Mechanical thrombectomy with 'ADAPT' technique by transcervical access in acute ischemic stroke

Ischemic stroke with concomitant clear cell carcinoma of the ovary: A case report and review of literature

BACKGROUND

Ischemic stroke is a rare event associated with an elevated risk of blood clot formation owing to an underlying malignancy. Herein, we present a case of ovarian carcinoma that led to cerebral infarction.

CASE SUMMARY

A 43-year-old woman experienced sudden onset right-sided paralysis and difficulty speaking two days after discovery of a large ovarian tumor measuring approximately 14 cm, which was suspected to be malignant. Further examination revealed left middle cerebral artery infarction. The patient had a history of hypertension and adenomyosis. Following stabilization with heparin treatment and vital signs management, the patient underwent debulking surgery, including total hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and bilateral pelvic and para-aortic lymph node dissection. The final diagnosis was clear cell carcinoma of the right ovary (stage IA). Subsequently, the patient completed six rounds of adjuvant chemotherapy while simultaneously undergoing rehabilitation. Presently, the patient is able to walk independently, although she still experiences aphasia.

CONCLUSION

Prompt medical intervention and interdisciplinary care are crucial in the setting of incidental findings such as a large ovarian tumor.

Direct carotid artery puncture for acute ischemic stroke: Local experience and systematic review

BACKGROUND

To establish surgical access during endovascular treatment of ischemic stroke, femoral artery puncture is most commonly performed followed by a small number of radial artery access procedures. However, there are few reports of carotid artery puncture.

METHODS

We report the case of an 87-year-old woman who was admitted to hospital with hemiplegia of the left limb and loss of consciousness for 40 min, accompanied by urinary incontinence. After complicated transfemoral and transradial attempts, the patient underwent emergency direct carotid artery puncture (DCAP) for the treatment of acute ischemic stroke. We reviewed the literature on this topic over a 7-year period (September 2014 to April 2022), including 202 patients with acute ischemic stroke who underwent emergency DCAP and endovascular surgery.

RESULTS

The average age of these patients was 80.5 years. The left DCAP accounted for 52.5% (106/202) of the cases. Local anesthesia was utilized in 33.9% (64/189) of the cases. Angio-Seal was utilized for closure in 53.7% (79/147) of the patients. About half (105/199) of the patients recovered or improved their limb function after DCAP. Postoperative complications were mainly neck hematoma and one of these patients died due to a fatal neck hematoma.

CONCLUSION

We describe the detailed procedure of the rare case of an emergency DCAP performed at our institution. DCAP provides an alternative treatment method in cases where thrombus removal access cannot be established through traditional methods.

Direct Carotid Puncture for Mechanical Thrombectomy in Acute Ischemic Stroke: Literature Review and a Single-Center Experience

BACKGROUND

Endovascular thrombectomy (EVT) for acute ischemic stroke via direct carotid puncture (DCP) has been commonly reported as case reports and series in the literature. However, the reported procedural risk and therapeutic outcome associated with this approach were variable. In this study, we aim to establish the role and safety profile of this alternative access technique by describing our single-center experience and conducting a comprehensive review of the literature.

METHODS

We conducted a retrospective review of consecutive patients at our center with large vessel occlusion (LVO) treated between 2018 and 2020 with DCP access. In addition, a literature review of studies published from 2012-2021 following PRISMA guidelines was conducted.

RESULTS

During the 3-year period, 11 patients with LVO were treated with EVT using DCP technique in our local cohort. A total of 216 cases were found in the literature search. A combined total of 227 cases were reviewed separately and collectively. Combining the data, DCP access was successfully achieved in 93.3% of the cases; 76.6% achieved satisfactory recanalization (mTICI ≥2b). DCP-related complications were seen in 20.3% of cases. A total of 32.4% patients were functionally independent (mRS ≤2) upon follow-up.

CONCLUSIONS

Results from the literature review and our experience illustrate DCP as a feasible approach for EVT. The role of DCP as a bailout is iterated despite a higher complication risk, which may be imperative in low-volume stroke centers. Further studies to evaluate the role of DCP as a primary vascular access technique for EVT in selected cases could be explored.

Systematic Review on Endovascular Access to Intracranial Arteries for Mechanical Thrombectomy in Acute Ischemic Stroke

PURPOSE

In acute ischemic stroke for large vessel occlusions, delayed or failed access to intracranial occlusions has a negative impact on procedural and clinical outcomes. The aim of this review is to identify and quantify access failures and challenges in mechanical thrombectomy.

METHODS

A systematic literature review of PubMed and Scopus databases from January 2014 to October 2020 was performed. Articles reporting consecutive patients were used to calculate a crude failure rate of femoral and alternative accesses.

RESULTS

A total of 50 articles met the inclusion criteria, totalling 12,838 interventions. Failure to access the occlusion through transfemoral access occurred in 4.4% of patients, most commonly due to challenging supra-aortic vessel anatomy, decreasing to 3.6% when all alternative access routes were attempted. Failed access from alternative routes (direct carotid, radial and brachial approaches) attempted first-line or after failed femoral attempt were reported in 7.3% of patients. The occurrence rate of potentially challenging features (anatomical, diseases or others) ranged from 4.7% to 47.4%, primarily impacting the access time, procedure time, recanalization and clinical outcomes.

CONCLUSION

Failure to access the occlusion is a significant contributor to failed recanalization, regardless of access routes. Challenging, but eventually successful access is also a relevant factor in procedural and clinical outcomes; however challenging access requires a universal definition to enable quantification, so that methods for procedural optimization can be critically assessed.

Cerebral angiography: Techniques and practice

As a refresher course on current techniques and practice of cerebral angiography, this chapter outlines the steps in effective angiography, incorporating modern quality and safety considerations. The format is step-by-step from preprocedure to intraprocedure to postprocedure for ease of reference. The chapter will serve as a framework for the fledgling angiographer, augmenting the important teaching provided by a seasoned angiographer.

Carotid cutdown for mechanical thrombectomy in the setting of intravenous tissue plasminogen activator: A technical report

Acute ischemic stroke (AIS) is a leading cause of mortality and morbidity in the world. Patients are usually treated with endovascular methods and access is often gained trans-femoral or trans-radial. In patients with difficult anatomy, in rare cases the approach must be done trans-cervical. Our case illustrates a patient who received IVTPA prior to attempted endovascular treatment, leading to a direct carotid cutdown for mechanical thrombectomy. Our patient presented with a left M1 occlusion and had received intravenous thrombolytic at the presentation of his symptoms. Due to unfavorable anatomy and tortuous aortic arch, conventional access could not be obtained. In order to achieve reperfusion while maintaining hemostasis, a decision was made to perform an open carotid cutdown to catherize the left internal carotid artery to successfully retrieve the thrombus. This resulted in a TICI2B revascularization. This is the first reported case of direct carotid access in the setting of acute ischemic stroke with IVTPA. Open technique allowed us to maintain hemostasis while bypassing the tortuous arch and achieving reperfusion and give the patient the best chance for a functional recovery.

Rescue carotid puncture for ischemic stroke treated by endovascular therapy: a multicentric analysis and systematic review

BACKGROUND

Endovascular therapy (EVT) for acute ischemic stroke (AIS) can be challenging in older patients with supra-aortic tortuosity. Rescue carotid puncture (RCP) can be an alternative in case of supra-aortic catheterization failure by femoral access, but data regarding RCP are scarce. We sought to investigate the feasibility, effectiveness and safety of RCP for AIS treated by EVT.

METHODS

Patients treated by EVT with RCP were included from January 2012 to December 2019 in the Endovascular Treatment in Ischemic Stroke (ETIS) multicentric registry. Main outcomes included reperfusion rates ( ≥ TICI2B), 3 month functional outcome (modified Rankin Scale) and 3 month mortality. We also performed an additional systematic review of the literature according to the PRISMA checklist to summarize previous studies on RCP.

RESULTS

25 patients treated by EVT with RCP were included from the ETIS registry. RCP mainly concerned elderly patients (median age 85 years, range 73-92) with supra-aortic tortuosity (n=16 (64%)). Intravenous thrombolysis (IVT) was used for nine patients (36%). Successful reperfusion was achieved in 64%, 87.5% of patients were dependent at 3 months, and 3 month mortality was 45.8%. The systematic review yielded comparable results. In pooled individual data, there was a shift toward better functional outcome in patients with successful reperfusion (median (IQR) 4 (2-6) vs 6 (4-6), p=0.011).

CONCLUSION

RCP mainly concerned elderly patients admitted for AIS with anterior LVO with supra-aortic tortuosity. The procedure seemed feasible, notably for patients treated with IVT, and led to significant reperfusion rates at the end of procedure, but with pronounced unfavorable outcomes at 3 months. RCP should be performed under general anesthesia to avoid life-threatening complications and ensure airways safety. Finally, RCP led to low rates of closure complications, emphasizing that this concern should not withhold RCP, if indicated.

Direct carotid puncture for mechanical thrombectomy in acute ischemic stroke patients with prohibitive vascular access

OBJECTIVE

While the benefit of mechanical thrombectomy (MT) for patients with anterior circulation acute ischemic stroke with large-vessel occlusion (AIS-LVO) has been clearly established, difficult vascular access may make the intervention impossible or unduly prolonged. In this study, the authors evaluated safety as well as radiographic and functional outcomes in stroke patients treated with MT via direct carotid puncture (DCP) for prohibitive vascular access.

METHODS

The authors retrospectively studied patients from their prospective AIS-LVO database who underwent attempted MT between 2015 and 2018. Patients with prohibitive vascular access were divided into two groups: 1) aborted MT (abMT) after failed transfemoral access and 2) attempted MT via DCP. Functional outcome was assessed using the modified Rankin Scale at 3 months. Associations with outcome were analyzed using ordinal logistic regression.

RESULTS

Of 352 consecutive patients with anterior circulation AIS-LVO who underwent attempted MT, 37 patients (10.5%) were deemed to have prohibitive vascular access (mean age [± SD] 82 ± 11 years, mean National Institutes of Health Stroke Scale [NIHSS] score 17 ± 5, with females accounting for 75% of the patients). There were 20 patients in the DCP group and 17 in the abMT group. The two groups were well matched for the known predictors of clinical outcome: age, sex, and admission NIHSS score. Direct carotid access was successfully obtained in 19 of 20 patients. Successful reperfusion (thrombolysis in cerebral infarction score 2b or 3) was achieved in 16 (84%) of 19 patients in the DCP group. Carotid access complications included an inability to catheterize the carotid artery in 1 patient, neck hematomas in 4 patients, non-flow-limiting common carotid artery (CCA) dissections in 2 patients, and a delayed, fatal carotid blowout in 1 patient. The neck hematomas and non-flow-limiting CCA dissections did not require any subsequent interventions and remained clinically silent. Compared with the abMT group, patients in the DCP group had smaller infarct volumes (11 vs 48 ml, p = 0.04), a greater reduction in NIHSS score (-4 vs +2.9, p = 0.03), and better functional outcome (shift analysis for 3-month modified Rankin Scale score: adjusted OR 5.2, 95% CI 1.02-24.5; p = 0.048).

CONCLUSIONS

DCP for emergency MT in patients with anterior circulation AIS-LVO and prohibitive vascular access is safe and effective and is associated with higher recanalization rates, smaller infarct volumes, and improved functional outcome compared with patients with abMT after failed transfemoral access. DCP should be considered in this patient population.

Trans-Carotid and Trans-Radial Access for Mechanical Thrombectomy for Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

Objective We aim to demonstrate the safety and effectiveness of extra-femoral endovascular access for mechanical thrombectomy for acute ischemic stroke patients whose vascular anatomy precludes safe or maneuverable trans-femoral access. Methods Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to conduct a systematic review and meta-analysis with articles published until March 2018. The search protocol, including research questions and inclusion and exclusion criteria, were developed a priori. Our own institutional retrospective data were included in the cohort of case series. Results Eleven studies including 51 patients were included. Age ranged from 4th to 10th decade of life (average: 9.3rd decade) and 40.1% received IV tissue plasminogen activator. Initial National Institutes of Health Stroke Scale (NIHSS) score ranged from 1 to 36, (average: 17.6). Of the 51 patients, 39 (76%) patients suffered from anterior circulation large vessel occlusions versus 12 (24%) from posterior circulation occlusions. Site of access included 26 (51%) radial artery punctures, 23 (45%) direct percutaneous cervical carotid punctures, 1 brachial artery puncture, and 1 direct extradural vertebral artery puncture. Technical success was achieved in 43/51 (84%) of patients. The average modified Rankin Scale at discharge was 2.93 (n=26). There were no complications in 25 patients who underwent radial arterial access. Two (7.4%) of 27 cervical access patients developed hematoma. Conclusions Trans-carotid and trans-radial access for intervention in acute ischemic stroke is safe and effective. There may be instances in which these approaches should be considered first line before standard femoral approaches.

Direct carotid puncture in acute ischaemic stroke intervention

Endovascular intervention for acute ischaemic stroke care is mostly performed in older patients, often with unfavourable aortic and supra-aortic anatomy, as well as cardiovascular comorbidities. A significant subset of them may benefit from transcervical access as the initial approach for mechanical thrombectomy. In fact, direct carotid artery puncture in these cases has the advantage to bypass the anatomical obstacles and achieve faster reperfusion. Caution is advised when common carotid artery access is pursued in order to avoid adverse events, including haematoma formation, iatrogenic arterial dissection and sheath kinking. In spite of potential complications, direct carotid puncture in acute ischaemic stroke intervention overcomes challenging angioarchitecture and may reduce the rate of poor clinical outcomes associated with delayed revascularisation in certain cases.

Transarterial and transvenous access for neurointerventional surgery: report of the SNIS Standards and Guidelines Committee

The purpose of this publication is to provide a comprehensive review on the techniques and tools used for vascular access in neurointerventional procedures. Using published literature, we reviewed data on access methods, sites, tools, and techniques for neurointerventions. Recommendations are provided based on quality of data/levels of evidence and, where appropriate, expert consensus. While tools and techniques continue to be developed, current literature and experience supports certain principles regarding vascular access for neurointerventional procedures.

Alternative Transcarotid Approach for Endovascular Treatment of Acute Ischemic Stroke Patients: A Case Series

PURPOSE

Mechanical thrombectomy has become the standard of care for acute stroke caused by large vessel occlusion. As more patients are treated endovascularly, the number of older patients with tortuous vessels has risen. In these patients, catheterizing the internal carotid artery via a transfemoral approach can be very difficult or even impossible. Therefore, in selected patients, alternative strategies to the transfemoral approach have to be applied.

MATERIALS AND METHODS

We report a case series of six patients undergoing mechanical thrombectomy via a combined transfemoral and transcarotid approach. Puncture of the carotid artery was conducted using roadmap guidance after an unsuccessful transfemoral attempt. Technical aspects and outcomes with this alternative approach were analyzed.

RESULTS

Direct puncture of the carotid artery was achieved in five out of six patients (83%). In three out of six patients (50%), revascularization (modified Thrombolysis in Cerebral Infarction score ≥2b) was restored. No complications related to endovascular therapy were documented. One patient showed good neurological outcome (modified Rankin Scale [mRS] 5 at admission, mRS 1 at discharge).

CONCLUSION

A combined transfemoral/transcarotid approach can be an alternative vascular access in patients with problematic vessel anatomy.

Influence of carotid tortuosity on internal carotid artery access time in the treatment of acute ischemic stroke

Purpose Carotid artery anatomy is thought to influence internal carotid artery access time (ICA-AT) in patients requiring mechanical thrombectomy for acute ischemic stroke. This study investigates the association between ICA-AT and carotid anatomy. Material and methods Computed tomography angiography (CTA) data of 76 consecutive patients presenting with acute ischemic stroke requiring mechanical thrombectomy for middle cerebral artery or carotid T occlusion were evaluated. The supraaortic extracranial vasculature was analyzed regarding take-off angles and curvature of the affected side. Digital subtraction angiography data were primarily analyzed regarding ICA-AT and secondarily regarding recanalization time and radiographic result. Results ICA-AT was significantly influenced by vessel tortuosity. Take-off angle of the left common carotid artery ( p = 0.001) and the brachiocephalic trunk ( p = 0.002) as well as the tortuosity of the common carotid artery ( p = 0.002) had highest impact on ICA-AT. For recanalization time, however, we found only the take-off angle of the left common carotid artery to be of significance ( p = 0.020). There was a tendency for ICA-AT to correlate with successful (mTICI ≥ 2 b) revascularization (average time of successful results was 24.3 minutes, of unsuccessful was 35.6 minutes; p = 0.065). Every evaluated segment with less carotid tortuosity showed a carotid AT below 25 minutes. Conclusion Supraaortic vessel tortuosity significantly influences ICA-AT in mechanical thrombectomy for an acute large vessel. There furthermore was a trend for lower successful recanalization rates with increasing ICA-AT.

Use of a complete autologous blood recovery system (the Sorin Xtra® Autotransfusion System) during mechanical thrombectomy of extensive cerebral venous sinus thrombosis

Background The endovascular therapy for cerebral venous sinus thrombosis (CVST) is currently accepted as a second-line treatment for patients who have failed or those in whom systemic anticoagulation is contraindicated or in a subgroup of patients presenting with rapid neurologic deterioration. A number of different mechanical and pharmacologic endovascular strategies have been reported, either as separate or combined approaches. These new catheters and aspiration systems have a high power and vacuum capacity, which carries a risk of anemization of the patient and hypovolemic shock, being necessitating the transfusion of the patient. Material and methods Because of the problems that donor blood transfusion can bring, we describe the use of a Sorin Xtra® Autotransfusion System (ATS). This complete autologous blood recovery system was designed for use in procedures where medium- to high-volume blood loss occurs, such as major surgeries. We have adapted it to recover all the blood aspirated during the mechanical thrombectomy procedures of the dural cerebral venous sinuses, since they are procedures that can cause a significant loss of blood. One advantage to this is the patient receives his or her own blood instead of donor blood, so there is no risk of contracting outside diseases or transfusion reactions. Conclusions This technical note describes a novel and previously unpublished technical approach to CVST that can be immediately applied to clinical practice. It also raises awareness among the interventional neuroradiologist and anesthesiologist communities about novel, potentially lifesaving endovascular treatments in patients with extensive CVST.