E-168 6 french/088 distal guide sheath access into the petrocavernous internal carotid artery to optimize mechanical thrombectomy

Abstract

Background Modern stent retriever-based thrombectomy techniques for emergent large vessel occlusions contributed to the successful clinical trials on endovascular acute ischemic stroke (AIS) intervention. Various adjunctive techniques have been described including the use of a balloon guide catheter (BGC) and/or distal access catheter (DAC) aspiration to improve first pass recanalization, complete reperfusion, and clinical outcomes. We describe a novel technique using a flexible 6French/088 distal guide sheath (DGS), defined as advancement into the petrocavernous internal carotid artery (ICA), to limit antegrade flow without a BGC and reduce the distance/tortuosity for clot extraction. We studied the relative safety and efficacy of DGS placement during standard stent retriever with DAC aspiration thrombectomy. Methods A retrospective review of 62 consecutive patients with intracranial ICA or M1-M2 middle cerebral artery (MCA) occlusions underwent stent retriever with DAC aspiration thrombectomy over a 15 month period. Patients were divided based on thrombectomy techniques, conventional stent retriever with DAC aspiration group (traditional group) and using an adjunctive DGS technique (target group). We compared patient demographics, presentations, times to treatment, recanalization efficiency (procedure time and passes), reperfusion efficacy using the modified Thrombolysis in Cerebral Ischemia (mTICI) scale including TICI 2 c, complications, and clinical outcomes of functional independence at 90 days (modified Rankin score 0–2). Statistical analysis for patients achieving functional independence used Wilcoxon-Mann-Whitney test. Results We identified 28 patients (median age 69 years with NIHSS 18) in the target group and 34 patients (median age 73 years with NIHSS 20) in the traditional group (p=0.11 and 0.12 respectively). In both target and traditional groups, IV tPA utilization (64.3% vs 64.7%, p-0.62), ICA occlusions (25% vs 29.4%, p=0.63), and median symptom onset to reperfusion times (242 min vs 274 min, p=0.63) were equivalent. While procedure times were equivocal in the target and traditional groups (median groin puncture to recanalization times of 28 minutes vs 31 minutes respectively, p=0.78), the target group offered higher rates of TICI ≥2 b reperfusion (100% vs 85.3%, p=0.04) and TICI ≥2 c reperfusion rates (64.3% vs 40.6%, p=0.04) as well as percentage of single pass recanalization (53.6% vs 26.5%, p=0.01), that corresponded with increased functional independence at 90 days (46.4% vs 37.5%, p=0.04). There was no significant difference in SICH complications (7.1% vs 11.8%, p=0.54) or 90 day mortality (7.1% vs 8.8%, p=0.81). Conclusions Optimizing mechanical thrombectomy techniques by advancing a DGS into the petro-cavernous ICA may confer higher reperfusion rates and improved clinical outcomes. Further investigation is required to confirm the benefit of this novel thrombectomy technique and its relative efficacy to adjunctive BGC techniques. Disclosures M. Darwish: None. P. Golnari: None. A. Muzaffar: None. M. Potts: None. M. Hurley: None. B. Jahromi: None. A. Shaibani: None. S. Ansari: None.