Utility of a Y-configured stentriever technique as a rescue method of thrombectomy for an intractable rooted thrombus located on the middle cerebral artery bifurcation: technical note

Mechanical Thrombectomy Using Double Stent Retriever Technique for Acute Ischemic Stroke Following Embolism From the Pulmonary Vein Stump After Left Upper Lobectomy: A Case Report

Acute ischemic stroke (AIS) following pulmonary lobectomy, which is traditionally attributed to air embolism and atrial fibrillation (AF), may occur after thrombus formation in the pulmonary vein stump (PVS). Herein, we document the mechanical thrombectomy (MT) of a carotid bifurcation occlusion post-left upper lobectomy (LUL) to manage AIS. A 76-year-old male with a history of diabetes, dyslipidemia, and a treated dural arteriovenous fistula at the transverse sigmoid junction, with no history of AF, successfully underwent LUL for a pulmonary tumor. The patient independently walked on postoperative day 1. He developed right hemiparesis and total aphasia on the morning of the second day after surgery, which was discovered by the nursing staff. A magnetic resonance imaging (MRI) confirmed an occlusion of the left common carotid artery (CCA). Tissue plasminogen activator (t-PA) was not administered owing to recent surgery. An urgent MT using multiple MT techniques carried out 90 minutes after the discovery of symptoms only achieved partial recanalization. Subsequently, a double stent retriever technique (DSRT) addressed the occlusion in the common and cervical internal carotid artery (ICA). Following this, a T occlusion was encountered, which was addressed with a combined approach using a single stent retriever (SR), achieving a thrombolysis in cerebral infarction (TICI) grade 2b result. However, postoperative aphasia and severe right hemiparesis remained. Postoperative imaging showed a significant left cerebral hemisphere infarction and a thrombus in the PVS. Oral edoxaban was administered, and PVS thrombosis did not recur. The patient was transferred to a rehabilitation facility 190 days post-embolization with a modified Rankin Scale score of 4. In this report, we demonstrate the challenging case of the DSRT in addressing AIS after LUL, which led to the formation of a massive thrombus and occlusion of the carotid artery, as revealed by the PVS. This case emphasizes the importance of collaborative efforts between thoracic surgeons and all staff involved in stroke care in managing such complex scenarios.

Double stent retriever technique for rescue recanalization in refractory large vessel occlusions

Acute ischemic stroke patients with large vessel occlusion (LVO) involving bifurcation usually have a difficult and high clot burden. By using conventional technique often resulting in a reduction in the possibility of successful recanalization. The double stent retriever technique can be considered for rescue recanalization. We reported a case of refractory terminal left internal carotid occlusion that was treated using double stent retriever technique. Two microcatheter were advanced across the occlusion were one to the superior branch of middle cerebral artery and another was on inferior branch. Both stent retrievers were pulled back together and complete recanalization was achieved. This technique were reported in some case series to be effective and based on our initial experience using this technique it seems the expansion improved after deployment of the second stent retriever and it traps the clot within its stent struts, to facilitate clot retrieval. Therefore, double stent retriever technique can be one of the choices for rescue recanalization in refractory clot occlusion and it may potentially help other clinicians in similar situations.

First Experience with the Nimbus Stentretriever

Purpose

To share our first experience with the Nimbus stentretriever, a multizone device designed to assist neurointerventionalists in handling fibrin-rich clots in endovascular stroke treatment.

Methods

We retrospectively analyzed the data of patients who were treated with the Nimbus stentretriever at our high-volume stroke center between May 2021 and May 2022. We evaluated the number of passes before Nimbus was used, the number of passes with nimbus, as well as the recanalization success before and after Nimbus according to the modified treatment in cerebral ischemia (mTICI) scale. Also, patient characteristics, procedural times and clinical outcomes were documented.

Results

A total of 21 consecutive patients were included in the study. An mTICI 2b/3 could be achieved in 76.2% and mTICI 2c/3 could be achieved in 57.1%. The mean number of passes was 3.4 before the use of Nimbus, 2.2 with Nimbus, and 5.4 for all passes with and without Nimbus and 4 occlusions (19.0%) were successfully recanalized with direct aspiration after the use of Nimbus. We observed seven subarachnoid hemorrhages (33.3%) and two cases of vasospasm.

Conclusion

In our series, the use of Nimbus resulted in successful recanalization in half of the patients after otherwise unsuccessful thrombectomy maneuvers; therefore, it should be considered as a rescue option if the maneuver with conventional stent retrievers was unsuccessful.

Crossing double stent retriever technique for refractory terminal internal carotid artery occlusion

Mechanical thrombectomy is highly effective for the recovery of acute ischemic stroke with large vessel occlusion. However, refractory occlusions are still encountered despite the use of currently available devices. In this article, we present a case of refractory terminal internal carotid artery occlusion treated with the "crossing double stent retriever technique." Two thrombectomy procedures with the combined technique using a stent retriever and aspiration catheter failed to recanalize the terminal internal carotid artery occlusion that involved the dominant anterior cerebral artery. We then applied the crossing double stent retriever technique as a rescue technique. Two microcatheters were advanced across the occlusion: one to the anterior cerebral artery and the other to the middle cerebral artery. First, a Trevo NXT 4 mm stent retriever was deployed from the anterior cerebral artery. Next, an additional Trevo NXT 4 mm stent retriever was deployed from the middle cerebral artery, and full immediate restoration of flow was achieved on angiography. Intraprocedural radiological images showed that the 2 microcatheters traversed different pathways, and the 2 stent retrievers completely covered the entire vessel with apparent in-stent clot sign. Both stent retrievers were then pulled back together, and a hard clot was retrieved. Subsequent angiography revealed complete recanalization. The crossing double stent retriever technique seems an effective rescue technique for treating refractory terminal internal carotid artery occlusion, especially with the anatomical feature of branching of the dominant anterior cerebral artery. This technique can facilitate the device-clot-vessel interaction by engaging the clot via 2 different device pathways.

First-line Double Stentriever Thrombectomy for M1/TICA Occlusions : Initial Experiences

BACKGROUND

Mechanical thrombectomy is the standard of care for acute ischemic stroke due to large-vessel occlusion; however, mechanical thrombectomy fails to achieve adequate recanalization in nearly one third of these cases. Rescue therapy using two stentrievers simultaneously yields good results in clots refractory to single stentriever treatment. We aimed to determine the safety and efficacy of first-line double stentriever thrombectomy for acute occlusion of the M1 segment of the middle cerebral artery and/or terminal internal carotid artery (TICA).

METHODS

This single-center study prospectively enrolled consecutive patients with a single M1/TICA occlusion to undergo double stentriever thrombectomy between May and October 2020. Outcomes included successful recanalization (modified thrombolysis in cerebral infarction, TICI 2b/3), first-pass effect, procedure times, number of device passes, symptomatic intracerebral hemorrhage, National Institutes of Health Stroke Scale Score (NIHSS) at discharge, 90-day functional independence (modified Rankin scale 0-2), and 90-day mortality.

RESULTS

We analyzed 39 patients median age 79 years (range 42-96 years); 23 (58.9%) female; 19 (48.7%) with TICA occlusions; 5 (12.8%) with mRS 3-5 at admission; mean NIHSS at admission, 17 ± 4.39). Mean time from symptom onset to final angiogram was 238.0 ± 94.6 min; mean intervention duration was 36.0 ± 24.2 min. The mean number of device passes was 1.5 ± 1.07. All patients had final TICI 2b/3, and 27 (69%) had TICI 2c/3 after the first pass. We observed 3 (7.9%) cases of intracerebral symptomatic hemorrhages. At 90 days, 16 (41%) patients were functionally independent and 9 (23%) had died. The percentage of patients with good clinical outcome at 90 days was 55.5% in the first-pass subgroup.

CONCLUSION

Our findings suggest that first-line double stentriever thrombectomy is safe and effective for M1/TICA occlusions.

Device size selection can enhance Y-stentrieving efficacy and safety as a rescue strategy in stroke thrombectomy

BACKGROUND

Despite advancements in stroke treatment, refractory clots are relatively common, prompting the exploration of alternative techniques. Bifurcation occlusions pose specific intraprocedural challenges, occasionally dealt with by two stentrievers deployed in Y-configuration. Previous studies have portrayed this strategy as feasible, yet little is known about its safety and efficacy, and how to best select retrievers.

OBJECTIVE

To determine whether device selection influences the efficacy and safety of Y-stentrieving.

METHODS

We performed a multicentric, retrospective analysis of patients undergoing Y-stentrieving rescue for bifurcation occlusions. Demographics, devices, procedural metrics, neurological severity, reperfusion, disability, and safety were assessed.

RESULTS

Y-configuration stents were used as a rescue maneuver after 2.16±1.5 failed attempts with other techniques in 20 patients. Successful reperfusion (modified Thrombolysis in Cerebral Infarction score 2b-3) was achieved in 70% of patients after the first Y-stentrieving attempt. The first stentriever more often had a larger diameter (5.15±0.92 vs 3.67±0.57 mm, p=0.017) and longer length (33.12±5.78 vs 20.67±1.15 mm, p=0.002) in successfully reperfused cases. Also, the diameter of the first device was associated with both any parenchymal (6.0 vs 4.71±0.99 mm, p=0.045) and symptomatic (6.0 vs 4.86±1.02 mm, p<0.001) hemorrhages. Exact logistic regression demonstrated that a longer length first stentriever independently predicted better angiographic outcomes (OR=1.26, p=0.036), and a 6 mm diameter first stentriever independently predicted more intracranial hemorrhages (OR=15.28, p=0.044). No periprocedural mortality was recorded.

CONCLUSION

Y-stentrieving is an effective and safe bail-out strategy for refractory bifurcation clots. Longer stents may promote better angiographic outcomes, whereas avoidance of disproportionately large retrievers may mitigate intracranial hemorrhage. Future studies should account for these factors when evaluating alternative stentriever techniques.

A Case of Acute Embolic Occlusion of the Common Carotid Artery in Which a Giant Thrombus Was Retrieved Using the Parallel Stent Retriever Technique

Objective

We report a case of embolic occlusion of the common carotid artery (CCA) in which a giant thrombus was retrieved using the parallel stent retriever technique.

Case Presentation

An 84-year-old woman without anticoagulant therapy despite a history of cardioembolic stroke presented to our hospital because of left hemiparesis after developing sudden vision loss in her right eye. Emergency angiography revealed a giant thrombus in the right CCA. After arresting flow in the CCA using a balloon-guided catheter (BGC), we deployed two stent retrievers in parallel from the internal carotid artery to the CCA, and slowly retrieved them simultaneously under manual aspiration through the BGC. As a result, complete recanalization was achieved.

Conclusion

Thrombi causing acute embolic occlusion of the CCA are often too large to be completely retrieved using conventional thrombectomy techniques. The parallel stent retriever technique may be effective in such cases.

Y-configuration double-stent-retriever thrombectomy for refractory thrombus in middle cerebral artery bifurcation: A case report

RATIONALE

Stent retriever mechanical thrombectomy is a recommended treatment for acute ischemic stroke. However, refractory thrombus in artery bifurcation can reduce the rate of successful revascularization.

PATIENT CONCERNS

A 72-year-old male, owing to the acute onset of almost complete right-sided hemiplegia and global aphasia, received bridging therapy. National Institutes of Health Stroke Scale score was 16 at the time of admission.

DIAGNOSES

Cerebral digital subtraction angiography revealed occlusion of the M1 segment of the left MCA.

INTERVENTIONS

Thrombectomy with 3 passes of the Solitaire FR device (Medtronic, Minneapolis, MN) was unsuccessful. Two stent retrievers were inserted in parallel by one microcatheter access point to each M2 branch, and then both stents were gradually retrieved out of the catheter while continuous suction was maintained.

OUTCOMES

After thrombectomy, subsequent follow-up angiograms showed mTICI 3 reperfusion of MCA. The patient has mRS 2 at discharge and the 3-month mRS score after stroke is 1 score.

LESSONS

The presented Y-configuration double-stent-retriever thrombectomy technique constitutes a safe and effective rescue treatment method for refractory thrombus in MCA bifurcation.

Y-Stent Rescue Technique for Failed Thrombectomy in Patients With Large Vessel Occlusion: A Case Series and Pooled Analysis

Objective: Y-stent thrombectomy is a recent rescue technique for failed thrombectomy in patients with emergent large vessel occlusion. We presented case series of using Y-stent rescue technique at different sites and investigate its feasibility and safety through pooled analysis of collected case report or series. Methods: Twenty-eight cases were screened from stroke databank who underwent thrombectomy between January 2015 and June 2019. Clinical, procedural, and follow-up data were investigated and pooled analysis of published literature was analyzed. Results: The occlusion sites include carotid terminus in 14 patients; siphon segment in 3; middle cerebral artery (MCA) in 4; basilar terminus in 7. The overall recanalization rate reached 85.7% (arterial occlusive lesion score 2-3); and final reperfusion rate 85.7% (modified Thrombolysis in Cerebral Infarction 2b-3). After literature review, totally, 52 cases were included. Good clinical outcome was achieved in 26 (50%) and mortality in 7 (17.3%). There is no significant difference on the SAH complication at different sites. Literature review shows no difference between each site in the reperfusion and complication rate. Conclusion: Our case series results suggest that high recanalization rate can be effectively achieved with Y-stent rescue technique for patients with refractory emergent large vessel occlusion. The safety of using this technique at different sites needs further investigation for patients.

Parallel Stent Retriever Technique for a Refractory Middle Cerebral Artery Embolism: A Technical Case Report

Objective

To report a patient who achieved complete recanalization using the parallel stent retriever (SR) technique for a refractory acute middle cerebral artery (MCA) embolism.

Case Presentation

An 86-year-old woman underwent an emergency thrombectomy for acute right MCA occlusion. Although thrombectomy has been attempted three times with the conventional technique using a single SR, no recanalization was achieved. Then, an innovative technique was used to deploy two SRs in parallel with the M1 segment of the MCA. Pulling them back simultaneously, the thrombus was retrieved, and complete recanalization was achieved.

Conclusion

The parallel SR technique is a feasible method and can be considered as one of the last treatment resorts for acute refractory embolisms at the major MCA trunk.