Abstract
Adjunctive techniques to stent retriever thrombectomy include balloon-guide catheters and/or distal access catheters for aspiration. We describe a novel technique using a flexible, 6 French 088 distal guide sheath advanced past the skull base to augment mechanical thrombectomy. We studied the relative safety and efficacy of this technique in the setting of a combined stent retriever-distal access catheter aspiration thrombectomy protocol. We performed a retrospective case-control study of intracranial internal carotid artery or M1-M2 middle cerebral artery occlusions requiring mechanical thrombectomy. Patients were divided into 2 groups based on thrombectomy techniques: conventional stent retriever with distal access catheter aspiration without (standard) and with adjunctive GUide sheath Advancement and aspiRation in the Distal petrocavernous internal carotid artery (GUARD). Using propensity score matching, we compared procedural safety, reperfusion efficacy using the modified Thrombolysis in Cerebral Infarction scale and clinical outcomes with the modified Rankin Scale. In comparing the GUARD (45 patients) versus standard (45 matched case controls) groups, there were no significant differences in demographics, NIHSS presentations, IV rtPA use, median onset-to-groin puncture times, procedural complications, symptomatic intracranial hemorrhage, or mortality. The GUARD group demonstrated significantly higher successful mTICI ≥2b reperfusion rates (98% versus 80%, P = .015) and improved functional mRS ≤2 outcomes (67% versus 43%, P = .04), with independent effects of the GUARD technique confirmed in a multivariable logistic regression model. The GUARD technique during mechanical thrombectomy with combined stent retrieval-distal access catheter aspiration is safe and effective in improving reperfusion and clinical outcomes.
Highlights
BACKGROUND AND PURPOSEAdjunctive techniques to stent retriever thrombectomy include balloon-guide catheters and/or distal access catheters for aspiration
Adaptations in thrombectomy techniques can be classified into 3 groups: traditional stent retriever thrombectomy, a distal access catheter (DAC) aspiration technique (A Direct Aspiration First Pass Technique [ADAPT] or Forced Aspiration Suction Thrombectomy [FAST]),[3,4] and a combined stent retriever with DAC aspiration approach (SOLUMBRA, Continuous Aspiration Prior To Intracranial Vascular Embolectomy [CAPTIVE], or Stent retriever Assisted Vacuum-locked Extraction [SAVE]).[5,6,7]
We investigated a novel method of flow modification via coaxial advancement and aspiration of a flexible 6F 088 distal guide sheath (DGS) past the skull base during mechanical thrombectomy, analogous to balloon guide catheter (BGC) and DAC adjunctive techniques
Summary
Institutional review board approval was obtained for a retrospective case-control study of all patients with acute ischemic stroke secondary to anterior circulation ELVO who underwent mechanical thrombectomy at 3 comprehensive stroke centers by 5 neurointerventionalists, using a standardized thrombectomy protocol from November 2016 to August 2018. A propensity score–matched analysis was performed to compare patients who underwent thrombectomy treated by the GUARD-versus-standard techniques with a ratio of 1:1 using confounding variables on the initial data analysis: age, IV rtPA use, CTP selection, and previous stroke/TIA as predictors with a greedy Euclidian matching algorithm and matching tolerance of 0.2. Fluoroscopic intraoperative images in the lateral (C) and antero-posterior (D) projections show stent retriever deployment across the supraclinoid ICA/M1 MCA occlusion with advancement of a large-bore ACE 68 distal access catheter (arrowheads) to the proximal aspect of the clot under vacuum aspiration, and triaxial advancement of the Neuron Max 088 guide sheath (arrows) distally into the posterior genu cavernous segment of the left ICA.
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