterial wall; however, all arteries remained patent by the time of assessment. In all cases, the degree of vascular injury increased with the number of passes. Compared with a SSRT, DSRT showed a higher severity of histological damage corresponding to the damage caused by 1.4 SSRT passes. However, in distal arteries, vascular damage was relatively similar when comparing SSRT with multiple passes and DSRT with one pass. The degree of vessel injury increases with the number of passes. Even though histological damage per pass was 1.4 higher with DSRT than SSRT, short-term vessel patency was not compromised after up to 3 DSRT passes. Further studies are needed to characterize the risk-benefit ratio of the DSRT in routine clinical practice.
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Affiliation(s)
- David Hernández
- Interventional Neuroradiology Section, Vall d'Hebron University Hospital, Pg Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - José Luis Cuevas
- Neurosurgery and Interventional Neuroradiology, Hospital de Puerto Montt, Puerto Montt, Chile
- Vall d'Hebron Research Institute, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Laura Ludovica Gramegna
- Department of Biomedical and Motor Sciences, University of Bologna, Bologna, Italy
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy
| | - Manuel Requena
- Interventional Neuroradiology Section, Vall d'Hebron University Hospital, Pg Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Stroke Unit, Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Carlos Piñana
- Interventional Neuroradiology Section, Vall d'Hebron University Hospital, Pg Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Marta de Dios
- Interventional Neuroradiology Section, Vall d'Hebron University Hospital, Pg Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Pilar Coscojuela
- Interventional Neuroradiology Section, Vall d'Hebron University Hospital, Pg Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Marielle Esteves
- Vall d'Hebron Research Institute, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Jiahui Li
- Vall d'Hebron Research Institute, Vall d'Hebron University Hospital, Barcelona, Spain
- Stroke Unit, Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Alberto Gil
- Interventional Neuroradiology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Marc Ribó
- Vall d'Hebron Research Institute, Vall d'Hebron University Hospital, Barcelona, Spain
- Stroke Unit, Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Alejandro Tomasello
- Interventional Neuroradiology Section, Vall d'Hebron University Hospital, Pg Vall d'Hebron 119-129, 08035, Barcelona, Spain.
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11
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Lu J, Hu X, Yuan T, Cao J, Zhao Y, Xiong C, Li K, Ye X, Xu T, Zhao J. 3D-Printed Poly (P-Dioxanone) Stent for Endovascular Application: In Vitro Evaluations. Polymers (Basel) 2022; 14:polym14091755. [PMID: 35566924 PMCID: PMC9103802 DOI: 10.3390/polym14091755] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/13/2022] [Accepted: 04/19/2022] [Indexed: 02/04/2023] Open
Abstract
Rapid formation of innovative, inexpensive, personalized, and quickly reproducible artery bioresorbable stents (BRSs) is significantly important for treating dangerous and sometimes deadly cerebrovascular disorders. It is greatly challenging to give BRSs excellent mechanical properties, biocompatibility, and bioabsorbability. The current BRSs, which are mostly fabricated from poly-l-lactide (PLLA), are usually applied to coronary revascularization but may not be suitable for cerebrovascular revascularization. Here, novel 3D-printed BRSs for cerebrovascular disease enabling anti-stenosis and gradually disappearing after vessel endothelialization are designed and fabricated by combining biocompatible poly (p-dioxanone) (PPDO) and 3D printing technology for the first time. We can control the strut thickness and vessel coverage of BRSs by adjusting the printing parameters to make the size of BRSs suitable for small-diameter vascular use. We added bis-(2,6-diisopropylphenyl) carbodiimide (commercial name: stabaxol®-1) to PPDO to improve its hydrolytic stability without affecting its mechanical properties and biocompatibility. In vitro cell experiments confirmed that endothelial cells can be conveniently seeded and attached to the BRSs and subsequently demonstrated good proliferation ability. Owing to the excellent mechanical properties of the monofilaments fabricated by the PPDO, the 3D-printed BRSs with PPDO monofilaments support desirable flexibility, therefore offering a novel BRS application in the vascular disorders field.
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Affiliation(s)
- Junlin Lu
- Beijing Tiantan Hospital, Department of Neurosurgery, Capital Medical University, Beijing 100070, China; (J.L.); (Y.Z.)
| | - Xulin Hu
- Clinical Medical College & Affiliated Hospital of Chengdu University, Chengdu University, Chengdu 610081, China; (X.H.); (K.L.)
| | - Tianyu Yuan
- State Key Laboratory for Turbulence and Complex Systems, Department of Mechanics and Engineering Science, College of Engineering, Peking University, Beijing 100871, China;
| | - Jianfei Cao
- School of Materials and Environmental Engineering, Chengdu Technology University, Chengdu 610041, China;
| | - Yuanli Zhao
- Beijing Tiantan Hospital, Department of Neurosurgery, Capital Medical University, Beijing 100070, China; (J.L.); (Y.Z.)
- Beijing Translational Engineering Enter for 3D Printer in Clinical Neuroscience, Beijing 100070, China
| | - Chengdong Xiong
- Chengdu Institute of Organic Chemistry, Chinese Academy of Sciences, Chengdu 610041, China;
| | - Kainan Li
- Clinical Medical College & Affiliated Hospital of Chengdu University, Chengdu University, Chengdu 610081, China; (X.H.); (K.L.)
| | - Xun Ye
- Beijing Tiantan Hospital, Department of Neurosurgery, Capital Medical University, Beijing 100070, China; (J.L.); (Y.Z.)
- Beijing Translational Engineering Enter for 3D Printer in Clinical Neuroscience, Beijing 100070, China
- Correspondence: (X.Y.); (T.X.); (J.Z.)
| | - Tao Xu
- Department of Mechanical Engineering, Tsinghua University, Beijing 100084, China
- Bio-Intelligent Manufacturing and Living Matter Bioprinting Center, Research Institute of Tsinghua University in Shenzhen, Tsinghua University, Shenzhen 518057, China
- East China Institute of Digital Medical Engineering, Shangrao 334000, China
- Correspondence: (X.Y.); (T.X.); (J.Z.)
| | - Jizong Zhao
- Beijing Tiantan Hospital, Department of Neurosurgery, Capital Medical University, Beijing 100070, China; (J.L.); (Y.Z.)
- Beijing Translational Engineering Enter for 3D Printer in Clinical Neuroscience, Beijing 100070, China
- Correspondence: (X.Y.); (T.X.); (J.Z.)
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12
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Aspects of ischemic stroke biomechanics derived using ex-vivo and in-vitro methods relating to mechanical thrombectomy. J Biomech 2021; 131:110900. [PMID: 34954526 DOI: 10.1016/j.jbiomech.2021.110900] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 10/01/2021] [Accepted: 12/02/2021] [Indexed: 12/11/2022]
Abstract
Establishing the underlying biomechanics of acute ischemic stroke (AIS) and its treatment is fundamental to developing more effective clinical treatments for one of society's most impactful diseases. Recent changes in AIS management, driven by clinical evidence of improved treatments, has already led to a rapid rate of innovation, which is likely to be sustained for many years to come. These unprecedented AIS triage and treatment innovations provide a great opportunity to better understand the disease. In this article we provide a perspective on the recreation of AIS in the laboratory to inform contemporary device design and procedural techniques in mechanical thrombectomy. Presentation of these findings, which have been used to solve the applied problem of designing mechanical thrombectomy devices, is intended to help inform the development of basic biomechanics solutions for AIS.
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13
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Cimflova P, McDonough R, Kappelhof M, Singh N, Kashani N, Ospel JM, Demchuk AM, Menon BK, Chen M, Sakai N, Fiehler J, Goyal M. Perceived Limits of Endovascular Treatment for Secondary Medium-Vessel-Occlusion Stroke. AJNR Am J Neuroradiol 2021; 42:2188-2193. [PMID: 34711552 DOI: 10.3174/ajnr.a7327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/18/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Thrombus embolization during mechanical thrombectomy occurs in up to 9% of cases, making secondary medium vessel occlusions of particular interest to neurointerventionalists. We sought to gain insight into the current endovascular treatment approaches for secondary medium vessel occlusion stroke in an international case-based survey because there are currently no clear recommendations for endovascular treatment in these patients. MATERIALS AND METHODS Survey participants were presented with 3 cases involving secondary medium vessel occlusions, each consisting of 3 case vignettes with changes in the patient's neurologic status (improvement, no change, unable to assess). Multivariable logistic regression analyses clustered by the respondent's identity were used to assess factors influencing the decision to treat. RESULTS In total, 366 physicians (56 women, 308 men, 2 undisclosed) from 44 countries provided 3294 responses to 9 scenarios. Most (54.1%, 1782/3294) were in favor of endovascular treatment. Participants were more likely to treat occlusions in the anterior M2/3 (74.3%; risk ratio = 2.62; 95% CI, 2.27-3.03) or A3 (59.7%; risk ratio = 2.11; 95% CI, 1.83-2.42) segment compared with the M3/4 segment (28.3%; reference). Physicians were less likely to pursue endovascular treatment in patients who showed neurologic improvement than in patients with an unchanged neurologic deficit (49.9% versus 57.0% responses in favor of endovascular treatment, respectively; risk ratio = 0.88, 95% CI, 0.83-0.92). Interventionalists and more experienced physicians were more likely to treat secondary medium vessel occlusions. CONCLUSIONS Physicians' willingness to treat secondary medium vessel occlusions endovascularly is limited and varies per occlusion location and change in neurologic status. More evidence on the safety and efficacy of endovascular treatment for secondary medium vessel occlusion stroke is needed.
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Affiliation(s)
- P Cimflova
- From the Departments of Clinical Neurosciences (P.C., N.S., A.M.D., B.K.M., M.G.).,Department of Medical Imaging (P.C.), St. Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - R McDonough
- Diagnostic Imaging (R.M., M.K., N.K., M.G.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada.,Department of Diagnostic and Interventional Neuroradiology (R.M., J.F.), University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - M Kappelhof
- Diagnostic Imaging (R.M., M.K., N.K., M.G.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada.,Department of Radiology and Nuclear Medicine (M.K.), University of Amsterdam, Amsterdam, the Netherlands
| | - N Singh
- From the Departments of Clinical Neurosciences (P.C., N.S., A.M.D., B.K.M., M.G.)
| | - N Kashani
- Diagnostic Imaging (R.M., M.K., N.K., M.G.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - J M Ospel
- Division of Neuroradiology (J.M.O.), Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - A M Demchuk
- From the Departments of Clinical Neurosciences (P.C., N.S., A.M.D., B.K.M., M.G.).,Hotchkiss Brain Institute (A.M.D.), Cumming School of Medicine, University of Calgary, Canada
| | - B K Menon
- From the Departments of Clinical Neurosciences (P.C., N.S., A.M.D., B.K.M., M.G.)
| | - M Chen
- Department of Neurological Sciences (M.C.), Rush University Medical Center, Chicago, Illinois
| | - N Sakai
- Department of Neurosurgery (N.S.), Kobe City Medical Centre General Hospital, Kobe, Japan
| | - J Fiehler
- Department of Diagnostic and Interventional Neuroradiology (R.M., J.F.), University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - M Goyal
- From the Departments of Clinical Neurosciences (P.C., N.S., A.M.D., B.K.M., M.G.) .,Diagnostic Imaging (R.M., M.K., N.K., M.G.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
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14
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The Tigertriever 13 for mechanical thrombectomy in distal and medium intracranial vessel occlusions. Neuroradiology 2021; 64:775-783. [PMID: 34623479 DOI: 10.1007/s00234-021-02792-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 08/14/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE To report our two-center initial experience using the Tigertriever 13 in the treatment of acute stroke of distal, medium vessel occlusions (DMVO). METHODS We performed a retrospective analysis of all patients treated by mechanical thrombectomy using the Tigertriever 13 device (a manually expandable low profile stent retriever) due to an acute DMVO. Locations included the anterior, middle, and posterior cerebral artery in the A2 and A3, the M3 and M4, and the P2 or P3 segment and the superior cerebellar artery. RESULTS Forty-three patients with 45 DMVOs underwent MTE using the Tigertriever 13 with the intention-to-treat approach between May 2019 and December 2020. After a median of two thrombectomy maneuvers, the successful recanalization rate (mTICI 2b-3) was 84.4% (38/45) with a first pass effect of 26.7% (12/45). The rate of symptomatic intracranial hemorrhages (sICH) and subarachnoid hemorrhages (SAH) was 7.0% (3/43) and 14.0% (6/43), respectively. At discharge, 53.5% (23/43) of the patients had a favorable clinical outcome (mRS 0-2). CONCLUSION Mechanical thrombectomy in DMVOs using the Tigertriever 13 leads to high recanalization rates. The incidence of mostly asymptomatic hemorrhagic events appears higher compared to MTE procedures in LVOs. Further studies will help to identify anatomic and clinical criteria to define a guideline for MTE in DMVOs.
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15
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Moran J, Lookstein RA, Ranade M. Peripheral Non-cerebrovascular Arterial Stent Retriever Applications. Vasc Endovascular Surg 2021; 56:62-69. [PMID: 34266315 DOI: 10.1177/15385744211028727] [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: 11/15/2022]
Abstract
Several treatment options exist for acute intra-abdominal arterial thromboembolic events, including systemic thrombolytics, endovascular therapy, and less commonly surgery. A novel alternative treatment intervention for acute intra-abdominal arterial thrombus is the use of stent retriever (SR) devices, tools traditionally applied for treatment of acute vascular thrombosis in stroke patients. This brief report presents two cases of acute intra-abdominal arterial thrombosis successfully managed by deployment of SRs. Furthermore, it details the history, device mechanism, and design of SRs and describes cases in literature involving effective extracranial SR application.
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Affiliation(s)
- Jacxelyn Moran
- Icahn School of Medicine, Mount Sinai West Hospital, NewYork, NY, USA
| | | | - Mona Ranade
- David Geffen School of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
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16
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Kalousek V, Yoo AJ, Sheth SA, Janardhan V, Mamic J, Janardhan V. Cyclical aspiration using a novel mechanical thrombectomy device is associated with a high TICI 3 first pass effect in large-vessel strokes. J Neuroimaging 2021; 31:912-924. [PMID: 34101284 PMCID: PMC8519104 DOI: 10.1111/jon.12889] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 05/13/2021] [Accepted: 05/14/2021] [Indexed: 01/01/2023] Open
Abstract
Background and Purpose Complete reperfusion (TICI 3) after the first thrombectomy attempt or first pass effect (FPE) is associated with best clinical outcomes in large‐vessel occlusion (LVO) acute ischemic stroke. While endovascular therapy techniques have improved substantially, FPE remains low (24–30%), and new methods to improve reperfusion efficiency are needed. Methods In a prospective observational cohort study, 40 consecutive patients underwent cyclical aspiration thrombectomy using CLEARTM Aspiration System (Insera Therapeutics Inc., Dallas, TX). Primary outcome included FPE with complete/near‐complete reperfusion (TICI 2c/3 FPE). Secondary outcomes included early neurological improvement measured by the National Institute of Health Stroke Scale (NIHSS), safety outcomes, and functional outcomes using modified Rankin Scale (mRS). Outcomes were compared against published historical controls. Results Among 38 patients who met criteria for LVO, median age was 75 (range 31–96). FPE was high (TICI 3: 26/38 [68%], TICI 2c/3: 29/38 [76%]). Among anterior circulation strokes, core lab‐adjudicated FPE remained high (TICI 3: 17/29 [59%], TICI 2c/3: 20/29 [69%]), with excellent final successful revascularization results (Final TICI 3: 24/29 [83%], Final TICI 2c/3: 27/29 [93%]). FPE in the CLEAR‐1 cohort was significantly higher compared to FPE using existing devices (meta‐analysis) from historical controls (TICI 2c/3: 76% vs. 28%, p = 0.0001). High rates of early neurological improvement were observed (delta NIHSS≥4: 35/38 [92.1%]; delta NIHSS≥10: 27/38 [71%]). Similarly, high rates of good functional outcomes (mRS 0–2: 32/38 [84%]) and low mortality (2/38 [5%]) were observed. Conclusion Cyclical aspiration using the CLEARTM Aspiration System is safe, effective, and achieved a high TICI 3 FPE for large‐vessel strokes.
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Affiliation(s)
- Vladimir Kalousek
- Department of Radiology, Zagreb, Croatia.,University Hospital Center 'Sestre Milosrdnice', Zagreb, Croatia
| | - Albert J Yoo
- Texas Stroke Institute, Dallas-Fort Worth, Texas.,Medical City Plano, Medical City Healthcare, Plano, Texas, USA
| | - Sunil A Sheth
- Department of Neurology, UTHealth McGovern Medical School, Houston, Texas, USA
| | | | - Josip Mamic
- Department of Radiology, Zagreb, Croatia.,University Hospital Center 'Sestre Milosrdnice', Zagreb, Croatia
| | - Vallabh Janardhan
- Medical City Plano, Medical City Healthcare, Plano, Texas, USA.,Insera Therapeutics, Inc., Dallas, Texas, USA
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17
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Janardhan V, Janardhan V, Kalousek V. COVID-19 as a Blood Clotting Disorder Masquerading as a Respiratory Illness: A Cerebrovascular Perspective and Therapeutic Implications for Stroke Thrombectomy. J Neuroimaging 2020; 30:555-561. [PMID: 32776617 PMCID: PMC7436381 DOI: 10.1111/jon.12770] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 07/26/2020] [Accepted: 07/28/2020] [Indexed: 12/15/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) as the name suggests was initially thought to only cause a respiratory illness. However, several reports have been published of patients with ischemic strokes in the setting of coronavirus disease 2019 (COVID‐19). The mechanisms of how SARS‐CoV‐2 results in blood clots and large vessel strokes need to be defined as it has therapeutic implications. SARS‐CoV‐2 enters the blood stream by breaching the blood‐air barrier via the lung capillary adjacent to the alveolus, and then attaches to the angiotensin‐converting enzyme II receptors on the endothelial cells. Once SARS‐CoV‐2 enters the blood stream, a cascade of events (Steps 1‐8) unfolds including accumulation of angiotensin II, reactive oxygen species, endothelial dysfunction, oxidation of beta 2 glycoprotein 1, formation of antiphospholipid antibody complexes promoting platelet aggregation, coagulation cascade, and formation of cross‐linked fibrin blood clots, leading to pulmonary emboli (PE) and large vessel strokes seen on angiographic imaging studies. There is emerging evidence for COVID‐19 being a blood clotting disorder and SARS‐CoV‐2 using the respiratory route to enter the blood stream. As the blood‐air barrier is breached, varying degrees of collateral damage occur. Although antiviral and immune therapies are studied, the role of blood thinners in the prevention, and management of blood clots in Covid‐19 need evaluation. In addition to ventilators and blood thinners, continuous aspiration and clot retrieval devices (approved in Europe, cleared in the United States) or cyclical aspiration devices (approved in Europe) need to be considered for the emergent management of life‐threatening clots including PE and large vessel strokes.
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Affiliation(s)
- Vallabh Janardhan
- Stroke & Interventional Neurology, Medical Center of Plano, Plano, TX.,Insera Therapeutics, Inc, Dallas, TX
| | | | - Vladimir Kalousek
- Department of Radiology, Clinical Hospital Center Sestre Milosrdnice, Zagreb, Croatia
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