Clot Aspiration Research Articles

Histotripsy Clot Liquefaction in a Porcine Intracerebral Hemorrhage Model.

Intracerebral hemorrhage (ICH) is characterized by a 30-d mortality rate of 40% and significant disability for those who survive. To investigate the initial safety concerns of histotripsy mediated clot liquefaction and aspiration in a porcine ICH model. Histotripsy is a noninvasive, focused ultrasound technique that generates cavitation to mechanically fractionate tissue. Histotripsy has the potential to liquefy clot in the brain and facilitate minimally invasive aspiration. About 1.75-mL clots were formed in the frontal lobe of the brain (n=18; n=6/group). The centers of the clots were liquefied with histotripsy 48 h after formation, and the content was either evacuated or left within the brain. A control group was left untreated. Pigs underwent magnetic resonance imaging (MRI) 7 to 8 d after clot formation and were subsequently euthanized. Neurological behavior was assessed throughout. Histological analysis was performed on harvested brains. A subset of pigs underwent acute analysis (≤6 h). Histotripsy was able to liquefy the center of clots without direct damage to the perihematomal brain tissue. An average volume of 0.9±0.5 mL was drained after histotripsy treatment. All groups showed mild ischemia and gliosis in the perihematomal region; however, there were no deaths or signs of neurological dysfunction in any groups. This study presents the first analysis of histotripsy-based liquefaction of ICH in vivo. Histotripsy safely liquefies clots without significant additional damage to the perihematomal region. The liquefied content of the clot can be easily evacuated, and the undrained clot has no effect on pig survival or neurological behavior.

Abstract WP14: Higher Aspiration Force Improves Technical Outcomes in ADAPT Thrombectomy for Ischemic Stroke

Introduction: Aspiration thrombectomy using the direct aspiration at first pass technique (ADAPT) has been shown to be non-inferior to stent-retriever thrombectomy in ischemic stroke trials. Favorable outcomes after ADAPT are dependent on successful recanalization and lower number of aspiration attempts. We investigated the impact of aspiration force on technical and clinical outcomes of ADAPT by modulating two underlying determinants, the aspiration catheter size and the reperfusion pump power. Methods: We performed a retrospective analysis of patients undergoing ADAPT thrombectomy between 01/2018 and 02/2019. Patient treated using ADAPT were included irrespective of age, onset to groin or whether thrombolytic therapy was administered. Patient demographics and outcomes were reviewed from patient charts and thrombectomy procedure notes. Patients were dichotomized based on the reperfusion pump used (MAX, 28.5 inHb power vs ENGINE, 29.2 inHg power) and further split into the different reperfusion catheters used. Results: This study included 194 patients who underwent ADAPT thrombectomy during the study period with mean age of 69, and of which 48% were females. Comparing patients treated with two different reperfusion pumps, ENGINE (N=73) and MAX (N=118), similar rates of favorable outcomes measured by 90-day modified Rankin score (mRS) were observed. However, patients in the ENGINE groups had significantly shorter procedure time (20 vs 27 min, p<0.05), lower number of aspiration attempts (1.9 vs 2.2 p<0.05), and low rates of rescue stent retriever therapy (14% vs 33%, p<0.05). The use of ENGINE was an independent predictor of shorter procedure time (p<0.05) and lower rates of symptomatic hemorrhage (p<0.1) compared to MAX pump. There was no significant difference in procedure time and rates of functional outcomes among patients undergoing ADAPT using different sizes of large bore catheters ACE 60, ACE68 and Jet 7. Conclusion: Success of ADAPT thrombectomy is dependent on successful aspiration of the occluding clot, and is dependent on the aspiration force. Higher aspiration forces can be achieved by increasing the power of reperfusion pump leading to better technical outcomes without increased complication rates.

Use of a clot aspiration system during transvenous lead extraction.

The optimal approach to the extraction of leads with large vegetations remains uncertain. High-risk patients with lead associated vegetations undergoing device extraction at Vanderbilt Hospital with concomitant use of the Penumbra Aspiration System (Penumbra Inc, Alameda, CA) are described. An 8.5 Fr Agilis NXT (Abbott Inc, St. Paul, MN) was advanced to the right atrium, through which a Penumbra Indigo Cat-8 catheter was advanced. Using intracardiac echocardiography, the Penumbra was positioned directly on the vegetation, suction was applied until adherent, and the Indigo catheter and Agilis sheath were then removed en-bloc and aspirated debris flushed out. This was repeated until debulking was considered successful. Eight cases were performed. The median vegetation size was 2 cm. Pathogens were Enterococcus, Staphylococcus, Candida, Cutibacterium, and Enterobacter. In seven of eight cases, aspiration successfully reduced vegetations to less than 1 cm before successful percutaneous cardiac implantable electronic device removal. One patient underwent surgical removal via thoracotomy. There were no acute complications related to the Penumbra catheter. Three patients had CT evidence of small pulmonary emboli postprocedure. The length of stay was 3 to 27 days. One patient died on POD 1 of refractory ventricular tachycardia unrelated to the procedure. One patient died of ongoing sepsis 2 weeks postextraction. The Penumbra Indigo Aspiration system can be useful for vegetation debulking before transvenous lead extraction.

Late Clinical Outcomes of Hybrid Catheter Intervention for Acute Massive Pulmonary Thromboembolism.

Purpose: We aimed to investigate the long-term outcomes of patients undergoing hybrid catheter intervention for acute massive pulmonary thromboembolism.Material and Methods: Twenty-five patients with hemodynamic impairment were treated with mechanical thrombus fragmentation, an intrapulmonary injection of mt-PA, and manual clot aspiration between August 1999 and June 2002. All patients were discharged after the procedure. Patients’ statuses were checked by medical record examinations and telephone interviews. The median follow-up was 141 months (115-168 months).Results: Ten patients died during follow-up, five for malignancy, three for septic shock, one for cerebral infarction, and one for heart failure. One patient had recurrence of pulmonary thromboembolism because of drug withdrawal by self-judgment. No chronic pulmonary thromboembolism was observed. The 1-year, 5-year, and 10-year survival rates were 87.5 ±6.8%, 83.3±7.6%, and 74.5±9.0%, respectively.Conclusion: Patients who undergo hybrid catheter intervention for acute massive pulmonary thromboembolism show good long-term outcomes.

ENDOSCOPIC INTRAVENTRICULAR HEMORRHAGE REMOVAL: CLINICAL OBSERVATION AND TECHNICAL FEATURES

The study objective is to describe a successful endoscopic therapy for a patient with hypertensive ventricular hemorrhage complicated by occlusive third ventricular hydrocephalus. Materials and methods. A 71-year-old patient with hypertensive hemorrhage into the III and IV ventricles, complicated by non-communicating hydrocephalus, was brought to hospital on the 1st day of the disease onset. Non-communicating hydrocephalus was accompanied by clinical signs of decompensation, depressed level of consciousness up to moderate coma (Glasgow Coma Scale score of 7). Specialists performed emergency endoscopic aspiration of blood clots from the III and IV ventricles and third ventriculostomy. Results. Endoscopically it was possible to remove the clots from the third ventricle and through the cerebral aqueduct from the fourth ventricle. Resuscitation and intensive care measures resulted in a favorable outcome: the patient was released with a moderate neurological deficit – left oculomotor nerve dysfunction. After 4 months, the patient required a ventriculoperitoneal shunt due to disresponsive form of hydrocephalus. Conclusion. Endoscopic aspiration allows removing hematomas from the third and fourth ventricles via the lateral ventricle effectively and safely.

Acute on chronic limb ischemia: From surgical embolectomy and thrombolysis to endovascular options

After the invention of the balloon catheter by Fogarty in 1963, surgical thromboembolectomy was considered the gold standard treatment for many years in patients with acute lower limb ischemia (ALLI). ALLI is a dramatic event, carrying a high risk of amputation and perioperative morbidity and mortality. The evolution of endovascular technologies has resulted in a variety of therapeutic options to establish arterial patency. In the 1970s, Dotter first introduced the idea of clot lysis in the treatment of ALLI, which was modified to catheter-directed thrombolysis, and now clot aspiration techniques. Currently, the majority of ALLI (about 70%) is arterial thrombosis, which generally occurs in the setting of preexisting vascular lesion. This condition is very common in patients with diabetes. Clinical presentation in case of thrombosis on atherosclerotic stenosis (so called “acute on chronic ischemia”) may be less severe, but treatment is generally more challenging than ALLI due to embolism, considering the complexity in device trackability through the diseased vessels, potential vessel injury, incomplete revascularization, and need of correction of underlying vascular lesions. Although surgery is still a treatment option, especially for ALLI, endovascular interventions have assumed a prominent role in restoring limb perfusion. In this review, the treatment options for ALLI are detailed from surgical thromboembolectomy to thrombolysis and current endovascular techniques, including mechanical fragmentation, rheolytic thrombectomy, and aspiration thrombectomy. The evolution to endovascular therapies has resulted in improved clinical outcomes and lower rates of morbidity.

Mo1339 EUS-FNA OF PANCREATIC SOLID MASSES: A PROSPECTIVE RANDOMIZED TRIAL COMPARING SUCTION WITH SLOW PULL

Endoscopic ultrasound fine needle aspiration (EUS-FNA) is a well established diagnostic method for pancreatic solid mass. In despite, there is no optimal aspiration technique to date. Application of suction(S) has the purpose to hold tissue against the cutting edge of the needle and aspirate cells into its channel. Slow pull (SP) sampling seems to have comparable results with less blood and clot aspiration. The objective of this study was compare the diagnostic yield of S versus SP technique for EUS-FNA of pancreatic solid masses. We randomized 50 patients with pancreatic solid masses to start EUS-FNA with suction or slow pull technique. Each patient were submitted to two passes with suction and two passes with SP . Cytholgical data was obtain from cell block and smear and classified for cellularity, blood content and diagnostic yield of each technique. There was no statistical difference in diagnostic yield between S and SP (p=0,344). Sensitivity, specificity and accuracy of S, SP and both methods were 89,8% vs 81,6% vs 95,9%; 100% vs 100% vs 100%; 90% vs 82% vs 96% respectively. PPV (100 vs 100 vs 100) were high for all techniques and NPV were low (16,7 vs 10,0 vs 33,3). There was no statistical differences between S and SP techniques in sensitivity, specificity and accuracy.

Endoscopic Ultrasound-Guided Fine Needle Aspiration of a Malignant Portal Vein Thrombus

Endoscopic Ultrasound Guided Fine Needle Aspiration of a Thrombus of Uncertain Etiology Thrombus indicates vascular invasion and advanced stages of malignancy when clot is contiguous with cancer. Recently, fine needle aspiration (FNA) has been used to upstage malignancy in cases of thrombi that are discontinuous to primary tumors [1]. We present a case of EUS-FNA of a portal vein thrombus (PVT) associated with pancreatic cancer. A 50-year-old woman presented to our hospital for a second opinion regarding pancreatic adenocarcinoma. She had previously been diagnosed with stage III disease and treated with neoadjuvant gemcitabine and abraxane based on CT scan and biopsy. She had no radiographic changes on follow-up and was ultimately not offered surgery. She then came to our institution for a second opinion regarding surgery or irreversible electroporation (IRE). CT imaging showed an ill-defined 2.4 cm mass in the pancreatic head and neck and a 3.2 cm pre-caval lymph node. The portal vein appeared stenotic and a 1.5 cm thrombus was noted. There was no clear evidence of neurovascular invasion. To further guide treatment decisions EUS with FNA of the PVT was performed. Two passes were made with a 22g non-core needle. Cytology of the clot aspirate confirmed pancreatic adenocarcinoma. EUS redemonstrated a 4.2 cm by 3.3 cm mass in the pancreas with malignant appearing peri-pancreatic lymph nodes. There was invasion of the splenic artery and abutment of the mass to the hepatic and superior mesenteric artery. Based on these findings she was upstaged to stage IV disease and neither surgery nor IRE were pursued. She recovered from the procedure without incident. She was continued on gemcitabine and Abraxane in conjunction with her local physicians and discharged home. Correct characterization of thrombi can increase staging accuracy of cancer. Accurate staging of cancer provides prognostic information, allows for selection of the most appropriate therapies, and avoids unnecessary harm. Few cases of EUS-FNA clot aspiration have been reported. This case adds to the literature that EUS-FNA of a clot can safely assist in the accurate staging of pancreatic adenocarcinoma.Figure: Axial CT Image of Portal Vein Thrombus.Figure: Coronal CT Image of Portal Vein Thrombus. Note Metal Biliary Stent in Place with Closely Associated Pancreatic Mass.Figure: Endoscopic Ultrasound Showing the Portal Vein Thrombus.

Safety and efficacy of stereotactic aspiration with fibrinolysis for deep-seated spontaneous intracerebral hemorrhages: A single-center experience

ObjectiveThe aim of this study was to evaluate feasibility and safety of stereotactic aspiration with fibrinolysis of deep-seated intracerebral hemorrhages (ICH). Materials and methodsFrom March 1995 until December 2016, 58 adult patients (34 men and 24 women; mean age of 56.8±11.8 years) presenting with deep-seated spontaneous supratentorial ICH were treated using a minimally invasive technique. Intracerebral hematomas were aspirated until obvious resistance to free-hand suction and subsequent clot fibrinolysis was done using either streptokinase or recombinant tissue-type plasminogen activator. CT scans were performed at intervals ranging from 24 to 72h. At discharge, functional outcomes were evaluated using the Glasgow outcome scale (GOS). The 30-day mortality rate was evaluated in all patients. ResultsThe average ICH volume on initial CT scan was 34.7±11.1cm3 (range, 20–90cm3). Mean residual hematoma volume after the treatment was 8.0±5.1cm3 (range, 3–32cm3). There was statistically significant reduction of ICH volume after the treatment (P<0.001). Median ICH reduction rate was 5cm3/d (range, 1.5–16.0cm3/d) and 17.2%/d (range, 5.27–40.0%/d). Median discharge GOS score was 3 (range, 1–4). Six (10.9%) patients died during the 30-day follow-up period. Treatment related complications were observed in three (5.5%) patients. In two patients asymptomatic increase of ICH volume occurred and one patient was diagnosed with CNS infection. ConclusionsStereotactic clot aspiration with subsequent fibrinolytic therapy is safe and feasible treatment procedure associated with significant hematoma resolution rates and acceptable patient outcomes.

Endovascular Stroke Therapy Focused on Stent Retriever Thrombectomy and Direct Clot Aspiration: Historical Review and Modern Application.

Intravenous recombinant tissue plasminogen activator had been the only approved treatment for acute ischemic stroke since its approval in 1995. However, the restrictive time window, numerous contraindications, and its low recanalization rate were all limitations of this modality. Under those circumstances, endovascular stroke therapy went through a great evolution during the past two decades of intravenous thrombolysis. The results of the 2013 randomized trials for endovascular stroke therapy were neutral, although they were limited by insufficient imaging screening at enrollment, early-generation devices with less efficacy, and treatment delays. Huge progress was made in 2015, as there were five randomized clinical trials which all demonstrated the safety and efficacy of endovascular stroke treatment. Despite differences in detail patient enrollment criteria, all 5 trials employed key factors for good functional recovery; (1) screening with non-invasive imaging to identify the proximal occlusion and exclude a large infarct core, (2) using highly effective modern thrombectomy devices mainly with stent retriever, and (3) establishment of a fast workflow to achieve effective reperfusion. The results of those trials indicate that modern thrombectomy devices can allow for faster and more effective reperfusion, which can lead to improved clinical outcomes compared to intravenous thrombolysis alone. These advances in mechanical thrombectomy are promising in the global fight against ischemic stroke-related disability and mortality. Two current mainstreams among such mechanical thrombectomy techniques, “stent retriever thrombectomy” and “direct clot aspiration”, are the topic of this review. Stent retriever thrombectomy using Solitaire and Trevo retriever will be firstly discussed. And, the commonalities and the differences between two major clot aspiration thrombectomy techniques; a direct aspiration first pass technique (ADAPT) and forced arterial suction thrombectomy (FAST), will be additionally explained. Finally, details regarding the combination of direct clot aspiration and stent retriever thrombectomy, the switching strategy and the Solumbra technique, will be described.

Erratum: Medical and Surgical Advances in Intracerebral Hemorrhage and Intraventricular Hemorrhage.

In recent decades, the medical and surgical treatment of intracerebral hemorrhage (ICH) have become the focus of a number of scientific investigations. This effort has been led by an international group of neurologists and neurosurgeons with the goal of studying functional recovery and developing new medical and surgical treatments to facilitate improved clinical outcomes. Currently, two of the most pressing ICH investigational goals are (1) early blood pressure control, and (2) safe hematoma volume reduction. Answering these questions would support decision-making, level-of-care choices, and the global research strategy of developing biologically informed treatments. The authors review the contemporary medical management and the conventional and minimally invasive surgical approaches to spontaneous ICH, as well as discuss the scope of the problem, recent clinical trials, management issues, and relevant questions for future research. They propose the hypothesis that strategies using minimally invasive techniques, including clot aspiration with stereotactic guidance, may give better results with improved clinical outcomes compared with standard open surgical approaches. They also discuss the level of evidence for the variously known approaches.

Endovenous Treatment for Acute Massive Pulmonary Thromboembolism.

Treatment for venous thromboembolic conditions differs significantly depending on whether the condition is acute or chronic. Endovenous treatment is now available for treating the most severe cases of acute massive pulmonary thromboembolism, and the goal is rapid central clot removal to relieve life-threatening pulmonary circulation. Endovenous catheter interventions include catheter-directed thrombolysis and catheter-assisted thrombus removal. The latter is divided into aspiration thrombectomy, fragmentation, and rheolytic thrombectomy. Data from cohort studies indicate that the clinical outcome and safety after open surgical treatment and endovenous treatment may be comparable. This paper reviews the current approaches to endovenous treatment for acute massive pulmonary thromboembolism, and presents our study of hybrid treatment using a combination of local fibrinolysis, mechanical fragmentation, and clot aspiration.

Extraction of Atrial and Pulmonary Thrombi Using Angiovac Aspiration System with Transesophageal Echocardiography and Fluoroscopic Guidance

Surgical embolectomy is widely used to treat massive or submassive pulmonary thromboembolism and chronic thromboembolic pulmonary hypertension. [1]-[3] However, recently a new minimally invasive transvenous approach to clot evacuation using the AngioVac aspiration system (Vortex Medical, Norwell, Massachusetts) such as AngioVac aspiration system has been successfully used for retrieval of right atrial clot [4]-[6]. This is the first case report describing evacuation of trans-septal thrombus using an AngioVac aspiration system utilizing transesophageal echocardiograph (TEE) and fluoroscopic guidance. This case report also highlights the potential complications involved in AngioVac system which were readily diagnosed using TEE. We present a 66-year-old Caucasian female with a right atrial thrombus extending into left atrium through a patent for ovale (PFO) defect and a pulmonary artery thrombus. She underwent suction evacuation with an AngioVac aspiration system under TEE and fluoroscopic guidance. The right atrial thrombus extending into left atrium through a PFO was successfully evacuated through the PFO. However, the evacuation of the clot in the pulmonary artery was complicated by a rupture of the right ventricle requiring emergent sternotomy, cardiopulmonary bypass (CPB) and transient extracorporeal mechanical oxygenation (ECMO) support. The patient rapidly improved post-operatively and was discharged from hospital. Echocardiographic documentation of right heart thrombus and pulmonary emboli has poor prognostic implications. This report delineates the utility of TEE for visualization of cannula placement and real time aspiration of clots through the cannula. Potential complications associated with this technique are mechanical dislodge of thrombus from its attachment with subsequent embolization and rupture of cardiac chambers. Accessing the thrombus in the PA can be challenging and actual visualization of the cannula in the PA is often difficult and available only through TEE. This report highlights the utility of TEE for demonstrating trans-septal clot and the importance of precise positioning of cannula in avoiding complications. In spite of complications, AngioVac aspiration system under TEE and fluoroscopic guidance may become a safe alternative for surgical removal of intracardiac thrombi.

Medical and Surgical Advances in Intracerebral Hemorrhage and Intraventricular Hemorrhage.

In recent decades, the medical and surgical treatment of intracerebral hemorrhage (ICH) have become the focus of a number of scientific investigations. This effort has been led by an international group of neurologists and neurosurgeons with the goal of studying functional recovery and developing new medical and surgical treatments to facilitate improved clinical outcomes. Currently, two of the most pressing ICH investigational goals are (1) early blood pressure control, and (2) safe hematoma volume reduction. Answering these questions would support decision-making, level-of-care choices, and the global research strategy of developing biologically informed treatments. The authors review the contemporary medical management and the conventional and minimally invasive surgical approaches to spontaneous ICH, as well as discuss the scope of the problem, recent clinical trials, management issues, and relevant questions for future research. They propose the hypothesis that strategies using minimally invasive techniques, including clot aspiration with stereotactic guidance, may give better results with improved clinical outcomes compared with standard open surgical approaches. They also discuss the level of evidence for the variously known approaches.

Rapid Clearance of Lateral Ventricular Hematoma via Frontal Eminence Puncture and Aspiration: A Technical Note.

Background Intraventricular extension of a parenchymal hemorrhage is an independent predictor of poor outcome and might be complicated by delayed hydrocephalus. We describe a method for the rapid and effective removal of a lateral ventricular hematoma via catheter-based puncture and aspiration. Methods A catheter-based aspiration of a ventricular hematoma via a frontal eminence (FE) puncture was performed in 10 patients with thalamic and ganglionic hemorrhage perforating into the lateral ventricle. Paralleling the long axis of the lateral ventricle, a flexible silicone catheter was moved anteroposteriorly and rotated simultaneously to facilitate clot aspiration and removal. Computed tomography scans before and after surgery were compared for assessment of ventricular clot volume, Graeb score, and the ventriculocranial ratio (VCR). The Glasgow Coma Scale (GCS) score and Glasgow Outcome Scale (GOS) score were assessed at 14 days and 12 months following surgery, respectively. Results In all 10 patients, catheter-based aspiration resulted in substantial hematoma removal with a clearance rate of 64.9%, a reduced Graeb score by 61.8%, and an elevated GCS score by 52.7%. The procedure was performed safely without occurrence of another hemorrhage, infection, and catheter obstruction in any case. At 12-month follow-up, VCR was reduced by 22.5%, no delayed hydrocephalus occurred, and a favorable outcome with an average GOS of 4.6 was observed in this small cohort of patients. Conclusion Catheter-based aspiration of a ventricular hematoma via FE puncture rapidly, efficiently, and safely reduced the clot in the ventricular system, prevented delayed hydrocephalus sufficiently, and produced a favorable outcome.

Surgical Strategies for Spontaneous Intracerebral Hemorrhage.

In recent decades, the surgical treatment of intracerebral hemorrhage (ICH) has become a focus of scientific inquest. This effort has been led by an international group of neurologists and neurosurgeons with the goal of studying functional recovery and developing new surgical techniques to facilitate improved clinical outcomes. Currently, the two most pressing ICH investigational goals are (1) early blood pressure control, and (2) safe hematoma volume reduction. Achieving these goals would support decision-making, level-of-care choices, and the global research strategy of developing biologically informed treatments. Herein the authors review conventional and minimally invasive surgical approaches to spontaneous ICH, articulating the scope of the problem, recent clinical trials, management issues, and relevant questions for future research. The authors propose that strategies using minimally invasive techniques including clot aspiration with stereotactic guidance may give better results with improved clinical outcomes compared with standard open surgical approaches.

Extensive basal ganglia hematomas treated by local thrombolysis versus conservative management – a comparative retrospective analysis

Objectives: Single-target puncture plus catheter insertion into the clot is a routine step in hematoma aspiration and local thrombolysis for spontaneous intracerebral haemorrhage (ICH). However, multiple-target puncture of this procedure may imply faster hematoma reduction for large-area ICH. We retrospectively examined the outcomes after clot aspiration plus local thrombolysis with single-/double-target and conservative therapy for extensive basal ganglic hematomas. Methods: A case note review was conducted on a consecutive series of ICH patients in a single centre with huge basal ganglia hematomas who underwent clots aspiration and thrombolysis or pure medical therapy. We analysed the clinical presentation, radiological features and treatment outcomes of ICH patients in single-target group, double-target group and conservative group. Results: A total of 92 ICH cases were included in this study. At the post-treatment assessment, the average level by hematoma size in single-target and double-group was respectively smaller than that in the conservative group (20.61 ml vs. 15.75 ml vs 60.53 ml, p < 0.01). The 30-day case fatality rate in conservative group was respectively significantly higher than that in single-target and double-target groups (50% vs. 14.70% vs. 20.59%, p < 0.01). At the time of 6-month follow-up, the proportion of good survival in conservative group was respectively remarkably less than that in single- and double-target group (29.17% vs.64.71% vs. 67.65%, p < 0.01). But no difference was detected with respect to 30-day mortality or long-time outcome between the two micro-invasive groups (p = 0.53 and 0.798, respectively). Conclusion: Our data suggested for the massive basal ganglia hematomas, clot aspiration and thrombolysis can improve the short- and long-term prognosis compared with the pure conservative therapy. But, no evidence was found to demonstrate double-target of this procedure to be more effective than single-target to improve the outcome.

Implications of limiting mechanical thrombectomy to patients with emergent large vessel occlusion meeting top tier evidence criteria

BackgroundRecent guidelines for endovascular management of emergent large vessel occlusion (ELVO) award top tier evidence to the same selective criteria in recent trials. We aimed to understand how guideline adherence...

First-line lesional aspiration in acute stroke thrombectomy using a novel intermediate catheter: Initial experiences with the SOFIA.

Five randomized controlled trials (RCTs) on endovascular therapy (EVT) of stroke have proven a clinical benefit over conservative treatment or IV-thrombolysis alone. Lesional clot aspiration with a dedicated system can achieve revascularization without an additional retriever (a direct-aspiration first-pass technique, ADAPT), and the SOFIA has been shown to be both safe and efficacious in a multicentric retrospective study. We have evaluated a subset of these data acquired in two major stroke centers with regard to using the SOFIA for first-line lesional aspiration. Thirty patients with large-vessel occlusions treated with first-line lesional aspiration were identified. Procedural data, clot length, reperfusion success (mTICI), procedural timings, complications, and clinical status at admission, discharge and at 90 days were analyzed. The median baseline NIHSS was 16. IV thrombolysis was administered in 15/30 patients. Ninety-three percent of occlusions were in the anterior circulation. TICI ≥ 2b was achieved in 90% of multimodality treatments; lesional aspiration was successful in 67% within a median time of 20 minutes. The highest first-attempt success rate was in MCA occlusions (median time to recanalization 10 minutes). There were no device-related events. Symptomatic intracerebral hemorrhage (sICH) occurred in 10%, but never with sole lesional aspiration. Embolization to new territories was recorded in 1/30 (3%). Median discharge NIHSS was 7; 30% were mRS ≤ 2 at discharge and 43% at 90-day follow-up. Lesional aspiration with SOFIA is in line with published data. The SOFIA may be used as a first-line device, aiming at fast recanalization by sole aspiration with good safety and efficacy. If unsuccessful, it converts into part of a stent retriever-based multimodality treatment.

A numerical framework to investigate hemodynamics during endovascular mechanical recanalization in acute stroke.

Ischemic stroke, caused by embolism of cerebral vessels, inflicts high morbidity and mortality. Endovascular aspiration of the blood clot is an interventional technique for the recanalization of the occluded arteries. However, the hemodynamics in the Circle of Willis (CoW) are not completely understood, which results in medical misjudgment and complications during surgeries. In this study we establish a multiscale description of cerebral hemodynamics during aspiration thrombectomy. First, the CoW is modeled as a 1D pipe network on the basis of computed tomography angiography (CTA) scans. Afterwards, a vascular occlusion is placed in the middle cerebral artery and the relevant section of the CoW is transferred to a 3D computational fluid dynamic (CFD) domain. A suction catheter in different positions is included in the CFD simulations. The boundary conditions of the 3D domain are taken from the 1D domain to ensure system coupling. A Eulerian-Eulerian multiphase simulation describes the process of thrombus aspiration. The physiological blood flow in the 1D and 3D domains is validated with literature data. Further on, it is proved that domain reduction and pressure coupling at the boundaries are an appropriate method to reduce computational costs. Future work will apply the developed framework to various clinical questions.