Intracranial bailout stenting with the Acclino (Flex) Stent/NeuroSpeed Balloon Catheter after failed thrombectomy in acute ischemic stroke: a multicenter experience

Stenting of Mobile Calcified Emboli After Failed Thrombectomy in Acute Ischemic Stroke: Case Report and Literature Review

See related article, p 958 Best currently available evidence for intracranial stenting (ICS) in intracranial atherosclerotic disease (ICAD) patients comes from secondary stroke prevention studies.1,2 However, these data do not allow any conclusion on the efficacy or safety of ICS in acute stroke patients. Chang et al3 present multicenter experiences with permanent ICS as rescue therapy after failed mechanical thrombectomy (MT) in patients with acute ischemic stroke in the carotid territory. In their study, MT failed in 148 of 591 (25%) patients with occlusions of the internal carotid artery or middle cerebral artery (M1). This rate exceeds the rate of poor recanalization of 8% to 18% as known from the large recent MT trials4–8 which at least in part might be explained by different incidence of ICAD in the trial populations. In their study, Chang et al3 observed significantly better outcomes after rescue ICS than after traditional management without increasing symptomatic intracranial hemorrhage rate or mortality (modified Rankin Scale score of 0–2; 39.6% versus 22.0%; P =0.031). The …

Background: Limited prospective data exists on the use of intra-arterial (IA) thrombolytics as rescue therapy(RT) after failed mechanical thrombectomy(MT) in acute ischemic stroke(AIS) patients with large vessel occlusions LVO). The aim of this study is to investigate the use of IA recombinant tissue plasminogen activator(IA-rtPA) as RT in the prospective STRATIS Registry. Methods: Data from the STRATIS Registry, a multicenter study of AIS patients treated with the Solitaire stent-retriever as the first choice therapy within 8 hours from symptoms onset, were analyzed. Clinical and angiographic outcomes were compared between patients treated with and without IA-rtPA. Both anterior and posterior circulation occlusions were included in this substudy. Results: Of the 938 STRATIS patients with IA-tPA use reported, 809 and 129 were in the no IA-rtPA(83.2%) and IA-rtPA(13.8%)groups, respectively. No difference was seen in baseline demographics. Site of occlusion was similar between the groups, with the majority occurring in the MCA(72.4% versus 73.6%, p=0.74). IV-rtPA was administered in 63.0% and 70.5% of no IA-rtPA and IA-rtPA patients(p=0.11). Median IA-rtPA dose was 4mg(IQR 2-12). Mean onset to arterial puncture time was shorter in the IA-rtPA group(200.2±104.6 versus 228.2±98.5 minutes, p=0.003); however, mean puncture to procedure end time was longer in the IA-rtPA group(78.7±43.1 versus 63.1±35.9 minutes). Mean number of passes (2.2±1.4 versus 1.8±1.2,p=0.001) and rate of distal embolization(67.8% versus 54.5%, p=0.007) was significantly higher in the IA-rtPA group. Core lab adjudicated substantial reperfusion (mTICI≥2b) was achieved in 88.4% and 84.7% of no IA-rtPA and IA-rtPA patients(p=0.16). No difference was observed in rates of symptomatic intracranial hemorrhage(sICH) (1.4% versus 1.6%,p=0.70), good functional outcome (mRS≥2, 57.3% versus 59.2%, p=0.86), or mortality (15.5% versus 13.3%,p=0.80) at 90-days. Conclusion: Use of IA-rtPA after failed thrombectomy was not associated with an increased risk of sICH or mortality in the STRATIS Registry. These results suggest that IA thrombolysis may be a safe option as rescue therapy in select patients.

Rescue Intracranial Stenting After Failed Mechanical Thrombectomy for Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

A 42-year-old woman was referred to our institution with sudden onset of ataxia, facial paresis, horizontal gaze palsy, and progressive dysarthria. The patient worsened within a few minutes, with appearance of left hemiparesis. The National Institutes of Health Stroke Scale Score was 13. On computer tomography scan 2 hours after stroke onset, no brain stem lesion or intracranial bleeding was visible. Computed tomographic angiography revealed a mid basilar vessel occlusion, which suggested embolic basilar artery occlusion. A 4-vessel angiogram with a 5F diagnostic catheter confirmed the basilar artery occlusion and depicted more precisely the location of the thrombus (Figure 1A). Figure 1. A, Digital subtraction angiography after vertebral injection demonstrates a mid basilar vessel occlusion. B, The angiogram after placement of the stent from the left P1 segment (white arrow) into the basilar artery showed flow restoration of the basilar artery with a narrowing in the middle part of the vessel due to compression of the thrombus into the arterial wall (black arrows). C, …

Bail-out intracranial stenting with Solitaire AB device after unsuccessful thrombectomy in acute ischemic stroke of anterior circulation

We aimed to evaluate the association between rescue therapy (RT) and functional outcomes compared to medical management (MM) in patients presenting after failed mechanical thrombectomy (MT). This cross-sectional study utilized prospectively collected and maintained data from the Society of Vascular and Interventional Neurology Registry, spanning from 2011 to 2021. The cohort comprised patients with large vessel occlusions (LVOs) with failed MT. The primary outcome was the shift in the degree of disability, as gauged by the modified Rankin Scale (mRS) at 90 days. Additional outcomes included functional independence (90-day mRS score of 0-2), symptomatic intracranial hemorrhage (sICH), and 90-day mortality. Of a total of 7,018 patients, 958 presented failed MT and were included in the analysis. The RT group comprised 407 (42.4%) patients, and the MM group consisted of 551 (57.5%) patients. After adjusting for confounders, the RT group showed a favorable shift in the overall 90-day mRS distribution (adjusted common odds ratio = 1.79, 95% confidence interval [CI] = 1.32-2.45, p < 0.001) and higher rates of functional independence (RT: 28.8% vs MM: 15.7%, adjusted odds ratio [aOR] = 1.93, 95% CI = 1.21-3.07, p = 0.005) compared to the MM group. RT also showed lower rates of sICH (RT: 3.8% vs MM: 9.1%, aOR = 0.52, 95% CI = 0.28-0.97, p = 0.039) and 90-day mortality (RT: 33.4% vs MM: 45.5%, aOR = 0.61, 95% CI = 0.42-0.89, p = 0.009). Our findings advocate for the utilization of RT as a potential treatment strategy for cases of LVO resistant to first-line MT techniques. Prospective studies are warranted to validate these observations and optimize the endovascular approach for failed MT patients. ANN NEUROL 2024;96:343-355.

No. 67 Spontaneous and assisted recanalization of hemodialysis access after prior failed thrombectomy and abandonment: the Lazarus phenomenon

BackgroundGuide catheter (GC) placement, whether distal or proximal, may influence the efficacy and safety of mechanical thrombectomy (MT) for acute ischemic stroke (AIS) due to large vessel occlusion (LVO). However, definitions of placement and procedural strategies vary across studies, limiting clarity.MethodsWe systematically searched PubMed, Embase, Scopus, and Web of Science from inception to September 1, 2024. Comparative studies of adult patients with anterior circulation AIS-LVO undergoing MT that reported GC placement were included. Both balloon GCs (BGCs) and non-BGCs were eligible. Data were pooled using random-effects models in R. Outcomes included functional independence (modified Rankin Scale 0-2 at 90 days), successful reperfusion (modified thrombolysis in cerebral infarction ≥2b or expanded thrombolysis in cerebral infarction ≥2c), first-pass recanalization (FPR), mortality, puncture-to-recanalization (PTR) time, and complications. Subgroup analyses were performed by thrombectomy technique and catheter type.ResultsSeven retrospective studies comprising 2148 patients (1042 proximal, 1106 distal) were analyzed. Distal placement was associated with higher rates of functional independence (risk ratio (RR): 1.25, 95% confidence interval (CI): 1.10-1.42), successful reperfusion (RR: 1.13, 95% CI: 1.04-1.22), and FPR (RR: 1.35, 95% CI: 1.15-1.58), as well as lower 90-day mortality (RR: 0.52, 95% CI: 0.28-0.82). PTR time was shorter with distal placement (mean difference: -7.7 min, 95% CI: -10.8 to -4.6). No significant differences were observed for symptomatic intracranial hemorrhage (RR: 0.96, 95% CI: 0.55-1.65) or emboli to new territory (RR: 0.84, 95% CI: 0.28-2.52). Benefits were consistent across both BGCs and non-BGCs. Heterogeneity existed in outcome definitions and techniques, and publication bias could not be excluded.ConclusionsDistal GC placement is associated with improved reperfusion, efficiency, and functional outcomes in MT for anterior circulation AIS-LVO, without increased complications. Given the retrospective nature of included studies, anatomic confounding, and inconsistent outcome definitions, findings should be considered preliminary. Multicenter trials are needed to confirm whether catheter position independently predicts MT outcomes.

The benefit of the routine application of aspiration thrombectomy in primary percutaneous coronary intervention (PPCI) is now well established. The optimal management of patients who have 'failed' thrombectomy, characterized by a large residual thrombus burden after repeated mechanical thrombectomy, however, is not known. We report a case of failed aspiration thrombectomy in a 55-year-old man who was admitted to our institution with chest pain non-ST-elevation myocardial infarction due to a huge nonocclusive thrombus in an aneurysmatic segment of the left anterior descending coronary artery. Aspiration thrombectomy did little to reduce thrombus load and so the patient was treated with unfractioned heparin infusion and warfarin. Repeat coronary angiography at 7 days revealed complete thrombus resolution with thrombolysis in myocardial infarction grade 3 anterograde flow.This case demonstrates the potential for appropriate anticoagulation therapy as a treatment option for the management of patients following failed thrombectomy in PPCI.

Although mechanical thrombectomy (MT) is an effective treatment for large vessel occlusion (LVO) with a high successful recanalization rate, MT failure (MTF) occurs in 10-15% of cases and is associated with unfavorable outcomes. However, little is known about the clinical, technical, and radiological reasons for MTF. We investigated the technical factors associated with MTF. We conducted a retrospective analysis of consecutive patients with anterior LVO prospectively included in the ongoing observational multicenter ROSSETTI registry. Patients were categorized according to the success (≥mTICI 2b) or failure (<mTICI 2b) of the MT procedure. Baseline clinical and demographic characteristics, endovascular MT techniques, and angiographic and clinical outcomes were compared. Multivariate analysis for prediction of MTF was performed. We analyzed 4135 patients, including 325 patients (7.9%) with MTF. Patients in the MTF group had a significantly lower Alberta Stroke Program Early CT Score (ASPECTS) at baseline (8 (7-10) vs 9 (8-10)), longer time since last time seen well (279 min vs 262 min), increased MT procedure time (76 min vs 31 min), higher rate of complications (23% vs 4%), higher symptomatic intracerebral hemorrhage (21% vs 7.9%), higher 24 hour National Institutes of Health Stroke Scale score (19 vs 6), worse functional outcome at 3 months (modified Rankin Scale score 0-2, 15.6% vs 53%), and higher mortality (45% vs 20%). Four or more passes were an independent predictor of MTF (OR 3.46, 95% CI 2.58 to 4.63; P<0.001). None of the endovascular techniques demonstrated a higher likelihood of MTF. In this study, MTF in anterior circulation LVO was associated with a high complication rate and worse outcomes.

Background: Mechanical thrombectomy (MT) fails to achieve successful reperfusion in up to 20% of large vessel occlusions (LVOs). Rescue strategies (RS) have shown promise in multicenter studies and meta-analyses. We aimed to evaluate the association between RS with functional outcomes compared to medical management (MM) in patients who underwent failed MT. Methods: This is a cross-sectional study using prospectively collected data from the Society of Vascular and Interventional Neurology (SVIN) Registry from 2018 to 2021. We included all adult patients with anterior circulation LVOs who experienced a failed MT (mTICI 0-2a after multiple attempts to clot retrieval) at the 14 participating centers. The patients were divided into two groups: those who received RS (including balloon angioplasty alone, intracranial stenting with or without balloon angioplasty) and those who only received MM. The primary outcome was the shift in the degree of disability, as measured by the mRS at 90 days. Additional outcomes included functional independence (90-day mRS score of 0-2), sICH, and mortality at 90 days. Results: A total of 642 patients were included in the analysis. The RS group consisted of 294 (45.8%) patients, while the MM group comprised 348 (54.2%) patients. A mTICI score of 2b-3 was achieved in 242/293 (82.6%) patients in the RS group. After adjusting for confounders, the RS group showed a favorable shift in the overall 90-day mRS distribution (acOR=1.97, 95%CI 1.36-2.85, p =&lt;0.001) and higher rates of functional independence (RS: 30.7% vs. MM: 12%, aOR=2.39, 95%CI 1.34-4.26, p =0.003) ( Figure ) compared to the MM group. RS also showed lower rates of sICH (RS: 2.7% vs. MM: 9%, aOR=0.32, 95%CI 0.14-0.71, p =0.005) and 90-day mortality (RS: 29.5% vs. MM: 49.7%, aOR=0.49, 95%CI 0.33-0.74, p =&lt;0.001). Conclusion: Our findings support the use of RS as a potential alternative for stroke patients with failed MT. Further prospective studies are needed to validate these observations.

Background and Purpose: Large vessel occlusion secondary to intracranial atherosclerotic disease (ICAD-LVO) has an estimated prevalence of 10-30%. Registry-based reports from high volume centers indicate that about 4-7% of mechanical thrombectomy (MT) due to LVO are accompanied with intracranial rescue stenting in the US, yet the trend and utilization of rescue stenting in US is unknown. Methods: Analysis of US National Inpatient Sample of strokes with mechanical thrombectomy with or without concomitant intracranial stenting from October 1st, 2016, to December 31st, 2020, was performed. Patient- and hospital-level characteristics were analyzed. Outcomes included favorable disposition (discharged to home) and in-hospital mortality. Results: Among 68,975 of stroke MT with recorded NIHSS during the study period (51.1% women; mean age, 69.1 [SD, 14.6] years; mean NIHSS score of 15.1 [SD, 7.7]), 1,635 (2.3%) underwent concomitant intracranial stenting (44% women; mean age, 64.8 [SD, 13.7] years; mean NIHSS score of 13.8 [SD, 8.1]). Characteristics associated with intracranial stent utilization were male sex, history of diabetes, hypertension, or chronic kidney disease, absence of atrial fibrillation or CHF, and southern US region. Favorable outcome was achieved in 23.6% of MT with stenting versus 32.3% without stenting (P&lt;0.001). In-hospital mortality occurred in 17.1% of MTs with stenting versus 10.5% without stenting (P&lt;0.001). In multivariable analysis among MTs with concomitant intracranial stenting, favorable outcome was associated with lower presenting NIHSS (OR, 0.91 [95% CI, 0.87-0.95], P&lt;0.001), and absence of DM (OR, 0.41 [95% CI, 0.20-0.85], P&lt;0.01). In-hospital mortality was associated with male sex (OR, 3.08 [95% CI, 1.38-6.87], P=0.005) and concomitant IV lytic administration (OR, 2.45 [95% CI, 1.01-5.96], P=0.02). Conclusions: In US practice, less than 3/100 MT’s are performed with concomitant intracranial stenting which is well below the prevalence of failed thrombectomy rates due to underlying ICAD-LVO. Further studies are needed to improve outcomes in this subset of patients.

Bi-directional feedback mechanisms exist between the heart and brain, which have been implicated in heart failure. We postulate that aortic stenosis may alter cerebral haemodynamics and influence functional outcomes after endovascular thrombectomy for acute ischaemic stroke. We compared clinical characteristics, echocardiographic profile and outcomes in patients with or without aortic stenosis that underwent endovascular thrombectomy for large vessel occlusion acute ischaemic stroke. Consecutive acute ischaemic stroke patients with anterior and posterior circulation large vessel occlusion (internal carotid artery, middle cerebral artery and basilar artery) who underwent endovascular thrombectomy were studied. Patients were divided into those with significant aortic stenosis (aortic valve area <1.5 cm2) and without. Univariate and multivariate analyses were employed to compare and determine predictors of functional outcomes measured by modified Rankin scale at three months. We identified 26 (8.5%) patients with significant aortic stenosis. These patients were older (median age 76 (interquartile range 68-84) vs. 67 (interquartile range 56-75) years, p = 0.001), but similar in terms of medical comorbidities and echocardiographic profile. Rates of successful recanalisation (73.1% vs. 78.0%), symptomatic intracranial haemorrhage (7.7% and 7.9%) and mortality (11.5% vs. 12.6%) were similar. Significant aortic stenosis was independently associated with poorer functional outcome (modified Rankin scale >2) at three months (adjusted odds ratio 2.7, 95% confidence interval 1.1-7.5, p = 0.048), after adjusting for age, door-to-puncture times, stroke severity and rates of successful recanalisation. In acute ischaemic stroke patients managed with endovascular thrombectomy, significant aortic stenosis is associated with poor functional outcome despite comparable recanalisation rates. Larger cohort studies are needed to explore this relationship further.

<h3>Background</h3> Mechanical thrombectomy (MT) is the standard of care for acute ischemic stroke secondary to large vessel occlusion (LVO). MT success (MTS) is associated with a five times greater chance of achieving a favorable clinical outcome. Despite major advances in catheter and stent retriever (SR) technology, MT failure (MTF) still occurs in approximately 15% of cases. The purpose of this study is to investigate the patient and procedural characteristics that predict MTF. <h3>Methods</h3> This is a retrospective review of the prospectively collected, multi-center, multi-national Stroke Thrombectomy and Aneurysm Registry (STAR). Patients who underwent MT for anterior or posterior circulation LVO were included. Patients were categorized by MTS or MTF, defined as modified Thrombolysis in Cerebral Infarction (mTICI) 2b or greater and less than mTICI 2b, respectively. Patient demographics, pretreatment information, and treatment information were compared and then included in a univariate (UVA) and multivariate analysis (MVA) for prediction of MTF. <h3>Results</h3> A total of 8452 patients were included in the analysis, of whom 1301(15.4%) experienced MTF. Patients in the MTF group were older (73 vs 71 years, p=0.008) and had higher percentage of poor pre-morbid mRS (10.8% vs 8.4%, p=0.17). No significant differences were found between race, sex, pre stroke medical comorbidities or Alberta Stroke Program Early CT Score (ASPECTS). Onset to puncture was greater in the MTF group (442 vs. 411 min, p=0.006). There were more ICA occlusions (15.6% vs. 13.5%) and basilar occlusions (7.8% vs. 6.2%) in the MTF group and more M1 occlusions (42.2% vs 37.5%) in the MTS group (p&lt;0.001). More patients underwent aspiration as the final technique in the MTS group (35.3% vs 32.9%). Number of passes (3 vs 2) and total procedure time (77.3 vs 46.1 min) were higher in the MTF group (p&lt;0.001). More patients in the MTF group required IA thrombolytic (14.7% vs. 8.3%, p&lt;0.001). More patients in the MTS group had rescue intracranial stenting (7.9% vs 4.8%). There were more complications (14.7% vs 6.2%) and more symptomatic ICH (9.9% vs 5.7%, p&lt;0.001) in the MTF group. Favorable outcome at 90 days was greater in the MTS group (42.6% vs 18.3%, P&lt;0.001). On UVA, age, poor pretreatment mRS, posterior circulation occlusion, final technique SR, increased number of passes, and increased procedure time were associated with increased odds of MTF, while M1-M2 occlusions and rescue intracranial stenting with decreased odds of MTF. These correlations remained significant on MVA for final technique SR, rescue intracranial stenting, number of passes, and procedure time. <h3>Conclusion</h3> In one of the largest studies to evaluate factors associated with failure MT in real world practice, we demonstrate that MTF is associated with significantly more complications and worse outcome. Final use of aspiration and rescue intracranial stenting may increase chances of recanalization. <h3>Disclosures</h3> <b>M. Webb:</b> None. <b>M. Essibayi:</b> None. <b>S. Al Kasab:</b> None. <b>I. Maier:</b> None. <b>M. Psychogios:</b> None. <b>A. Alawieh:</b> None. <b>S. Wolfe:</b> None. <b>A. Arthur:</b> None. <b>T. Dumont:</b> None. <b>P. Kan:</b> None. <b>J. Kim:</b> None. <b>R. De Leacy:</b> None. <b>J. Osbun:</b> None. <b>A. Rai:</b> None. <b>P. Jabbour:</b> None. <b>M. Park:</b> None. <b>R. Crosa:</b> None. <b>M. Levitt:</b> None. <b>A. Polifka:</b> None. <b>W. Casagrande:</b> None. <b>S. Yoshimura:</b> None. <b>C. Matouk:</b> None. <b>R. Williamson:</b> None. <b>B. Gory:</b> None. <b>M. Mokim:</b> None. <b>I. Fragata:</b> None. <b>D. Romano:</b> None. <b>S. Chowdry:</b> None. <b>M. Moss:</b> None. <b>D. Behme:</b> None. <b>K. Limaye:</b> None. <b>A. Spiotta:</b> None. <b>J. Mascitelli:</b> 2; C; Stryker.