Insights Into Intra-arterial Thrombolysis in the Modern Era of Mechanical Thrombectomy.

Alicia C Castonguay,Osama O Zaidat,Ashutosh Jadhav,Syed F Zaidi,Mouhammad A Jumaa,Diogo C Haussen,Hisham Salahuddin

doi:10.3389/fneur.2019.01195

Abstract

Background and Purpose: The role of intra-arterial (IA) thrombolysis in modern endovascular therapy is not well-understood. Here, we surveyed neurointerventionalists to understand their current clinical practices and opinions of IA thrombolysis in the new era of mechanical thrombectomy (MT).Method: A 24-question anonymous survey was distributed via email to the members of the Society of Vascular and Interventional Neurology.Results: One hundred and four responses were included in the analysis. Most respondents were interventional neurologists (76.9%) and had ≥5-years in neuro-interventional practice (80.8%). IA thrombolytics are presently used by 60.6%. Aspiration plus stent-retriever was the most common MT approach used with IA-thrombolysis (66.0%). IA-thrombolysis was used in mainly three approaches: (1) treatment of primary distal occlusions, (2) as rescue after proximal occlusion thrombectomy, and (3) or as adjunct therapy to primary MT approach. The most frequent IA-rtPA dose was 3–10 mg, with 1 mg/min infusion rate (56.6%). 84.9% do not have a standardized protocol for administering IA-rtPA. About half (50.9%) believed there should be no time limit for administering IA lytic if there is a favorable imaging profile, while 30.2% indicated ≤6 h. Most respondents (76.5%) would consider using IA-tenecteplase in a trial setting. Only 12.9% felt there was no role for IA thrombolysis in modern endovascular practice. Respondents with ≥10-years' experience were less supportive of the future of IA lytic (98.0 vs. 76.4%, p = 0.006).Conclusion: IA-thrombolysis is currently used in clinical practice; however, there is no clear consensus on best practices or criteria for administration. Further studies are needed to define the role of IA-thrombolysis in the context of MT.

Highlights

Mechanical thrombectomy (MT) has become the gold standard for the treatment of large vessels occlusions (LVOs), limited complete reperfusion rates by current generation stent-retrievers give way for adjunctive therapies to potentially augment their revascularization effectiveness
Recent studies have demonstrated promising results of IA recombinant tissue plasminogen activator in the context of mechanical thrombectomy (MT) [2,3,4]; the role of IA thrombolysis in contemporary endovascular therapy is not well-understood and limited data exists on its current use in real-world practice
Our study revealed that most respondents use IA thrombolysis in their current clinical practice; few implement standardized protocols for IA-recombinant tissue plasminogen activator (rtPA) administration

Summary

Introduction

Mechanical thrombectomy (MT) has become the gold standard for the treatment of large vessels occlusions (LVOs), limited complete reperfusion rates by current generation stent-retrievers give way for adjunctive therapies to potentially augment their revascularization effectiveness. Intra-arterial (IA) thrombolysis, once a first-line therapy for LVOs prior to the advent of MT, has reemerged with a potential new role in the modern endovascular era. We surveyed the neuro-interventional field to evaluate the current clinical practices and opinions of IA thrombolysis in the context of MT and to better understand its future role in endovascular stroke therapy. The role of intra-arterial (IA) thrombolysis in modern endovascular therapy is not well-understood. We surveyed neurointerventionalists to understand their current clinical practices and opinions of IA thrombolysis in the new era of mechanical thrombectomy (MT)

Methods

Results

Discussion

Conclusion