Abstract
BackgroundThe historical development of interventional stroke treatment shows a wide variation of different techniques and materials used. Thus, the question of the present work is whether the technical and procedural differences of thrombectomy techniques lead to different technical and clinical results.Methods and resultsAnalysis of a mixed retrospective/prospective database of all endovascular treated patients with an occlusion of the Carotid-T or M1 segment of the MCA at a single comprehensive stroke center since 2008. Patients were classified regarding the technical approach used. Six hundred sixty-eight patients were available for the final analysis. Reperfusion rates ranged between 56% and 100% depending on the technical approach. The use of balloon guide catheters and most recently the establishment of combination techniques using balloon guide catheters, aspiration catheters and stent retrievers have shown a further significant increase in the rates of successful recanalization, full recanalization and first-pass recanalization. Additionally, the technical development of interventional techniques has led to a subsequent drop in complications, embolization into previously unaffected territories in particular.ConclusionTechnical success of MT has improved substantially over the past decade owing to improved materials and procedural innovations. Combination techniques including flow modulation have emerged to be the most effective approach and should be considered as a standard of care.Level of evidence: Level 3, retrospective study.
Highlights
The first attempts at intra-arterial (i.a.) therapy of emergent large vessel occlusions (LVO) were already being conducted in the early 1980s, based upon attempts to dissolve the thrombus by the application of intraarterial drugs, it took more than 20 years to develop the first promising approaches to using mechanical clot retraction techniques1–3 and implementing first generation mechanical thrombectomy (MT) devices like the Merci device (Concentric Medical, San Francisco, CA, USA),4 the Phenox Clot Retriever (Phenox GmbH, Bochum, Germany),5,6 or the Penumbra Separator (Penumbra, Alameda, CA, USA),7 partially combined with i.a. thrombolysis as individual treatments
After the implementation of so-called stent retrievers as thrombectomy devices, five randomized controlled trials in 2015 demonstrated impressively the effectivity of mechanical thrombectomy with thrombolysis in comparison to thrombolysis alone,11–15 leading to adaptions in stroke guidelines worldwide with stent retrievers as thrombectomy devices recommended as a first line technique in LVOs
A further 88 patients had to be excluded as mixed techniques were used in these patients
Summary
The first attempts at intra-arterial (i.a.) therapy of emergent large vessel occlusions (LVO) were already being conducted in the early 1980s, based upon attempts to dissolve the thrombus by the application of intraarterial drugs, it took more than 20 years to develop the first promising approaches to using mechanical clot retraction techniques and implementing first generation mechanical thrombectomy (MT) devices like the Merci device (Concentric Medical, San Francisco, CA, USA), the Phenox Clot Retriever (Phenox GmbH, Bochum, Germany), or the Penumbra Separator (Penumbra, Alameda, CA, USA), partially combined with i.a. thrombolysis as individual treatments. At this point, the technical evolution seemed to have reached its preliminary peak and the development of further improvements was generally considered as probably of minor relevance This perception seems to have been premature, as several further technical and procedural changes, adaptions, combinations or new developments have shown partially substantial improvements in technical and clinical success of the thrombectomy procedure, e.g. sole aspiration maneuvers (ADAPT, A Direct Aspiration First Pass Technique), the use of balloon guiding catheters (BGC) instead of normal guiding catheters or long sheaths, the combined use of stent retrievers, distal access catheters and BGC and/or the withdrawal of the stent retriever only partially retracted into the distal access catheter compared with primary complete retractions of the stent retriever into the distal access catheter..
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