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Knapen RRMM, Celen M, Pinckaers FME, Wagemans BAJM, van Zwam WH, van Oostenbrugge RJ, van der Leij C. Comparison of Clinical and Radiological Outcomes Between Different (Balloon) Guide Catheter With and Without Inflated Balloon in Acute Ischemic Stroke Patients: A MaSQ-Registry Study. Cardiovasc Intervent Radiol 2024; 47:918-928. [PMID: 38639780 PMCID: PMC11239717 DOI: 10.1007/s00270-024-03718-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 03/23/2024] [Indexed: 04/20/2024]
Abstract
PURPOSE Balloon guide catheters (BGCs) are used in endovascular treatment (EVT) for ischemic stroke. Previous literature did not distinguish between BGC use with and without inflated balloon. This study aims to compare outcomes between non-BCG and BGC use with and without inflated balloon during EVT. METHODS Patients who underwent EVT for anterior circulation ischemic stroke between September 2020 and February 2023 were analyzed. Patients were divided into three groups: non-BGC, BGC with inflated balloon, or BGC without inflated balloon. The primary outcome was the ordinal modified Rankin Scale (mRS) at 90-day follow-up. Secondary outcomes included expanded Thrombolysis In Cerebral Ischemia score (eTICI) and periprocedural complications. Regression analyses with BGC with inflated balloon as comparator were performed with adjustments. Subgroup analyses were conducted based on first-line thrombectomy technique. RESULTS Out of 511 patients, 428 patients were included. Compared to BCG with inflated balloon, the mRS at 90 days did not differ in the group without inflated balloon (adjusted common [ac]OR: 1.07, 95%CI 0.67-1.73) or non-BGC (acOR: 1.42, 95%CI 0.83-2.42). Compared to patients treated with a BGC with inflated balloon, those treated with BGC without inflated balloon had lower eTICI scores (acOR: 0.59, 95%CI 0.37-0.94), and patients treated with non-BGC had lower chances of periprocedural complications (aOR: 0.41, 95%CI 0.20-0.86). CONCLUSIONS This study shows no clinical differences in ischemic stroke patients treated with BGC with inflated balloon compared to non-BGC and BGC without inflated balloon, despite lower periprocedural complication rates in the non-BGC group and lower eTICI scores in the BGC without inflated balloon group. LEVEL OF EVIDENCE Level 3, non-controlled retrospective cohort study.
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Affiliation(s)
- R R M M Knapen
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+ and School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands.
- School for Cardiovascular Diseases Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.
| | - M Celen
- Department of Neurology, Zuyderland MC, Heerlen, Sittard-Geleen, The Netherlands
| | - F M E Pinckaers
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+ and School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
| | - B A J M Wagemans
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - W H van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+ and School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
| | - R J van Oostenbrugge
- Department of Neurology, Maastricht University Medical Center+ and School for Cardiovascular Diseases (CARIM), Maastricht, The Netherlands
| | - C van der Leij
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
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Patki P, Simon S, Costanzo F, Manning KB. Current Approaches and Methods to Understand Acute Ischemic Stroke Treatment Using Aspiration Thrombectomy. Cardiovasc Eng Technol 2024:10.1007/s13239-024-00735-0. [PMID: 38886306 DOI: 10.1007/s13239-024-00735-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 05/21/2024] [Indexed: 06/20/2024]
Abstract
Acute ischemic stroke occurs when a blood clot occludes a cerebral artery. Mechanical interventions, primarily stent retrievers and aspiration thrombectomy, are used currently for removing the occluding clot and restoring blood flow. Aspiration involves using a long catheter to traverse the cerebral vasculature to reach the blood clot, followed by application of suction through the catheter bore. Aspiration is also used in conjunction with other techniques such as stent retrievers and balloon guide catheters. Despite the wide use of aspiration, our physical understanding of the process and the causes of the failure of aspiration to retrieve cerebral clots in certain scenarios is not well understood. Experimental and computational studies can help develop the capability to provide deeper insights into the procedure and enable development of new devices and more effective treatment methods. We recapitulate the aspiration-based thrombectomy techniques in clinical practice and provide a perspective of existing engineering methods for aspiration. We articulate the current knowledge gap in the understanding of aspiration and highlight possible directions for future engineering studies to bridge this gap, help clinical translation of engineering studies, and develop new patient-specific stroke therapy.
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Affiliation(s)
- Priyanka Patki
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, PA, 16802, USA
| | - Scott Simon
- Department of Neurosurgery, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Francesco Costanzo
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, PA, 16802, USA
- Center for Neural Engineering, The Pennsylvania State University, University Park, PA, 16802, USA
- Department of Engineering Science and Mechanics, The Pennsylvania State University, University Park, PA, 16802, USA
| | - Keefe B Manning
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, PA, 16802, USA.
- Center for Neural Engineering, The Pennsylvania State University, University Park, PA, 16802, USA.
- Department of Surgery, Penn State Hershey Medical Center, Hershey, PA, USA.
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Kim LH, Choi J, Zhou J, Wolman D, Pendharkar AV, Lansberg MG, Albers GW, Dodd R, Do HM, Pulli B, Heit JJ, Telischak NA. Matched-pair analysis of patients with ischemic stroke undergoing thrombectomy using next-generation balloon guide catheters. J Neurointerv Surg 2024; 16:595-598. [PMID: 37793796 DOI: 10.1136/jnis-2023-020635] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 09/08/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND Balloon guide catheters (BGCs) have not been widely adopted, possibly due to the incompatibility of past-generation BGCs with large-bore intermediate catheters. The next-generation BGC is compatible with large-bore catheters. We compared outcomes of thrombectomy cases using BGCs versus conventional guide catheters. METHODS We conducted a retrospective study of 110 thrombectomy cases using BGCs (n=55) and non-BGCs (n=55). Sixty consecutive thrombectomy cases in whom the BOBBY BGC was used at a single institution between February 2021 and March 2022 were identified. Of these, 55 BGC cases were 1:1 matched with non-BGC cases by proceduralists, age, gender, stent retriever + aspiration device versus aspiration-only, and site of occlusion. First-pass effect was defined as Thrombolysis In Cerebral Infarction 2b or higher with a single pass. RESULTS The BGC and non-BGC cohorts had similar mean age (67.2 vs 68.9 years), gender distribution (43.6% vs 47.3% women), median initial National Institutes of Health Stroke Scale score (14 vs 15), and median pretreatment ischemic core volumes (12 mL vs 11.5 mL). BGC and non-BGC cases had similar rates of single pass (60.0% vs 54.6%), first-pass effect (58.2% vs 49.1%), and complications (1.8% vs 9.1%). In aspiration-only cases, the BGC cohort had a significantly higher rate of first-pass effect (100% vs 50.0%, p=0.01). BGC was associated with a higher likelihood of achieving a modified Rankin Scale score of 2 at discharge (OR 7.76, p=0.02). No additional procedural time was required for BGC cases (46.7 vs 48.2 min). CONCLUSION BGCs may be safely adopted with comparable procedural efficacy, benefits to aspiration-only techniques, and earlier functional improvement compared with conventional guide catheters.
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Affiliation(s)
- Lily H Kim
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - John Choi
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - James Zhou
- California Northstate University College of Medicine, Elk Grove, California, USA
| | - Dylan Wolman
- Radiology, Kaiser Permanente, Portland, Oregon, USA
| | - Arjun V Pendharkar
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Maarten G Lansberg
- Neurology and Neurological Sciences, Stanford University, Stanford, California, USA
| | - Gregory W Albers
- Neurology and Neurological Sciences, Stanford University, Stanford, California, USA
| | - Robert Dodd
- Neurosurgery and Radiology, Stanford University, Stanford, California, USA
| | - Huy M Do
- Radiology, Neuroadiology and Neurointervention Division, Stanford University, Stanford, California, USA
| | - Benjamin Pulli
- Radiology, Neuroadiology and Neurointervention Division, Stanford University, Stanford, California, USA
| | - Jeremy J Heit
- Radiology, Neuroadiology and Neurointervention Division, Stanford University, Stanford, California, USA
| | - Nicholas A Telischak
- Radiology, Neuroadiology and Neurointervention Division, Stanford University, Stanford, California, USA
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Orscelik A, Kallmes DF, Bilgin C, Musmar B, Senol YC, Kobeissi H, Elawady SS, Cunningham C, Matsukawa H, Zandpazandi S, Sowlat MM, Maier I, Al Kasab S, Jabbour P, Kim JT, Wolfe SQ, Rai A, Starke RM, Psychogios MN, Samaniego EA, Arthur AS, Yoshimura S, Cuellar H, Howard BM, Alawieh A, Romano DG, Tanweer O, Mascitelli J, Fragata I, Polifka AJ, Osbun JW, Crosa RJ, Matouk C, Park MS, Levitt MR, Moss M, Dumont TM, Williamson R, Navia P, Kan P, De Leacy R, Chowdhry SA, Ezzeldin M, Spiotta AM, Brinjikji W. Comparison of balloon guide catheter versus non-balloon guide catheter for mechanical thrombectomy in patients with distal medium vessel occlusion. J Neurointerv Surg 2024; 16:587-594. [PMID: 37918906 DOI: 10.1136/jnis-2023-020925] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 10/19/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Several studies have established the safety and efficacy of balloon guide catheters (BGCs) for large vessel occlusions. However, the utility of BGCs remains largely unexplored for distal medium vessel occlusions (DMVOs). In this study, we aim to compare the outcomes of BGC vs. Non-BGC in patients undergoing mechanical thrombectomy (MT) for DMVO. METHOD This retrospective study from the Stroke Thrombectomy and Aneurysm Registry (STAR) encompassed adult patients with acute anterior cerebral artery, posterior cerebral artery, and middle cerebral artery-M2-3-4 occlusions. Procedure times, safety, recanalization, and neurological outcomes were compared between the two groups, with subgroup analysis based on first-line thrombectomy techniques. RESULTS A total of 1508 patients were included, with 231 patients (15.3%) in the BGC group and 1277 patients (84.7%) in the non-BGC group. The BGC group had a lower modified Thrombolysis in Cerebral Infarction (mTICI) score ≥2C (43.2% vs 52.7%, P=0.01), longer time from puncture to intracranial access (15 vs 8 min, P<0.01), and from puncture to final recanalization (97 vs 34 min, P<0.01). In the Solumbra subgroup, the first pass effect (FPE) rate was lower in the BGC group (17.4% vs 30.7%, P=0.03). Regarding clinical outcomes, the BGC group had a lower rate of distal embolization (8.8% vs 14.9%, P=0.03). CONCLUSION Our study found that use of BGC in patients with DMVO was associated with lower mTICI scores, decreased FPE rates, reduced distal embolization, and longer procedure times.
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Affiliation(s)
- Atakan Orscelik
- Department of Radiology, Mayo Clinic Rochester, Rochester, Minnesota, USA
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - David F Kallmes
- Department of Radiology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Cem Bilgin
- Department of Radiology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Basel Musmar
- Department of Radiology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Yigit Can Senol
- Department of Radiology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Hassan Kobeissi
- Department of Radiology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Sameh Samir Elawady
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Conor Cunningham
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Hidetoshi Matsukawa
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Sara Zandpazandi
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Mohammad-Mahdi Sowlat
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ilko Maier
- Department of Neurology, University Medicine Goettingen, Goettingen, NS, Germany
| | - Sami Al Kasab
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Gwangju, Gwangju, Korea (the Republic of)
| | - Stacey Q Wolfe
- Department of Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Ansaar Rai
- Department of Radiology, West Virginia University Hospitals, Morgantown, West Virginia, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Edgar A Samaniego
- Department of Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center/Semmes Murphey Foundation, Memphis, Tennessee, USA
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Hugo Cuellar
- Department of Neurosurgery, Louisiana State University Health Shreveport, Shreveport, Louisiana, USA
| | - Brian M Howard
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Ali Alawieh
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Daniele G Romano
- Department of Neuroradiology, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy
| | - Omar Tanweer
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Justin Mascitelli
- Department of Neurosurgery, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Isabel Fragata
- Department of Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Adam J Polifka
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Joshua W Osbun
- Department of Neurosurgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Roberto Javier Crosa
- Department of Endovascular Neurosurgery, Médica Uruguaya, Montevideo, Montevideo, Uruguay
| | - Charles Matouk
- Department of Neurosurgery, Yale University, New Haven, Connecticut, USA
| | - Min S Park
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Mark Moss
- Department of Interventional Neuroradiology, Washington Regional Medical Center, Fayetteville, Arkansas, USA
| | - Travis M Dumont
- Department of Surgery, Division of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA
| | - Richard Williamson
- Department of Neurology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Pedro Navia
- Department of Interventional and Diagnostic Neuroradiology, Hospital Universitario La Paz, Madrid, Spain
| | - Peter Kan
- Department of Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Reade De Leacy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shakeel A Chowdhry
- Department of Neurosurgery, North Shore University Health System, Evanston, Illinois, USA
| | - Mohamad Ezzeldin
- Department of Clinical Sciences, University of Houston, HCA Houston Healthcare, Kingwood, Texas, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic Rochester, Rochester, Minnesota, USA
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Webb M, Essibayi MA, Al Kasab S, Maier IL, Psychogios MN, Grossberg JA, Alawieh A, Wolfe SQ, Arthur A, Dumont T, Kan P, Kim JT, De Leacy R, Osbun J, Rai A, Jabbour P, Park MS, Crosa R, Levitt MR, Polifka A, Yoshimura S, Matouk C, Williamson RW, Fragata I, Chowdhry SA, Starke RM, Samaniego EA, Cuellar H, Spiotta A, Mascitelli J. Predictors of Angiographic Outcome After Failed Thrombectomy for Large Vessel Occlusion: Insights from the Stroke Thrombectomy and Aneurysm Registry. Neurosurgery 2023; 93:1168-1179. [PMID: 37377425 DOI: 10.1227/neu.0000000000002560] [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: 10/21/2022] [Accepted: 04/17/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Mechanical thrombectomy failure (MTF) occurs in approximately 15% of cases. OBJECTIVE To investigate factors that predict MTF. METHODS This was a retrospective review of prospectively collected data from the Stroke Thrombectomy and Aneurysm Registry. Patients who underwent mechanical thrombectomy (MT) for large vessel occlusion (LVO) were included. Patients were categorized by mechanical thrombectomy success (MTS) (≥mTICI 2b) or MTF ( RESULTS A total of 6780 patients were included, and 1001 experienced anterior circulation MTF. Patients in the MTF group were older (73 vs 72, P = .044) and had higher poor premorbid modified Rankin Scale (mRS) (10.8% vs 8.4%, P = .017). Onset to puncture time was greater in the MTF group (273 vs 260 min, P = .08). No significant differences were found between the access site, use of balloon guide catheter, frontline technique, or first-pass devices between the MTF and MTS groups. More complications occurred in the MTF group (14% vs 5.8%), including symptomatic intracerebral hemorrhage (9.4% vs 6.1%) and craniectomies (10% vs 2.8%) ( P < .001). On UVA, age, poor pretreatment mRS, increased number of passes, and increased procedure time were associated with MTF. Internal carotid artery, M1, and M2 occlusions had decreased odds of MTF. Poor preprocedure mRS, number of passes, and procedure time remained significant on MVA. A subgroup analysis of posterior circulation LVO revealed that number of passes and total procedure time correlated with increased odds of MTF ( P < .001) while rescue stenting was associated with less odds of MTF (odds ratio 0.20, 95% CI 0.06-0.63). Number of passes remained significant on MVA of posterior circulation occlusion subgroup analysis. CONCLUSION Anterior circulation MTF is associated with more complications and worse outcomes. No differences were found between techniques or devises used for the first pass during MT. Rescue intracranial stenting may decrease the likelihood of MTF for posterior circulation MT.
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Affiliation(s)
- Matthew Webb
- Department of Neurosurgery, University of Texas Health Science Center San Antonio, San Antonio , Texas , USA
| | | | - Sami Al Kasab
- Medical University of South Carolina, Charleston , South Carolina , USA
| | - Ilko L Maier
- University Medical Center Göttingen, Göttingen , Germany
| | | | | | | | | | - Adam Arthur
- University of Tennessee Health Science Center, Memphis , Tennessee , USA
| | - Travis Dumont
- Bannner University of Arizona Medical Center, Tucson , Arizona , USA
| | - Peter Kan
- University of Texas Medical Branch, Galveston , Texas , USA
| | - Joon-Tae Kim
- Chonnam National University Hospital, Gwangju , South Korea
| | | | - Joshua Osbun
- Washington University in St. Louis, St. Louis , Missouri , USA
| | - Ansaar Rai
- Department of Neuroradiology, School of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Pascal Jabbour
- Department of Neuroradiology, School of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Min S Park
- Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Roberto Crosa
- University of Virginia, Charlottesville , Virginia , USA
| | - Michael R Levitt
- Centro Endovascular Neurológico, Médica Uruguaya, Montevideo , Uruguay
| | - Adam Polifka
- University of Washington, Seattle , Washington , USA
| | | | | | | | - Isabel Fragata
- Allegheny General Hospital, Pittsburgh , Pennsylvania , USA
| | | | - Robert M Starke
- NorthShore University Health System, Evanston , Illinois , USA
| | | | | | - Alejandro Spiotta
- Medical University of South Carolina, Charleston , South Carolina , USA
| | - Justin Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center San Antonio, San Antonio , Texas , USA
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Cuoco JA, Entwistle JJ, Siddiq F, Puri AS, Woodward K, Hanel RA, Ansari SA, Frei D, Patel BM. The balloon occlusion sheath for stroke (BOSS) balloon guide catheter for stroke intervention: Safety and technical success. Interv Neuroradiol 2023:15910199231198273. [PMID: 37649344 DOI: 10.1177/15910199231198273] [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: 09/01/2023] Open
Abstract
BACKGROUND We describe the first-in-human experience using the Balloon Occlusion Stroke Sheath (BOSSTM) balloon-guide catheter to perform stroke thrombectomy in 50 consecutive patients enrolled in the Flow Arrest Safety and Technical success with balloon-guide catheters trial. This aspiration system includes a novel 9.4F balloon-guide catheter conduit for the insertion and guidance of catheters with a balloon providing temporary flow arrest. METHODS The Flow Arrest Safety and Technical success with balloon-guide catheter trial is a single-arm, prospective, multi-center, non-randomized, observational registry evaluating the use of the market-released BOSSTM balloon-guide catheter in adult patients diagnosed with an acute ischemic stroke attributable to large vessel occlusion. The purpose of the current trial was to assess the safety and technical success associated with the use of the BOSSTM balloon-guide catheter. RESULTS Fifty patients met inclusion criteria with a mean baseline National Institutes of Health Stroke Scale (NIHSS) of 16. Treatment devices, including aspiration and stent retriever devices, were used in a total of 88 passes. The BOSSTM balloon-guide catheter was compatible with all stroke thrombectomy treatment devices used in 98% (49/50) of procedures. Balloon inflation and flow arrest were achieved in 100% (50/50) and 98% (49/50) of cases, respectively. Balloon deflation and retraction were observed in 100% (50/50) of cases. Successful reperfusion (modified thrombolysis in cerebral infarction score > 2b) was achieved in 100% of cases with single-pass reperfusion achieved in 62% (31/50) of cases. CONCLUSIONS The BOSSTM balloon-guide catheter is a safe and technically effective adjunctive device for mechanical thrombectomy of acute ischemic stroke due to large vessel occlusion.
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Affiliation(s)
- Joshua A Cuoco
- Department of Neurosurgery, Carilion Clinic, Roanoke, VA, USA
| | | | - Farhan Siddiq
- Department of Neurosurgery, University of Missouri, Columbia, MO, USA
| | - Ajit S Puri
- Department of Radiology, New England Center for Stroke Research, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Keith Woodward
- Department of Neurointerventional Radiology, Fort Saunders Regional Medical Center, Knoxville, TN, USA
| | - Ricardo A Hanel
- Department of Neurosurgery, Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, FL, USA
- Baptist Medical Center Jacksonville, FL, USA
| | - Sameer A Ansari
- Department of Radiology, Neurology, Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Donald Frei
- Department of Neurointerventional Surgery, Swedish Medical Center, Denver, CO, USA
- Radiology Imaging Associates, RIA Neurovascular Clinic, Englewood, CO, USA
| | - Biraj M Patel
- Department of Neurosurgery, Carilion Clinic, Roanoke, VA, USA
- Department of Radiology, Carilion Clinic, Roanoke, VA, USA
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Dhillon PS, Butt W, Podlasek A, Bhogal P, McConachie N, Lenthall R, Nair S, Malik L, Lynch J, Goddard T, Barrett E, Krishnan K, Dineen RA, England TJ. Effect of proximal blood flow arrest during endovascular thrombectomy (ProFATE): Study protocol for a multicentre randomised controlled trial. Eur Stroke J 2023; 8:581-590. [PMID: 37231682 DOI: 10.1177/23969873231166194] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Observational studies have demonstrated improved outcomes with the adjunctive use of balloon guide catheters (BGC) during endovascular thrombectomy (EVT) for anterior circulation acute ischaemic stroke (AIS). However, the lack of high-level evidence and global practice heterogeneity justifies a randomised controlled trial (RCT) to investigate the effect of transient proximal blood flow arrest on the procedural and clinical outcomes of patients with AIS following EVT. HYPOTHESIS Proximal blood flow arrest in the cervical internal carotid artery during EVT for proximal large vessel occlusion is superior to no flow arrest in achieving complete vessel recanalisation. METHODS ProFATE is an investigator-initiated, pragmatic, multicentre RCT with blinding of participants and outcome assessment. An estimated 124 participants with an anterior circulation AIS due to large vessel occlusion, an NIHSS of ⩾2, ASPECTS ⩾ 5 and eligible for EVT using a first-line combined technique (contact aspiration and stent retriever) or contact aspiration only will be randomised (1:1) to receive BGC balloon inflation or no inflation during EVT. OUTCOMES The primary outcome is the proportion of patients achieving near-complete/complete vessel recanalisation (eTICI 2c-3) at the end of the EVT procedure. Secondary outcomes include the functional outcome (modified Rankin Scale at 90 days), new or distal vascular territory clot embolisation rate, near-complete/complete recanalisation after the first pass, symptomatic intracranial haemorrhage, procedure-related complications and death at 90 days. DISCUSSION This is the first RCT to investigate the effect of proximal blood flow arrest during EVT using a BGC on the procedural and clinical outcomes of patients with AIS due to large vessel occlusion.
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Affiliation(s)
- Permesh Singh Dhillon
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Waleed Butt
- Interventional Neuroradiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - Anna Podlasek
- Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Tayside Innovation Medtech Ecosystem (TIME), University of Dundee, Dundee, UK
| | - Pervinder Bhogal
- Interventional Neuroradiology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Norman McConachie
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Robert Lenthall
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Sujit Nair
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Luqman Malik
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Jeremy Lynch
- Interventional Neuroradiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Tony Goddard
- Interventional Neuroradiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Emma Barrett
- Department of Research and Innovation (Medical Statistics), Manchester University NHS Foundation Trust, Manchester, UK
- Centre for Biostatistics, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - Kailash Krishnan
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, University of Nottingham, Derby, UK
| | - Robert A Dineen
- Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Timothy J England
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, University of Nottingham, Derby, UK
- Stroke, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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8
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Lee H, Park T, Baek J, Kim S, Lee S, Ryou K. Undeflatable balloon guide catheter (BGC) during endovascular procedure: Rescue strategy. J Cerebrovasc Endovasc Neurosurg 2022; 24:372-379. [PMID: 35794749 PMCID: PMC9829560 DOI: 10.7461/jcen.2022.e2021.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/27/2021] [Indexed: 01/21/2023] Open
Abstract
The use of a balloon guide catheter (BGC) in the endovascular management of acute ischemic stroke is known to improve the efficacy and efficiency of the procedure by reducing the risk of distal embolization. During the procedure, the balloon of the catheter causes a temporary arrest of cerebral blood flow. However, failure of the balloon to deflate during the BGC procedure can result in catastrophic complications, including aggravated hypoxic damage.<br/> This paper aims to share the resolution and methodological analysis of our experience with BGC balloon deflation failure, which was confirmed by a reproducible experiment under similar conditions.
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Affiliation(s)
- Hyungkyu Lee
- Department of Neurosurgery, Cheju Halla General Hospital, Jeju, Korea
| | - Taejoon Park
- Department of Neurosurgery, Cheju Halla General Hospital, Jeju, Korea,Correspondence to Taejoon Park Department of Neurosurgery, Cheju Halla General Hospital, 65 Doryeong-ro, Jeju-si, Jeju-do 63127, Korea Tel +82-64-740-5000 Fax +82-64-743-3110 E-mail
| | - Jinwook Baek
- Department of Neurosurgery, Cheju Halla General Hospital, Jeju, Korea
| | - Seonghwan Kim
- Department of Neurosurgery, Cheju Halla General Hospital, Jeju, Korea
| | - Sangpyung Lee
- Department of Neurosurgery, Cheju Halla General Hospital, Jeju, Korea
| | - Kyoungsoo Ryou
- Department of Neurosurgery, Cheju Halla General Hospital, Jeju, Korea
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9
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Li J, Ribo M. REACT Aspiration Catheters: Clinical Experience and Technical Considerations. Neurointervention 2022; 17:70-77. [PMID: 35718472 PMCID: PMC9256469 DOI: 10.5469/neuroint.2022.00255] [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] [Received: 05/25/2022] [Accepted: 06/08/2022] [Indexed: 11/29/2022] Open
Abstract
Aspiration catheters are widely used in mechanical thrombectomy procedures to treat acute ischemic stroke due to large vessel occlusion. The key performance requirements for aspiration catheters are ease of navigation and effective aspiration. In this work, we review the clinical experience and in vitro studies of REACT aspiration catheters (Medtronic, Minneapolis, MN, USA). In vitro experiments showed that REACT catheters exhibit solid performance in navigation and aspiration. Previous studies reported that the recanalization capacity of the aspiration catheters can be influenced by the devices’ inner diameter and tip distensibility, the catheter-to-vessel diameter ratio, the negative pressure delivered by the vacuum generator, the cyclical aspiration mode, the proximal flow arrest, and the angle of interaction between catheter and clot. REACT catheters can be navigated through the vasculature without any support from a microcatheter/ microwire in favorable anatomical configurations. In challenging situations, mostly encountered when crossing the ophthalmic segment of the internal carotid artery, the use of the stentriever anchoring technique or delivery assist catheter can facilitate the navigation. Three clinical studies reporting on 299 patients who underwent mechanical thrombectomy with REACT catheters were included in this review. Successful recanalization (modified treatment in cerebral ischemia score 2b–3) was achieved in 89–96% of cases, no procedural complications related to REACT catheters were reported, and functional independence (modified Rankin Scale 0–2) at 90-days was 24–36%. In vitro experimental evaluations and clinical studies support the safety and effectiveness of the REACT catheters.
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Affiliation(s)
- Jiahui Li
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marc Ribo
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
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10
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The Q and A-The MIVI Q Catheters for Aspiration Thrombectomy-Initial Experience from London. J Clin Med 2021; 10:jcm10245844. [PMID: 34945140 PMCID: PMC8705839 DOI: 10.3390/jcm10245844] [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] [Received: 09/20/2021] [Revised: 11/28/2021] [Accepted: 12/08/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Aspiration thrombectomy is a widely accepted treatment option for large vessel occlusion (LVO). The MIVI aspiration system has a novel design to maximize the lumen size. We present the results of our initial experience with this innovative aspiration thrombectomy system. Materials and Methods: Retrospectively, we reviewed our database to find all cases of LVO treated with the MIVI Q system (February 2019 and July 2020). In addition, we recorded the baseline demographics, NIHSS, ASPECT, mTICI scores, procedural time, complications, and 90 day mRS. Results: Herein, we identified 25 patients with an average age of 65.3 ± 19.3 years (range 19–89), majority of whom were female (n = 14, 56%). The average NIHSS was 16.9 ± 6.7 (range 6–30), and the average CT ASPECT was 7.9 ± 1.4 (range 5–10). The most common clot location was the M1 segment of the MCA (n = 16, 64%). Four of the patients had tandem lesions (16%). The average clot length was 21.7 ± 31 mm (range 2–130 mm). Of the 23 cases where the Q catheter reached the proximal clot face, mTICI ≥ 2b was achieved on the first pass in 11 cases (44%), and at the end of the ‘Q aspiration’ only the procedures with 16 patients achieved mTICI ≥ 2b recanalization (64%). Stent-retrievers were used in 13 cases (52%). At the end of the procedure, 24 patients (96%) achieved mTICI ≥ 2b with 18 patients (72%) achieving mTICI ≥ 2c. The average number of passes with the Q catheter, including when it was used for SOLUMBRA, was 2.1 ± 2.2 (range 1–10). The mean procedure time was 69 ± 32 mins (range 7–116 mins). No complications were associated with the MIVI Q. Conclusions: The MIVI aspiration system is a novel technology with regards to aspiration mechanical thrombectomy. The system is easy to use with early results comparable to other large-bore catheter systems. However, further studies are needed.
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11
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Yang W, Zhang L, Li Z, Zhang Y, Li H, Hua W, Li J, Zhang H, Shen H, Xing P, Zhang Y, Hong B, Liu J, Yang P. Endovascular Treatment for Acute Basilar Artery Occlusion: A Comparison of Arteriosclerotic, Embolic and Tandem Lesions. Cardiovasc Intervent Radiol 2021; 44:1954-1963. [PMID: 34741196 DOI: 10.1007/s00270-021-02994-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 10/16/2021] [Indexed: 12/31/2022]
Abstract
PURPOSE To evaluate the safety and efficacy of endovascular treatment (EVT) for patients with acute ischemic stroke (AIS) due to intracranial atherosclerosis-related basilar artery occlusion (ICAS-related BAO) by comparison with embolic and tandem occlusion. METHODS We retrospectively reviewed consecutive patients with AIS due to BAO who underwent EVT. Patients were assigned to the ICAS-related group and embolic group, and tandem group based on the etiology. Baseline data, procedural details, and clinical outcomes were compared between the three groups. RESULTS A total of 100 patients (ICAS-related group: 31; embolic group: 41; tandem group: 28) were included. No significant difference was observed in the successful reperfusion (mTICI 2b or 3), but the procedural time differed significantly (60 min vs. 43 min vs. 60 min, P = 0.010). There were no differences in the different intracranial hemorrhage grades among the three groups (P = 0.134). After adjusting for baseline differences, there was no significant difference in pairwise comparisons regarding favorable outcome (mRS 0-2), moderate outcome (mRS 0-3), and mortality. CONCLUSIONS Endovascular treatment for patients with acute ICAS-related BAO had equal efficacy and safety compared with embolic BAO and tandem BAO. Primary endovascular treatment and rescue modalities were effective treatments for acute ICAS-related BAO.
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Affiliation(s)
- Wenjin Yang
- Cerebrovascular Disease Center, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China.,Department of Neurosurgery, Pudong New Area People's Hospital, 490 Chuanhuan South Road, Shanghai, 201299, China
| | - Lei Zhang
- Cerebrovascular Disease Center, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Zifu Li
- Cerebrovascular Disease Center, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Yongxin Zhang
- Cerebrovascular Disease Center, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - He Li
- Cerebrovascular Disease Center, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Weilong Hua
- Cerebrovascular Disease Center, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Jianan Li
- Cerebrovascular Disease Center, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Hongjian Zhang
- Cerebrovascular Disease Center, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Hongjian Shen
- Cerebrovascular Disease Center, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Pengfei Xing
- Cerebrovascular Disease Center, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Yongwei Zhang
- Cerebrovascular Disease Center, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Bo Hong
- Cerebrovascular Disease Center, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Jianmin Liu
- Cerebrovascular Disease Center, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Pengfei Yang
- Cerebrovascular Disease Center, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China.
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12
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Podlasek A, Dhillon PS, Jewett G, Shahein A, Goyal M, Almekhlafi M. Clinical and Procedural Outcomes with or without Balloon Guide Catheters during Endovascular Thrombectomy in Acute Ischemic Stroke: A Systematic Review and Meta-analysis with First-line Technique Subgroup Analysis. AJNR Am J Neuroradiol 2021; 42:1464-1471. [PMID: 34045301 DOI: 10.3174/ajnr.a7164] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 03/16/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Balloon guide catheters are increasingly used to improve clot retrieval by temporarily stopping proximal blood flow during endovascular thrombectomy. PURPOSE Our aim was to provide a summary of the literature comparing the procedural and clinical outcomes of endovascular thrombectomy with or without balloon guide catheters, depending on the first-line technique used. DATA SOURCES We used PubMed/MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews. STUDY SELECTION We chose studies that compared using balloon guide catheters with not using them. DATA ANALYSIS Random effects meta-analysis was performed to compare the procedural outcomes measured as the first-pass effect, successful reperfusion, number of passes, procedural duration, arterial puncture to reperfusion time, distal emboli, and clinical outcomes. DATA SYNTHESIS Overall, a meta-analysis of 16 studies (5507 patients, 50.8% treated with balloon guide catheters and 49.2% without them) shows that the use of balloon guide catheters increases the odds of achieving a first-pass effect (OR = 1.92; 95% CI, 1.34-2.76; P < .001), successful reperfusion (OR = 1.85; 95% CI, 1.42-2.40; P < .001), and good functional outcome (OR =1.48; 95% CI, 1.27-1.73; P < .001). Balloon guide catheters reduce the number of passes (mean difference = -0.35; 95% CI, -0.65 to -0.04; P = .02), procedural time (mean difference = -19.73; 95% CI, -34.63 to -4.83; P = .009), incidence of distal or new territory emboli (OR = 0.5; 95% CI, 0.26-0.98; P = .04), and mortality (OR = 0.72; 95% CI, 0.62-0.85; P < .001). Similar benefits of balloon guide catheters are observed when the first-line technique was a stent retriever or contact aspiration, but not for a combined approach. LIMITATIONS The analysis was based on nonrandomized trials with a moderate risk of bias. CONCLUSIONS Current literature suggests improved clinical and procedural outcomes associated with the use of balloon guide catheters during endovascular thrombectomy, especially when using the first-line stent retriever.
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Affiliation(s)
- A Podlasek
- From the Department of Neuroscience and Vascular Simulation (A.P.), School of Medicine, Anglia Ruskin University, Chelmsford, Essex, UK
- National Institute of Health Research Nottingham Biomedical Research Centre (A.P., P.S.D.), University of Nottingham, Nottingham, UK
- Clinical Radiology (A.P., P.S.D.), Queens Medical Centre, Nottingham University Hospitals National Health Service Trust, Nottingham, UK
| | - P S Dhillon
- National Institute of Health Research Nottingham Biomedical Research Centre (A.P., P.S.D.), University of Nottingham, Nottingham, UK
- Clinical Radiology (A.P., P.S.D.), Queens Medical Centre, Nottingham University Hospitals National Health Service Trust, Nottingham, UK
| | - G Jewett
- Department of Clinical Neurosciences (G.J., A.S., M.G., M.A.), University of Calgary, Calgary, Alberta, Canada
| | - A Shahein
- Department of Clinical Neurosciences (G.J., A.S., M.G., M.A.), University of Calgary, Calgary, Alberta, Canada
| | - M Goyal
- Department of Clinical Neurosciences (G.J., A.S., M.G., M.A.), University of Calgary, Calgary, Alberta, Canada
- Department of Radiology (M.G., M.A.), University of Calgary, Calgary, Alberta, Canada
| | - M Almekhlafi
- Department of Clinical Neurosciences (G.J., A.S., M.G., M.A.), University of Calgary, Calgary, Alberta, Canada
- Department of Radiology (M.G., M.A.), University of Calgary, Calgary, Alberta, Canada
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13
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Goyal M, Kappelhof M, Ospel JM, Bala F. Balloon guide catheters: use, reject, or randomize? Neuroradiology 2021; 63:1179-1183. [PMID: 34100099 DOI: 10.1007/s00234-021-02739-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 05/24/2021] [Indexed: 10/21/2022]
Abstract
Thrombectomy devices played an important role in the success of endovascular treatment trials over the past five years. A balloon guide catheter (BGC) is an adjunctive device used to arrest and reverse flow by inflating the balloon at its tip, which allows for flow reversal in intracranial arteries during retrieval of thrombectomy devices by applying concomitant aspiration through its lumen. Thereby, it can decrease the risk of clot fragmentation and distal embolization. Despite the numerous benchtop and clinical observational studies showing the superiority of BGC to conventional guide catheters in improving reperfusion quality and clinical outcome, its use is still low in clinical practice. The reasons behind this reluctance might be related to technical and cost issues. Therefore, high level evidence data, i.e., a randomized clinical trial, are needed to increase its implementation in thrombectomy procedures. Nonetheless, several obstacles and challenges can prevent the completion of such a trial, and efforts are needed to overcome them. We provide an overview of the current opinions about BGCs in the neurointerventional community and discuss the feasibility and challenges of a possible randomized trial to answer the question "should a BGC be routinely used in endovascular treatment of acute ischemic stroke?"
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Affiliation(s)
- Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.
- Department of Diagnostic Imaging, University of Calgary, Calgary, Canada.
| | - Manon Kappelhof
- Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Johanna M Ospel
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basil, Switzerland
| | - Fouzi Bala
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
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14
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Baek SH, Kim S, Kang M, Choi JH, Kwon HJ, Kim DW. Effect of distal access catheter tip position on angiographic and clinical outcomes following thrombectomy using the combined stent-retriever and aspiration approach. PLoS One 2021; 16:e0252641. [PMID: 34111176 PMCID: PMC8192018 DOI: 10.1371/journal.pone.0252641] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 05/19/2021] [Indexed: 11/19/2022] Open
Abstract
Purpose Mechanical thrombectomy using the stent-retriever in conjunction with the distal access catheter may improve the rates of successful revascularization and clinical outcomes in patients with acute stroke. We aimed to compare two different thrombectomy techniques, according to the position of the distal access catheter tip in the combined stent-retriever and aspiration approach. Methods In this retrospective study, patients with middle cerebral artery occlusion treated with the combined technique were divided into two groups based on the tip position of the distal access catheter: distal group (catheter placed adjacent to the thrombus) and proximal group (catheter placed in the cavernous segment of the internal carotid artery below the ophthalmic artery). Baseline characteristics, angiographic results, and clinical outcomes were compared. Results Eighty-three patients (distal group, n = 45; proximal group, n = 38) were included. Higher complete reperfusion was observed in the distal group (unweighted analysis: 66.7% vs. 42.1%, p = 0.025; weighted analysis: 74.0% vs. 28.8%; p = 0.002). In the multivariate analysis, the distal tip position was independently associated with complete reperfusion (unweighted analysis: aOR, 4.10; 95% CI, 1.40–11.98; p = 0.01; weighted analysis: aOR, 5.20; 95% CI, 1.72–15.78; p = 0.004). The distal group also showed more favorable clinical outcomes and early neurological improvement (unweighted analysis: 62.2% vs. 55.3%; p = 0.521, 60% vs. 50%; p = 0.361, respectively; weighted analysis: 62.7% vs. 61.1%; p = 0.877, 66% vs. 45.7%; p = 0.062, respectively). However, more arterial dissections were observed in the distal group (8.9%, n = 4 vs. 2.6%, n = 1; p = 0.36). In the distal group, one patient with vascular injury died due to complications. No cases of emboli in new territory were observed. Conclusions Distal tip position of the distal access catheter has a significant impact on reperfusion in patients with acute ischemic stroke. However, there was also a higher rate of vascular injury as the catheter was advanced further. If advancement to the target lesion is too difficult, placing it in the cavernous internal carotid artery may be a viable method without complications.
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Affiliation(s)
- Sang Hun Baek
- Department of Radiology, Busan Regional Cardio-Cerebrovascular Disease Center, Dong-A University Hospital, Busan, Republic of Korea
| | - Sanghyeon Kim
- Department of Radiology, Busan Regional Cardio-Cerebrovascular Disease Center, Dong-A University Hospital, Busan, Republic of Korea
- * E-mail:
| | - Myongjin Kang
- Department of Radiology, Busan Regional Cardio-Cerebrovascular Disease Center, Dong-A University Hospital, Busan, Republic of Korea
| | - Jae-Hyung Choi
- Department of Neurosurgery, Busan Regional Cardio-Cerebrovascular Disease Center, Dong-A University Hospital, Busan, Republic of Korea
| | - Hee Jin Kwon
- Department of Radiology, Busan Regional Cardio-Cerebrovascular Disease Center, Dong-A University Hospital, Busan, Republic of Korea
| | - Dong Won Kim
- Department of Radiology, Busan Regional Cardio-Cerebrovascular Disease Center, Dong-A University Hospital, Busan, Republic of Korea
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15
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Kim YW, Kang DH, Son W, Hwang YH, Kim YS, Shin JW, Lim JW, Koh HS, Kwon HJ. Usefulness of combination usage of balloon guide catheter with contact aspiration thrombectomy. Acta Neurochir (Wien) 2021; 163:1787-1797. [PMID: 33723972 DOI: 10.1007/s00701-021-04787-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 02/22/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Angiographic outcomes of contact aspiration thrombectomy (CAT), a frontline thrombectomy strategy, can vary depending on balloon guide catheter (BGC) usage, stroke etiology, and occlusion location. The purpose of this study was to analyze conditional outcomes of CAT to determine which result in maximum angiographic benefits. METHODS Patients who received CAT for anterior circulation occlusive stroke between January 2017 and December 2018 were included. Angiographic and clinical outcomes were compared relative to BGC use, stroke etiology, and occlusion location. Multivariable analyses for first-pass reperfusion (FPR) and favorable clinical outcome were performed. RESULTS Of 160 included patients, the rates of FPR, successful reperfusion after CAT, final successful reperfusion, and favorable clinical outcome were 43.1%, 58.1%, 81.9%, and 60.6%, respectively. BGC use was associated with a higher rate of FPR, successful reperfusion after CAT, a lower rate of distal embolization, and faster reperfusion. Based on subgroup analysis, BGC usage in ICA, MCA M1 occlusion, and cardioembolism were associated with higher FPR, successful reperfusion after CAT, and lower distal embolization. Faster reperfusion was achieved in ICA occlusions and cardioembolisms. BGC usage was an independent predictor of FPR. Favorable clinical outcome was associated with male gender, low initial NIHSS score, fast onset to reperfusion, and FPR. CONCLUSIONS In CAT, BGC usage was associated with better angiographic outcomes, including higher FPR, successful reperfusion after CAT, prevention of distal embolization, and faster reperfusion, especially in proximal occlusions and cardioembolisms. These conditions may play a role in maximizing the benefits of CAT.
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16
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Dossani RH, Waqas M, Baig AA, Cappuzzo JM, Popoola D, Rai H, Monteiro A, Levy A, Hashmi E, Davies JM, Levy EI, Siddiqui AH. Walrus Balloon Guide Catheter for Stroke Intervention: Technical Considerations and Clinical Outcomes. World Neurosurg 2021; 152:e144-e148. [PMID: 34033957 DOI: 10.1016/j.wneu.2021.05.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/13/2021] [Accepted: 05/14/2021] [Indexed: 09/30/2022]
Abstract
BACKGROUND The use of balloon guide catheters (BGCs) for proximal flow arrest during neurointerventional procedures has been limited owing to the incompatibility of BGCs with large-bore aspiration catheters and difficulty in device navigation. The objective of our study was to describe the use of the Walrus catheter (Q'Apel Medical, Fremont, California, USA), a new 8F BGC, with a variety of aspiration catheters and procedures requiring flow arrest. METHODS Consecutive cases using Walrus BGCs for proximal flow arrest during mechanical thrombectomy for acute stroke cases were recorded. The procedure indication, vessel occlusion site, technique, first-pass effect (modified thrombolysis in cerebral infarction score of 2C or 3 after the first recanalization attempt), and complications were recorded and evaluated statistically. RESULTS Our study included 57 patients who had undergone mechanical thrombectomy. In addition to mechanical thrombectomy, the Walrus BGC was used in conjunction with the following techniques: stent retrieval in 2 patients (3.5%), stent retrieval followed by aspiration (Solumbra technique) in 41 (71.9%), and aspiration followed by stent retrieval in 14 patients (24.6%). Eight different aspiration catheters were used in 56 of these 57 procedures. The first-pass effect (modified thrombolysis in cerebral infarction score of 2C and 3) was achieved in 36 (63.2%) of 57 procedures. Two patients (3.5%) had experienced intraoperative complications (symptomatic intracerebral hemorrhage) and one patient (1.8%) had died in-hospital. CONCLUSIONS Our results have demonstrated that the Walrus BGC is a highly navigable 8F guide catheter compatible with most available aspiration catheters. Owing to its compatibility with most available aspiration catheters and ease of use, the Walrus BGC is a valuable addition to the tools available for mechanical thrombectomy.
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Affiliation(s)
- Rimal H Dossani
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Ammad A Baig
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Justin M Cappuzzo
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Daniel Popoola
- Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
| | - Hamid Rai
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Andre Monteiro
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Aaron Levy
- University of California Santa Barbara, Santa Barbara, California, USA
| | | | - Jason M Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA; Department of Bioinformatics, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA; Canon Stroke and Vascular Research Center, State University of New York at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA; Jacobs Institute, Buffalo, New York, USA
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA; Canon Stroke and Vascular Research Center, State University of New York at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA; Jacobs Institute, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA; Department of Bioinformatics, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA; University of California Santa Barbara, Santa Barbara, California, USA; Jacobs Institute, Buffalo, New York, USA.
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17
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Waqas M, Li W, Patel TR, Chin F, Tutino VM, Dossani RH, Ren Z, Guerrero WR, Borlongan CV, Pressman E, Snyder K, Davies JM, Ley EI, Ionita CN, Siddiqui AH, Mokin M. Clot imaging characteristics predict first pass effect of aspiration-first approach to thrombectomy. Interv Neuroradiol 2021; 28:152-159. [PMID: 34000868 DOI: 10.1177/15910199211019174] [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] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The value of clot imaging in patients with emergent large vessel occlusion (ELVO) treated with thrombectomy is unknown. METHODS We performed retrospective analysis of clot imaging (clot density, perviousness, length, diameter, distance to the internal carotid artery (ICA) terminus and angle of interaction (AOI) between clot and the aspiration catheter) of consecutive cases of middle cerebral artery (MCA) occlusion and its association with first pass effect (FPE, TICI 2c-3 after a first attempt). RESULTS Patients (n = 90 total) with FPE had shorter clot length (9.9 ± 4.5 mm vs. 11.7 ± 4.6 mm, P = 0.07), shorter distance from ICA terminus (11.0 ± 7.1 mm vs. 14.7 ± 9.8 mm, P = 0.048), higher perviousness (39.39 ± 29.5 vs 25.43 ± 17.6, P = 0.006) and larger AOI (153.6 ± 17.6 vs 140.3 ± 23.5, P = 0.004) compared to no-FPE patients. In multivariate analysis, distance from ICA terminus to clot ≤13.5 mm (odds ratio (OR) 11.05, 95% confidence interval (CI) 2.65-46.15, P = 0.001), clot length ≤9.9 mm (OR 7.34; 95% CI 1.8-29.96, P = 0.005), perviousness ≥ 19.9 (OR 2.54, 95% CI 0.84-7.6, P = 0.09) and AOI ≥ 137°^ (OR 6.8, 95% CI 1.55-29.8, P = 0.011) were independent predictors of FPE. The optimal cut off derived using Youden's index was 6.5. The area under the curve of a score predictive of FPE success was 0.816 (0.728-0.904, P < 0.001). In a validation cohort (n = 30), sensitivity, specificity, positive and negative predictive value of a score of 6-10 were 72.7%, 73.6%, 61.5% and 82.3%. CONCLUSIONS Clot imaging predicts the likelihood of achieving FPE in patients with MCA ELVO treated with the aspiration-first approach.
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Affiliation(s)
- Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Weizhe Li
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, USA
| | - Tatsat R Patel
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA.,Department of Mechanical and Aerospace Engineering, University at Buffalo, Buffalo, NY, USA
| | - Felix Chin
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Vincent M Tutino
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA.,Department of Mechanical and Aerospace Engineering, University at Buffalo, Buffalo, NY, USA
| | - Rimal H Dossani
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA.,Department of Mechanical and Aerospace Engineering, University at Buffalo, Buffalo, NY, USA
| | - Zeguang Ren
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, USA.,Tampa General Hospital, Neurosciences Center, Tampa, FL, USA
| | - Waldo R Guerrero
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, USA.,Tampa General Hospital, Neurosciences Center, Tampa, FL, USA
| | - Cesario V Borlongan
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, USA
| | - Elliot Pressman
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, USA
| | - Kenneth Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Jason M Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Elad I Ley
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Ciprian N Ionita
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Maxim Mokin
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, USA.,Tampa General Hospital, Neurosciences Center, Tampa, FL, USA
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18
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Li J, Castaño O, Tomasello A, de Dios Lascuevas M, Canals P, Engel E, Ribo M. Catheter tip distensibility substantially influences the aspiration force of thrombectomy devices. J Neurointerv Surg 2021; 14:neurintsurg-2021-017487. [PMID: 33858973 DOI: 10.1136/neurintsurg-2021-017487] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 03/30/2021] [Accepted: 04/01/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND A direct aspiration first pass thrombectomy (ADAPT) is a fast-growing technique for which a broad catalog of catheters that provide a wide range of aspiration forces can be used. We aimed to characterize different catheters' aspiration performance on stiff clots in an in vitro vascular model. We hypothesized that labeled catheter inner diameter (labeled-ID) is not the only parameter that affects the aspiration force (asp-F) and that thrombus-catheter tip interaction and distensibility also play a major role. METHODS We designed an experimental setup consisting of a 3D-printed carotid artery immersed in a water deposit. We measured asp-F and distensibility of catheter tips when performing ADAPT on a stiff clot analog larger than catheter labeled-ID. Correlations between asp-F, catheter ID, and tip distensibility were statistically assessed. RESULTS Experimental asp-F and catheter labeled-ID were correlated (r=0.9601; P<0.01). The relative difference between experimental and theoretical asp-F (obtained by the product of the tip's section area by the vacuum pressure) correlated with tip's distensibility (r=0.9050; P<0.01), evidencing that ADAPT performance is highly influenced by catheter tip shape-adaptability to the clot and that the effective ID (eff-ID) may differ from the labeled-ID specified by manufacturers. Eff-ID showed the highest correlation with experimental asp-F (r=0.9944; P<0.01), confirming that eff-ID rather than labeled-ID should be considered to better estimate the device efficiency. CONCLUSIONS Catheter tip distensibility can induce a significant impact on ADAPT performance when retrieving a stiff clot larger than the device ID. Our findings might contribute to optimizing thrombectomy strategies and the design of novel aspiration catheters.
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Affiliation(s)
- Jiahui Li
- Stroke Unit, Neurology, Hospital Vall d'Hebron, Barcelona, Spain.,Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Oscar Castaño
- Electronics and Biomedical Engineering, University of Barcelona, Barcelona, Spain.,Biomaterials for Regenerative Therapies, Institute for Bioengineering in Catalonia, Barcelona, Spain
| | | | | | - Pere Canals
- Stroke Unit, Neurology, Hospital Vall d'Hebron, Barcelona, Spain.,Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Elisabeth Engel
- CIBER en Bioingeniería, Biomateriales y Nanomedicina, CIBER, Madrid, Spain.,Materials Science and Engineering, Technical University of Catalonia, Barcelona, Spain
| | - Marc Ribo
- Stroke Unit, Neurology, Hospital Vall d'Hebron, Barcelona, Spain .,Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
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19
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Lee JS, Hwang YH, Sohn SI. Factors Contributing to an Efficacious Endovascular Treatment for Acute Ischemic Stroke in Asian Population. Neurointervention 2021; 16:91-110. [PMID: 33765729 PMCID: PMC8261106 DOI: 10.5469/neuroint.2020.00339] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 02/19/2021] [Indexed: 12/13/2022] Open
Abstract
Although randomized control trials about endovascular treatment (EVT) of emergent large vessel occlusion (LVO) have demonstrated the success of mechanical thrombectomy as the choice of treatment, a wide range of caveats remain unaddressed. Asian patients were rarely included in the trials, thereby raising the question of whether the treatment could be generalized. In addition, there remains a concern on the feasibility of the method with respect to its application against intracranial atherosclerosis (ICAS)-related LVO, frequently observed in the Asian population. It is important to include evidence on ICAS LVO from Asian countries in the future for a comprehensive understanding of LVO etiology. Besides the issues with EVT, prognostic concerns in diabetes patients, acute kidney injury following EVT, neuroprotective management against reperfusion injury, and other peri-EVT issues should be considered in clinical practice. In the current article, we present an in-depth review of the literature that revises information pertaining to such concerns.
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Affiliation(s)
- Jin Soo Lee
- Department of Neurology, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Yang-Ha Hwang
- Department of Neurology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University Dongsan Hospital, Kyemyung University School of Medicine, Daegu, Korea
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20
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Lee SJ, Park SY, Hong JM, Choi JW, Kang DH, Kim YW, Kim YS, Hong JH, Kim CH, Yoo J, Nogueira RG, Hwang YH, Sohn SI, Lee JS. Etiological Approach to Understanding Recanalization Failure in Intracranial Large Vessel Occlusion and Thrombectomy: Close to Embolism but Distant From Atherosclerosis. Front Neurol 2021; 11:598216. [PMID: 33536994 PMCID: PMC7848124 DOI: 10.3389/fneur.2020.598216] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 12/10/2020] [Indexed: 12/28/2022] Open
Abstract
Introduction: In patients with intracranial large vessel occlusion (LVO) who undergo endovascular treatment (EVT), recanalization failure may be related to intracranial atherosclerotic stenosis (ICAS). We evaluated whether the risk factors of recanalization failure could possibly be a marker of ICAS among various types of LVO. Methods: From a multicenter registry, patients with middle cerebral artery M1 segment occlusions who underwent thrombectomy within 24 h were included. Based on the on-procedure and post-procedure angiographic findings, patients were classified into embolic, ICAS-related, tandem occlusion, and recanalization failure groups. Recanalization failure was defined if the occluded vessel could not be recanalized by stent retrieval, contact aspiration, or local lytics treatment. Risk factors, imaging markers, and EVT methods were compared between groups. Results: Among 326 patients, 214 were classified as embolism, 76 as ICAS, 16 as tandem, and 20 as recanalization failure. The group with recanalization failure showed higher scores on the National Institutes of Health Stroke Scale (NIHSS) (median, 16.0 vs. 14.5 vs. 14.0 vs. 17.0, p = 0.097), frequent atrial fibrillation (59.3 vs. 18.4 vs. 0 vs. 40.0% p < 0.001), and elevation in erythrocyte sedimentation rate (ESR) (14.5 ± 15.7 vs. 15.0 ± 14.1 vs. 21.2 ± 19.5 vs. 36.0 ± 32.9, p < 0.001) among the groups. The rate of computed tomography angiography-based truncal-type occlusion in recanalization failure group was not as high as that in the ICAS group (8.1 vs. 37.5 vs. 0 vs. 16.7%, p < 0.001). Balloon guide catheters (BGC) were less frequently utilized in the recanalization failure group as compared to their use in the other groups (72.0 vs. 72.4 vs. 62.5 vs. 30.0%, p = 0.001). In the multivariable analysis, initial higher NIHSS [odds ratio (OR), 1.11 95% confidence interval (CI), 1.01–1.22 p = 0.027], higher ESR (OR, 1.03 CI, 1.01–1.05 p = 0.006), and non-use of BGCs (OR, 3.41 CI, 1.14–10.17 p = 0.028) were associated with recanalization failure. In M1 occlusions, the predominant mechanism of recanalization failure was presumed to be embolic in 80% and due to ICAS in 20%. Conclusion: The analysis of recanalization failures does not suggest an underlying predominant ICAS mechanism. Sufficient utilization of thrombectomy devices and procedures may improve the rates of recanalization.
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Affiliation(s)
- Seong-Joon Lee
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
| | - So Young Park
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
| | - Ji Man Hong
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
| | - Jin Wook Choi
- Department of Radiology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
| | - Dong-Hun Kang
- Department of Neurosurgery, School of Medicine, Kyungpook National University, Daegu, South Korea.,Department of Radiology, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Yong-Won Kim
- Department of Radiology, School of Medicine, Kyungpook National University, Daegu, South Korea.,Department of Neurology, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Yong-Sun Kim
- Department of Radiology, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Chang-Hyun Kim
- Department of Neurosurgery, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Joonsang Yoo
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, South Korea.,Department of Neurology, National Health Insurance Service Ilsan Hospital, Goyang, South Korea
| | - Raul G Nogueira
- Department of Neurology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, United States
| | - Yang-Ha Hwang
- Department of Neurology, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Jin Soo Lee
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
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21
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Nogueira RG, Mohammaden MH, Al-Bayati AR, Frankel MR, Haussen DC. Preliminary experience with 088 large bore intracranial catheters during stroke thrombectomy. Interv Neuroradiol 2020; 27:427-433. [PMID: 33353466 DOI: 10.1177/1591019920982219] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND PURPOSE Thromboaspiration technology continues to evolve at an accelerated pace with increasing availability of larger and more navigable devices. Herein, we provide our initial experience with the intracranial navigation of a large-bore (.088" inner diameter) catheters during mechanical thrombectomy (MT). METHODS Retrospective review of consecutive large vessel occlusion stroke patients in whom a TracStar™ or Zoom 88™ (Imperative Care, Campbell, CA) large-bore catheters were utilized in MT. The primary outcome was successful reperfusion (eTICI2b-3) at the end of the procedure. Safety measures included procedural complications and rates of symptomatic intracranial hemorrhage. RESULTS Five patients (age,∼50-85 years; baseline NIHSS,17-23) were treated. The .088" catheters were used as the primary tool for contact aspiration in two patients (distal basilar artery and proximal MCA occlusions) with complete thrombus ingestion (eTICI3) during the first pass. In two patients, the .088" catheter was used for flow control where it was placed in the distal M1-segment of a patient with M2 occlusion treated with a combination of stent-retriever and .070" aspiration catheter and in the proximal M1 in a patient with distal M1 occlusion treated with .071" aspiration catheter resulting in eTICI3 reperfusion in both cases. In the fifth patient, the .088" catheter was navigated into the cavernous ICA to support .071" aspiration catheter treatment of an M2 occlusion resulting in eTCI2b67 reperfusion. Procedural duration ranged between 14 and 33 minutes. There were no adverse events. CONCLUSION Intracranial navigation of .088" large-bore catheters in MT appears technically feasible and safe. Larger prospective studies are warranted.
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Affiliation(s)
- Raul G Nogueira
- Department of Neurology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, USA
| | - Mahmoud H Mohammaden
- Department of Neurology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, USA
| | - Alhamza R Al-Bayati
- Department of Neurology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael R Frankel
- Department of Neurology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, USA
| | - Diogo C Haussen
- Department of Neurology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, USA
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22
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Hafeez MU, Kan P, Srivatsan A, Moore S, Jafari M, DeLaGarza C, Hafeez K, Nascimento FA, Srinivasan VM, Burkhardt JK, Chen S, Johnson J, Saleem Y. Comparison of First-Pass Efficacy Among Four Mechanical Thrombectomy Techniques: A Single-Center Experience. World Neurosurg 2020; 144:e533-e540. [PMID: 32891839 DOI: 10.1016/j.wneu.2020.08.209] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 08/29/2020] [Accepted: 08/29/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND First-pass efficacy (FPE) is an established marker of technical and clinical efficacy among mechanical thrombectomy (MT) techniques. It is unclear what the optimal approach is in achieving FPE. We present a single-center experience comparing rates of FPE among 2 MT techniques and evaluate the potential predictors of FPE among other outcomes. METHODS A single-center retrospective analysis was carried out of patients with consecutive large-vessel occlusion strokes (LVOS) of anterior circulation from September 2015 to April 2019 who underwent MT and for whom data were available on the status of FPE. Four MT techniques were identified: ADAPT (a direct first-pass aspiration), SrADAPT (stent retriever with aspiration), SRBG (stent retriever with balloon guide catheter), and STRAP (stent retriever-aspiration and proximal flow arrest). The primary outcome was FPE and secondary outcomes included the rate of successful reperfusion. RESULTS Among 226 patients with LVOS of the anterior circulation who underwent MT, data were available for 164 on FPE for the 4 MT techniques. SRBG was the most prevalent technique. No significant difference was found in rates of FPE among the 4 MT techniques (P = 0.332). No independent predictors of FPE were identified on multivariable analysis. STRAP had the highest rate of successful reperfusion compared with the other techniques (P = 0.049) and was the only independent predictor of that outcome (P = 0.027). CONCLUSIONS Among patients with LVOS of the anterior circulation, the rate of FPE did not differ among the 4 MT techniques. There were no predictors of FPE among the studied variables. STRAP was the only predictor of successful reperfusion.
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Affiliation(s)
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Aditya Srivatsan
- Department of Neurology, Baylor College of Medicine, Houston, Texas, USA
| | - Shawn Moore
- Department of Neurology, Baylor College of Medicine, Houston, Texas, USA
| | - Mostafa Jafari
- Department of Neurology, Baylor College of Medicine, Houston, Texas, USA
| | - Carlos DeLaGarza
- Department of Neurology, Baylor College of Medicine, Houston, Texas, USA
| | - Komal Hafeez
- Department of Neurology, Baylor College of Medicine, Houston, Texas, USA
| | - Fabio A Nascimento
- Department of Neurology, Baylor College of Medicine, Houston, Texas, USA
| | | | - Jan-Karl Burkhardt
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Stephen Chen
- Department of Interventional Neuroradiology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Jeremiah Johnson
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Yasir Saleem
- Department of Neurology, Baylor College of Medicine, Houston, Texas, USA
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23
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Velasco Gonzalez A, Görlich D, Buerke B, Münnich N, Sauerland C, Rusche T, Faldum A, Heindel W. Predictors of Successful First-Pass Thrombectomy with a Balloon Guide Catheter: Results of a Decision Tree Analysis. Transl Stroke Res 2020; 11:900-909. [PMID: 32447614 PMCID: PMC7496051 DOI: 10.1007/s12975-020-00784-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 01/13/2020] [Accepted: 01/28/2020] [Indexed: 02/06/2023]
Abstract
Complete recanalization after a single retrieval maneuver is an interventional goal in acute ischemic stroke and an independent factor for good clinical outcome. Anatomical biomarkers for predicting clot removal difficulties have not been comprehensively analyzed and await unused. We retrospectively evaluated 200 consecutive patients who suffered acute stroke and occlusion of the anterior circulation and were treated with mechanical thrombectomy through a balloon guide catheter (BGC). The primary objective was to evaluate the influence of carotid tortuosity and BGC positioning on the one-pass Modified Thrombolysis in Cerebral Infarction Scale (mTICI) 3 rate, and secondarily, the influence of communicating arteries on the angiographic results. After the first-pass mTICI 3, recanalization fell from 51 to 13%. The regression models and decision tree (supervised machine learning) results concurred: carotid tortuosity was the main constraint on efficacy, reducing the likelihood of mTICI 3 after one pass to 30%. BGC positioning was relevant only in carotid arteries without elongation: BGCs located in the distal internal carotid artery (ICA) had a 70% probability of complete recanalization after one pass, dropping to 43% if located in the proximal ICA. These findings demonstrate that first-pass mTICI 3 is influenced by anatomical and interventional factors capable of being anticipated, enabling the BGC technique to be adapted to patient’s anatomy to enhance effectivity.
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Affiliation(s)
- Aglaé Velasco Gonzalez
- Department of Clinical Radiology, Institute of Clinical Radiology and Neuroradiology, University Hospital of Muenster, Albert-Schweitzer-Campus 1, Building A1, 48149 Muenster, Germany
| | - Dennis Görlich
- Institute of Biostatistics and Clinical Research, University of Muenster, Schmeddingstraße 56, 48149 Muenster, Germany
| | - Boris Buerke
- Department of Clinical Radiology, Institute of Clinical Radiology and Neuroradiology, University Hospital of Muenster, Albert-Schweitzer-Campus 1, Building A1, 48149 Muenster, Germany
| | - Nico Münnich
- Department of Clinical Radiology, Institute of Clinical Radiology and Neuroradiology, University Hospital of Muenster, Albert-Schweitzer-Campus 1, Building A1, 48149 Muenster, Germany
| | - Cristina Sauerland
- Institute of Biostatistics and Clinical Research, University of Muenster, Schmeddingstraße 56, 48149 Muenster, Germany
| | - Thilo Rusche
- Department of Clinical Radiology, Institute of Clinical Radiology and Neuroradiology, University Hospital of Muenster, Albert-Schweitzer-Campus 1, Building A1, 48149 Muenster, Germany
| | - Andreas Faldum
- Institute of Biostatistics and Clinical Research, University of Muenster, Schmeddingstraße 56, 48149 Muenster, Germany
| | - Walter Heindel
- Department of Clinical Radiology, Institute of Clinical Radiology and Neuroradiology, University Hospital of Muenster, Albert-Schweitzer-Campus 1, Building A1, 48149 Muenster, Germany
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24
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Rajah GB, Lieber B, Kappel AD, Luqman AW. Distal transradial access in the anatomical snuffbox for balloon guide-assisted stentriever mechanical thrombectomy: Technical note and case report. Brain Circ 2020; 6:60-64. [PMID: 32166203 PMCID: PMC7045539 DOI: 10.4103/bc.bc_22_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 10/22/2019] [Accepted: 11/21/2019] [Indexed: 11/04/2022] Open
Abstract
Recent trends in neuroendovascular surgery have seen a rise in alternative access utilization. Social media feeds such as #RadialFirst or #RadialForNeuro are the beacons of a growing movement among more and more endovascular neurosurgeons, as they venture away from the traditional femoral access gravitating toward radial access. We have previously shown our distal radial access technique utilizing the snuffbox to be a reliable means of endovascular access and in addition to traditional ventral radial access provides access to the entire cerebrum. Stroke thrombectomy often encounters reticence from those who prefer transfemoral access over the radial access. Thrombectomy has been performed radially in a few series and only once previously in a case report of distal radial access for thrombectomy. Hesitance to adopt radial access for mechanical thrombectomy is often related to perceived increased access times and a lack of suitable balloon guide catheters for radial techniques. Here, we present one of the first descriptions of a distal transradial access with balloon guide flow arrest for stentriever thrombectomy.
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Affiliation(s)
- Gary B Rajah
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Bryan Lieber
- Department of Neurosurgery and Neurology, Wayne State University, Detroit, MI, USA
| | - Ari D Kappel
- Department of Neurosurgery and Neurology, Wayne State University, Detroit, MI, USA
| | - Ali W Luqman
- Department of Neurosurgery and Neurology, Wayne State University, Detroit, MI, USA.,Department of Neurosurgery, Detroit Medical Center, Detroit, MI, USA
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25
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Yi HJ, Sung JH, Lee DH. Safety and Efficacy of Intra-arterial Tirofiban Injection During Mechanical Thrombectomy for Large Artery Occlusion. Curr Neurovasc Res 2020; 16:416-424. [DOI: 10.2174/1567202616666191023154956] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 09/22/2019] [Accepted: 09/27/2019] [Indexed: 11/22/2022]
Abstract
Objective:
The safety and effect of intra-arterial (IA) tirofiban, a glycoprotein IIb/IIIa
inhibitor, during the stent retriever mechanical thrombectomy (MT) was investigated.
Methods:
From January 2015 to May 2019, a total of 327 patients underwent mechanical thrombectomy
of large artery occlusions (LAO). Patients were classified into two groups: MT with IA
tirofiban (MTT) group and MT only (MTO, without IA tirofiban) group. Clinical outcomes, radiological
results, and various complications, such as post thrombectomy hemorrhage, symptomatic
hemorrhage, other systemic bleeding, and hemorrhagic transformation of infarct were evaluated by
comparing the MTT group and MTO group. In addition, subgroup analysis was performed for patients
who underwent MT with prior intravenous (IV) tissue plasminogen activator (t-PA).
Results:
The MTT group needed a lower mean number of stent passes and showed a re-occlusion
rate as compared with the MTO group (P=0.038 and 0.022, respectively). Between the two groups,
there were no statistically significant differences in post thrombectomy hemorrhage, symptomatic
hemorrhage, other systemic bleeding complications, or hemorrhagic transformation of infarct (P =
0.511, 0.397, 0.429, and 0.355, respectively). In the subgroup analysis, similar findings were observed.
Conclusion:
The use of IA tirofiban during MT seems to be safe and potentially more effective
than only MT without IA tirofiban, even in patients who used IV t-PA before MT.
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Affiliation(s)
- Ho J. Yi
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae H. Sung
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong H. Lee
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Kim JH, Kim BM. Endovascular Treatment of Acute Ischemic Stroke. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2020; 81:562-576. [PMID: 36238610 PMCID: PMC9431927 DOI: 10.3348/jksr.2020.81.3.562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 05/04/2020] [Accepted: 05/16/2020] [Indexed: 11/25/2022]
Abstract
급성 허혈성 뇌졸중은 심각한 후유증이나 사망에 이르는 가장 큰 원인 질환들 중 하나이다. 제2세대 혈전제거기구가 도입된 이후로 급성 허혈성 뇌졸중에서 혈관 내 재개통 치료는 급속히 발전해 왔고, 최근에는 표준 치료 중의 하나가 되었다. 이 종설에서는 급성 허혈성 뇌졸중에서 혈관 내 치료와 고식적인 치료를 무작위 배정으로 비교한 임상 연구들의 결과를 간략히 기술하고, 새로이 개정된 급성 허혈성 뇌졸중에서의 혈관 내 치료의 적응증과, 현재 혈관내 치료에 쓰이는 기구들과 방법에 대해 알아보고자 한다.
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Affiliation(s)
- Jun Hwee Kim
- Department of Radiology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Byung Moon Kim
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Chueh JY, Kang DH, Kim BM, Gounis MJ. Role of Balloon Guide Catheter in Modern Endovascular Thrombectomy. J Korean Neurosurg Soc 2019; 63:14-25. [PMID: 31591997 PMCID: PMC6952736 DOI: 10.3340/jkns.2019.0114] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 06/21/2019] [Indexed: 01/09/2023] Open
Abstract
Proximal flow control achieved with a balloon guide catheter (BGC) during endovascular treatment of acute ischemic stroke is reviewed in this article. In clinical practice, BGCs offer a multi-faceted approach for clot retrieval by creating proximal flow arrest, reducing embolic burden, and shortening procedure time. Evaluation of frontline thrombectomy procedures with BGCs revealed advantages of combined use over the conventional guide catheter (CGC), notably in the significant reduction of distal emboli to both the affected and previously unaffected territories. Recently, new measures of early and complete reperfusion at first thrombectomy pass have been identified as independent predictors of improved outcomes, which were consistently demonstrated with use of BGC as a safe and effective option to minimize number of passes during intervention. Prior randomized controlled trials reported the positive correlation between BGC-treated patients and a lower risk of mortality as well as shortened procedure time. While BGC use is more common in stent retriever-mediated mechanical thrombectomy, preliminary data has shown the potential benefit of device application during contact aspiration thrombectomy to achieve successful recanalization. However, the question of which major endovascular strategy reigns superior as a frontline remains to be answered. Along with clinical case assessments, BGC performance during in-vitro simulation was analyzed to further understand mechanisms for optimization of thrombectomy technique.
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Affiliation(s)
- Ju-Yu Chueh
- Department of Radiology, New England Center for Stroke Research, University of Massachusetts Medical School, Worcester, MA, USA
| | - Dong-Hun Kang
- Department of Neurosurgery and Radiology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Byung Moon Kim
- Department of Radiology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Matthew J Gounis
- Department of Radiology, New England Center for Stroke Research, University of Massachusetts Medical School, Worcester, MA, USA
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Wu C, Chang W, Wu D, Wen C, Zhang J, Xu R, Liu X, Lian Y, Xie N, Li C, Wei W, Zhao W, Ma Z, Gao Z, Ji X. Angioplasty and/or stenting after thrombectomy in patients with underlying intracranial atherosclerotic stenosis. Neuroradiology 2019; 61:1073-1081. [DOI: 10.1007/s00234-019-02262-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 07/08/2019] [Indexed: 10/26/2022]
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Kang DH, Hwang YH. Frontline Contact Aspiration Treatment for Emergent Large Vessel Occlusion: A Review Focused on Practical Techniques. J Stroke 2019; 21:10-22. [PMID: 30732439 PMCID: PMC6372892 DOI: 10.5853/jos.2018.03076] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 01/08/2019] [Indexed: 01/08/2023] Open
Abstract
Endovascular thrombectomy (EVT) as the standard care for acute stroke due to large vessel occlusion has recently been validated through several randomized controlled trials (RCTs). Contact aspiration (CA) and stent retriever (SR) are the two major EVT methods currently used. Because the RCTs have mostly evaluated SR devices, there was a demand to test CA in relation to SR as a frontline EVT treatment method. Recently, the Contact Aspiration vs Stent Retriever for Successful Recanalization (ASTER) study, the first RCT to compare CA and SR, demonstrated similar efficacy between them as a frontline EVT for patients with large vessel occlusions. This facilitates further investigation to confirm better frontline EVT for patients with acute stroke. In this review, we discuss past and recent developments in CA techniques, focusing on related literature. Additionally, we describe practical skills to overcome technical difficulties that can be encountered during the CA procedure. Finally, we review the evolution of device technologies, including a newer version of using a large-bore aspiration catheter.
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Affiliation(s)
- Dong-Hun Kang
- Department of Neurosurgery, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea.,Department of Radiology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yang-Ha Hwang
- Department of Neurology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
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