Aspiration Catheter Research Articles

Improved first-pass effect in acute stroke thrombectomy using Solitaire-X compared to Solitaire-FR.

In acute ischemic stroke (AIS), successful endovascular thrombectomy (EVT) of large vessel occlusion (LVO) necessitates the most suited device. Solitaire-X has longer and larger diameter pusher wires than Solitaire-FR.As the role of a larger pusher-wire diameter is uncertain, we aim to compare procedural, clinical, and radiological outcomes for AIS patients undergoing EVT using either type of Solitaire device. Procedures were performed using the Solumbra technique, which combines a large-bore aspiration catheter with a stentriever. The primary outcome was to compare rates of successful first-pass recanalization (defined as TICI 2b/3 score). The secondary objectives were procedural (rates of successful recanalization), clinical (post-procedural NIHSS and days of hospitalization), and radiological (post-procedural ASPECT score and hemorrhagic transformation) outcome measures. Consecutive AIS patients undergoing EVT for LVO were recruited into a prospective multicenter database at our academic center. We have used Solitaire-FR until October 2020 and Solitaire-X ever since. We retrospectively analyzed our prospective consecutive registry. Included in our analysis are patients undergoing EVT using Solitaire only; patients with tandem lesions or underlying stenosis requiring emergent stenting during the procedure were excluded. The cohort of patients treated with Solitaire-X was compared with a cohort consisting of the most recent consecutive cases undergoing EVT with the Solitaire-FR. A total of 182 (71.9 ± 14, 61% male patients) AIS patients were included in the analysis with both groups (n = 91 each) sharing similar demographic characteristics, premorbid conditions, and stroke characteristics (time from symptom-onset, NIHSS, ASPECTS, occlusion site, and rates of intravenous-tPA treatment). The Solitaire-X group had a higher rate of first-pass recanalization (65.9% vs. 50.5%, p = 0.049). On 24-h post-procedural head-CT, the Solitaire-X group had higher ASPECT scores (6.51 ± 2.9 vs. 5.49 ± 3.4, p = 0.042) and lower post-procedural average bleeding volumes (0.67 ± 2.1 vs. 1.20 ± 3.4 mL, p = 0.041). The Solitaire-X group had shorter duration of hospitalization (16.6 ± 13.1 days vs. 25.1 ± 23.2, p = 0.033). On multivariate analysis, using Solitaire-X was the sole independent predictor of first-pass recanalization (OR 2.17, 95% CI 1.12-4.26, p = 0.023). In our study, the use of the Stentriever-X with a larger pusher-wire diameter was associated with a higher likelihood of first-pass effect and improved procedural, clinical, and radiological outcomes in AIS patients.

Use of angled-tip aspiration catheters is associated with a lower cost of thrombectomy in patients with acute ischemic stroke secondary to large and medium vessel occlusions.

Recently, the angled-tip Zoom™ aspiration catheters were introduced. The tip is designed to improve suction force for clot retrieval. We evaluated the possibility of reducing procedure costs when using angled-tip catheters and compared the safety and angiographic effectiveness of angled-tip versus straight-tip catheters. We conducted a retrospective single-center cohort study involving patients with acute ischemic stroke due to large and medium vessel occlusions. The patients were divided into two groups: the post-Zoom group, in which angled-tip aspiration catheters were used and the pre-Zoom group, in which traditional straight-tip catheters were employed. A total of 163 patients were included; 95 (58.3%) in the pre-Zoom group and 68 (41.7%) in the post-Zoom group. The groups were well-matched at entry. The post-Zoom group demonstrated a significant decrease in mean procedure cost ($9728 vs. $12,127; p = 0.002), shorter time to achieve modified thrombolysis in cerebral infarction ≥2b reperfusion (38.30 min vs. 53.26 min; p = 0.018), and shorter puncture to procedure completion time (46.42 min vs. 62.38 min; p = 0.022). Additionally, the mean procedural cost when using the ADAPT technique supported by the Zoom catheters was significantly lower than the Solumbra technique ($5754 ± $2806 vs. $13,498 ± $3244, p < 0.001). There were no differences in the rate of hemorrhage between the pre-Zoom group (17.9%) and the post-Zoom group (20.6%), p = 0.690. The study demonstrated significant benefits, including cost reduction and shorter time to achieve reperfusion in patients treated with Zoom aspiration catheters. These findings support the use of angled-tip catheters in acute ischemic stroke management.

Comparing Functional Outcomes and Safety Profiles of First-Line Aspiration Thrombectomy Versus Stentriever for Acute Basilar Artery Occlusion: Propensity Analysis of the PC-SEARCH Thrombectomy Registry.

Aspiration catheters (ASPs) and stentriever thrombectomy devices have comparable safety and efficacy in anterior circulation ischemic strokes. However, there is lack of high-quality comparative data in acute basilar artery occlusions. Our objective is to compare the outcomes and safety of ASPs and stentriever devices in acute basilar artery occlusions. This is an analysis of the retrospectively established PC-SEARCH Thrombectomy (Posterior-Circulation Ischemic Stroke Evaluation: Analyzing Radiographic and Intraprocedural Predictors for Mechanical Thrombectomy) registry. Patients were dichotomized based on their first-line thrombectomy device (ASP and stentriever) and associated with their 90-day functional outcomes, intraprocedural metrics, and safety measures. Propensity analysis based on unequal baseline characteristics was performed. Consecutive patients with acute basilar artery occlusions who received mechanical thrombectomy were included from January 2015 to December 2021. Patients received either first-line contact aspiration or stentriever mechanical thrombectomy. Primary clinical and safety outcomes were 90-day functional independence measured by a modified Rankin Scale score of 0 to 3 and symptomatic intracranial hemorrhage, respectively. Secondary outcomes included puncture-recanalization times, first-pass recanalization rates, crossovers to other thrombectomy device, and neurological/hospital complications. Five hundred eighteen patients were included in the registry, and a total of 383 patients were included (mean [SD] age, 65.5 [15] years; 228 [59%] men) in this analysis. Of these, 219 patients were first-line ASP while 164 patients received first-line stentriever devices. Median premorbid modified Rankin Scale was zero and median presenting National Institutes of Health Stroke Scale was 17 (interquartile range, 8-26). The proportion of favorable functional outcome was similar between the 2 techniques before (47.3% versus 42.5%; odds ratio, 1.22 [95% CI, 0.78-1.89]; P=0.38) and after propensity matching (odds ratio, 1.46 [95% CI, 0.85-2.49]; P=0.17). In our propensity-matched cohorts, puncture-recanalization times (18 versus 52 minutes; P<0.01) favored first-line ASP; however, first-pass recanalization rates (43.5% versus 44.5%; P=0.90) were similar between groups. First-line ASP was associated with higher rates of crossover (22% versus 6%; P<0.01), whereas stentriever was associated with higher rates of symptomatic intracranial hemorrhage (9.8% versus 3.4%; P=0.04). First-line ASP and stentriever methods demonstrated similar functional outcome and recanalization rates. Stentriever methods were associated with higher rates of symptomatic intracranial hemorrhage, whereas ASPs were associated with higher rates of crossover to alternative technique in patients with acute basilar occlusions.

Catheter-directed interventions in acute pulmonary embolism treatment

Abstract: Catheter-based interventions for acute pulmonary embolism (PE) have evolved over the past decades to achieve the benefits of systemic thrombolysis, avoiding though its systemic complications and offering a therapeutic option to a wider spectrum of PE patients who may be contraindicated for thrombolytics. Although numerous observational, retrospective, or small prospective studies have been performed to evaluate the myriad devices used in the preceding years, few are of adequate quality to support widespread use. However, we were seeing an increasing use of catheter thrombolytic and aspiration thrombectomy procedures in both US and Europe. Evidence is building up through several industry trials, and more recently, the PE-Thrombus Removal with Adjunctive Catheter-directed Therapy randomized National Institutes of Health-funded trial was approved to evaluate their benefit over anticoagulation alone in intermediate risk patients. The current evolution of these techniques and existing evidence for their use are summarized.

The effect of distal aspiration catheter position on collateral flow in mechanical thrombectomy - an in vitro study.

Endovascular mechanical thrombectomy for ischaemic stroke is one of the most effective treatments. Despite the devices and techniques that have been developed, thrombi are not always successfully retrieved. The incidence of futile reperfusion after successful clot retrieval also remains a major concern. We hypothesise that simply placing an aspiration catheter in the system compromises collateral flow which may have an impact on functional outcomes. An in vitro study was conducted using a physical pulsatile flow model designed in glass to mimic the anterior cerebral circulation with middle cerebral artery M1 segment occlusion. A 5Fr aspiration catheter was positioned at the supra-clinoid internal carotid (SC-ICA), carotid terminus (T-ICA) and M1. For each catheter position, the flow rate through the model's anterior cerebral (ACA) and posterior communicating (PCOM) arteries was measured (no aspiration applied). Our results showed significant mean percentage flow reductions in the ACA and PCOM with the catheter positioned at the SC-ICA (PCOM 59.14% ± 0.93, ACA 59.52% ± 0.82, p < 0.001), T-ICA (PCOM 81.54% ± 0.55, ACA 85.65% ± 1.54) and M1 (PCOM 75.79% ± 0.98, ACA 84.20% ± 0.43) (Mann-Whitney U Test, p < 0.001). These results indicate a significant reduction in collateral flow following the insertion of a wide bore catheter in an in vitro model. In a clinical setting, this could have an impact on patient outcome, particularly in prolonged procedures and those requiring several passes to achieve recanalisation.

Robot-assisted ileocystoplasty for the treatment of adult neurogenic bladder: A video demonstration and outcomes

Abstract Ileocystoplasty is one of the treatment options in the armamentarium for the management of adults with neurogenic bladder dysfunction, after failure of less invasive treatment alternatives, such as intravesical onabotulinum toxin A injection therapy and sacral neuromodulation. It has traditionally been performed as open surgery and can be associated with significant morbidity, especially in the early postoperative period.[1] Complications associated with open ileocystoplasty include prolonged postoperative ileus, wound infections, and pain. Performing robot-assisted ileocystoplasty can reduce the morbidity associated with open surgery[2] and has been shown to be safe and feasible in experienced hands,[3] although it may be associated with increased operative duration because of its learning curve. Our technique of robot-assisted ileocystoplasty and early postoperative outcomes is demonstrated in this video (Supplemental Digital Content, http://links.lww.com/CURRUROL/A47). Robotic console time was 180 minutes, with minimal blood loss. Eight-hourly catheter aspiration and flushes were performed to manage the mucus in the urine. There were no metabolic acidosis or electrolyte derangements postoperatively. The patient was discharged on postoperative day 5. Postoperative cystogram at week 2 showed no leak and the patient is doing well at 1 year postoperatively. Robotic ileocystoplasty is safe and feasible and can reduce the morbidity associated with open surgery with good outcomes.

Integrative Approaches in Acute Ischemic Stroke: From Symptom Recognition to Future Innovations.

Among the high prevalence of cerebrovascular diseases nowadays, acute ischemic stroke stands out, representing a significant worldwide health issue with important socio-economic implications. Prompt diagnosis and intervention are important milestones for the management of this multifaceted pathology, making understanding the various stroke-onset symptoms crucial. A key role in acute ischemic stroke management is emphasizing the essential role of a multi-disciplinary team, therefore, increasing the efficiency of recognition and treatment. Neuroimaging and neuroradiology have evolved dramatically over the years, with multiple approaches that provide a higher understanding of the morphological aspects as well as timely recognition of cerebral artery occlusions for effective therapy planning. Regarding the treatment matter, the pharmacological approach, particularly fibrinolytic therapy, has its merits and challenges. Endovascular thrombectomy, a game-changer in stroke management, has witnessed significant advances, with technologies like stent retrievers and aspiration catheters playing pivotal roles. For select patients, combining pharmacological and endovascular strategies offers evidence-backed benefits. The aim of our comprehensive study on acute ischemic stroke is to efficiently compare the current therapies, recognize novel possibilities from the literature, and describe the state of the art in the interdisciplinary approach to acute ischemic stroke. As we aspire for holistic patient management, the emphasis is not just on medical intervention but also on physical therapy, mental health, and community engagement. The future holds promising innovations, with artificial intelligence poised to reshape stroke diagnostics and treatments. Bridging the gap between groundbreaking research and clinical practice remains a challenge, urging continuous collaboration and research.

Partial (SAVE) versus Complete (Solumbra) Stent Retriever Retraction Technique for Mechanical Thrombectomy: A Randomized In Vitro Study.

Mechanical thrombectomy has become a first-line treatment for acute ischemic stroke. Several techniques combining stent retrievers and distal aspiration catheters have been described. We aimed to characterize the efficacy of 2 commonly used techniques according to clot characteristics. Soft (mean stiffness = 95.77 [SD, 5.80] kPa) or stiff (mean stiffness = 205.63 [SD, 6.70] kPa) clots (3 × 10 mm and 2 × 10 mm, respectively) were embolized to the distal M1 segment of the MCA in an in vitro model. The technique was randomly allocated (1:1): stent retriever assisted vacuum-locked extraction (SAVE) versus complete retraction (Solumbra). The primary end point was the percentage of first-pass recanalization. Secondary end points were periprocedural distal embolization measures. A total of 130 mechanical thrombectomies were performed (50 for soft clots and 15 for stiff clots per arm). Overall, the rate of first-pass recanalizaton was 35% with Solumbra and 15% with SAVE (P < .01). For stiff clots, the first-pass recanalizaton was equal for both methods (27%; P = 1.00). With soft clots, the first-pass recanalizaton was higher with Solumbra (38%) than with SAVE (12%; P < .01). When we used soft clots, the maximum embolus size (mean, 1.19 [SD, 0.9] mm versus 2.16 [SD, 1.48] mm; P < .01) and total area of emboli (mean, 1.82 [SD, 2.73] versus 3.34 [SD, 3.2]; P = .01) were also lower with Solumbra than with SAVE. Clot characteristics may influence the efficacy of the thrombectomy technique. In occlusions caused by soft clots, complete retrieval into the distal aspiration catheters achieved higher rates of first-pass recanalizaton and lower embolization.

Improving the Reachability of Contact Aspiration for Acute Ischemic Stroke Using a New Delivery Assist Catheter

This study aimed to improve the reachability of large lumen catheter for contact aspiration during acute ischemic stroke by a new delivery assist catheter. This study included 58 patients with large-vessel stroke treated using endovascular procedures at our institution and affiliated hospitals between July 2021 and January 2023. Contact aspiration, especially contact aspiration using nonpenetrating of thrombus (CANP) technique, was adopted as first-line thrombectomy for localized internal carotid artery, middle cerebral artery proximal (M1 segment), and basilar artery without tandem occlusion in acute stroke. The new delivery assist catheter (AXS Offset catheter, Stryker, Fremont, CA, USA) was standardized after its release. Results of this improved contact aspiration technique using the new delivery assist catheter, including reachability, procedure time, and first-pass effect, were compared with conventional catheters. Of the 58 patients, 43 underwent only thrombectomy for acute embolic stroke. CANP technique was attempted on 25 patients (25/43, 58.1%). Of these, a normal inner catheter (inner diameter: 0.021 or 0.027 inches) and the new delivery assist catheter were used on 10 (10/25, 40%) and 15 (15/25, 60%) patients, respectively. An aspiration catheter reached the thrombus for 5 patients (5/10, 50%) and 14 patients (14/15 93.3%) in the normal and new delivery assist catheter groups, respectively (P=0.023). There was no significant difference in the results of contact aspiration due to the delivery catheter. The new delivery assist catheter improved the reachability of the aspiration catheter to the thrombus and is an effective device for performing CANP technique.

First experience with Walrus balloon guide catheter in a whole-body flow model

PurposeFlow arrest using a balloon guide catheter (BGC) in mechanical thrombectomy (MT) due to large vessel occlusion has been associated with better outcomes. Known limitations of currently commercially available BGCs are incompatibility with large bore aspiration catheters (AC) and lack of distal flexibility. Walrus presents variable stiffness and compatibility with large bore AC. The goal of this study is to describe the first experience with Walrus in a realistic stroke simulation model.MethodsA full-length modular vascular model under physiological conditions was used. 8F+-Walrus inner-diameter (ID) 0.087in 95 cm combined with 6F-Sofia AC ID 0.070in 131 cm and an 8F-Flowgate2 BGC ID 0.084in 95 cm with a 5F-Sofia AC ID 0.055in 125 cm were used to perform aspiration MT. User surveys, access to target and occlusion site, technique, time of delivery, anatomical change, and catheter kick-back were assessed.ResultsSeven neuroradiologists with average of 10 years-experience in MT performed primary aspiration using the above-mentioned combinations in three different anatomies (N = 41). All operators would likely (29%) or very likely (71%) use again Walrus in combination with large bore AC and the majority (86%) found its navigability easier than with other BGCs. Time to reach final BGC position and catheter kick-back did not differ significantly among anatomies or catheter combinations (p > 0.05). However, Walrus was more likely to reach ICA petrous segment (p < 0.05) and intracranial occlusion with AC (p < 0.01).ConclusionThe Walrus combined with large bore AC presented significantly better distal access and navigability for primary aspiration in an in vitro stroke model.

Device use trends in neuroendovascular procedures in the United States from 2015 to 2020.

Neuroendovascular therapies involve an everchanging landscape of new technologies. Understanding the real-world timeframe of adaptation of such technologies can provide further guidance on mechanisms that could be employed to shorten the duration necessary for the widespread use of proven therapies. In this study, we aim to investigate the trends in the use of neuroendovascular technologies, utilizing the sales of neuroendovascular devices, as a proxy for procedural volume. Utilizing a device sales data registry from the Decision Resources Group, a healthcare research and consulting company, we examined trends in the sales of devices utilized in cerebrovascular thrombectomy, cerebral aneurysm treatment, and carotid stenting from the same 407 reporting hospitals in the United States between January 1, 2015, and January 1, 2020. Device sales per year were plotted as both the total number of devices sold per year as well as the percent of total device sales when compared against at least one other device. The Cochran-Armitage test for trend was performed when comparing at least two devices to each other. Analyses were performed using RStudio Version 1.1.456 (https://rstudio.com). Between 2015 and 2020, there was a significant increase in the use of flow-diverting stents as well as nondiverting stents utilized for coil assistance. However, the total number of coils utilized over the years has declined. In terms of stroke therapy, between 2015 and 2020, there was a trend of increased use of both aspiration catheters as well as stent retrievers, which plateaued in 2020. The number of stents used for carotid procedures has also been gradually increasing over time. Our study demonstrates an increase in the use of flow-diverting stents, nondiverting stents, carotid stents, and reperfusion devices for acute ischemic stroke intervention between 2015 and 2020. Coil use for aneurysmal treatment has declined.

Neuroendovascular Surgery Applications in Craniocervical Trauma.

Cerebrovascular injuries resulting from blunt or penetrating trauma to the head and neck often lead to local hemorrhage and stroke. These injuries present with a wide range of manifestations, including carotid or vertebral artery dissection, pseudoaneurysm, occlusion, transection, arteriovenous fistula, carotid-cavernous fistula, epistaxis, venous sinus thrombosis, and subdural hematoma. A selective review of the literature from 1989 to 2023 was conducted to explore various neuroendovascular surgical techniques for craniocervical trauma. A PubMed search was performed using these terms: endovascular, trauma, dissection, blunt cerebrovascular injury, pseudoaneurysm, occlusion, transection, vasospasm, carotid-cavernous fistula, arteriovenous fistula, epistaxis, cerebral venous sinus thrombosis, subdural hematoma, and middle meningeal artery embolization. An increasing array of neuroendovascular procedures are currently available to treat these traumatic injuries. Coils, liquid embolics (onyx or n-butyl cyanoacrylate), and polyvinyl alcohol particles can be used to embolize lesions, while stents, mechanical thrombectomy employing stent-retrievers or aspiration catheters, and balloon occlusion tests and super selective angiography offer additional treatment options based on the specific case. Neuroendovascular techniques prove valuable when surgical options are limited, although comparative data with surgical techniques in trauma cases is limited. Further research is needed to assess the efficacy and outcomes associated with these interventions.

Effect of Bridging Thrombolysis on the Efficacy of Stent Retriever Thrombectomy Techniques : Insights from the SWIFT-DIRECT trial.

There are little available data regarding the influence of intravenous thrombolysis (IVT) on the efficacy of different first line endovascular treatment (EVT) techniques. We used the dataset of the SWIFT-DIRECT trial which randomized 408 patients to IVT + EVT or EVT alone at 48international sites. The protocol required the use of astent retriever (SR), but concomitant use of aballoon guide catheter (BGC) and/or distal aspiration (DA) catheter was left to the discretion of the operators. Four first line techniques were applied in the study population: SR, SR + BGC, SR + DA, SR + DA + BGC. To assess whether the effect of allocation to IVT + EVT versus EVT alone was modified by the first line technique, interaction models were fitted for predefined outcomes. The primary outcome was first pass mTICI2c‑3 reperfusion (FPR). This study included 385 patients of whom 172 were treated with SR + DA, 121 with SR + DA + BGC, 57with SR + BGC and 35with SR. There was no evidence that the effect of IVT + EVT versus EVT alone would be modified by the choice of first line technique; however, allocation to IVT + EVT increased the odds of FPR by afactor of 1.68 (95% confidence interval, CI 1.11-2.54). This post hoc analysis does not suggest treatment effect heterogeneity of IVT + EVT vs EVT alone in different stent retriever techniques but provides evidence for increased FPR if bridging IVT is administered before stent retriever thrombectomy.

Novel Tenzing 7 Delivery Catheter for Thrombectomy in Acute Stroke: A Clinical Multicenter Experience

Background Preliminary in vitro and early clinical experience of the Tenzing 7 delivery catheter demonstrated high success rates of aspiration catheter intracranial delivery with minimal complications. This study aimed to examine the efficacy, safety, and efficiency of the Tenzing 7 delivery catheter to deliver therapeutic devices in aspiration mechanical thrombectomy for acute ischemic strokes using clinical experience from multiple institutions. Methods We performed a retrospective analysis of prospectively collected data from patients with acute ischemic stroke treated with aspiration mechanical thrombectomy using the Tenzing 7 delivery catheter between January 2020 and July 2022 at 6 high volume stroke centers. Primary efficacy outcome was success in aspiration catheter delivery to the face of the thrombus, and primary safety end point was rate of procedural complication. Results Of a total of 176 patients (mean age 70.1±14.9 years, 56.3% female, 89.2% middle cerebral artery occlusions), first‐pass effect (modified Thrombolysis in Cerebral Infarction score≥2B) was achieved in 90/166 (54.2%) successfully revascularized patients. Tenzing 7 delivered the aspiration catheter of choice to the site of occlusion in 95.9% of cases; the clot was not crossed with Tenzing 7 in 69% of cases. Successful recanalization (modified Thrombolysis in Cerebral Infarction score≥2B) was achieved in 94.9% of cases requiring a median of 1 pass (interquartile range 1–3). Nonflow limiting vessel dissection unrelated to Tenzing 7 occurred in 4 patients (2.3%), and intracranial vessel perforation unrelated to Tenzing 7 occurred in 4 cases (2.3%). Conclusion This multicenter clinical experience using Tenzing 7 in mechanical thrombectomy demonstrated high rates of technical success and a modest complication rate, similar to the published rates of technical success with other thrombectomy techniques. The Tenzing 7 delivery catheter is effective and safe for the delivery of the aspiration catheter in patients undergoing thrombectomy for acute ischemic stroke.

Strategies to reduce morbidity following pleurectomy and decortication for malignant pleural mesothelioma.

Pleurectomy and decortication (PD) in malignant pleural mesothelioma has a high morbidity mostly associated with aspiration pneumonia (PNA), deep vein thrombosis (DVT), and foreign catheter sepsis. We instituted four strategies to reduce these complications and report our experience. This was a retrospective review of patients who underwent PD at the University of Pennsylvania between 2015 and 2022. Our patients underwent standard of care PD in addition to tracheostomy and gastrostomy/jejunostomy tube with therapeutic anticoagulation (AC) leading up to surgery. Measured outcomes were postoperative PNA, DVT, and sepsis. The predicted risk of those same outcomes had patients not undergone the interventions was calculated based on the American College of Surgeons (ACS) surgical risk calculator (SRC). A McNemar's test was used to determine whether the risk of having PNA, DVT and sepsis differed between the two subgroups. Fifty-five patients were included in the study. The mean age was 70 years (SD 6.2) with a mean of 21 (SD 19) pack-years of smoking. PNA, DVT, and catheter-related sepsis occurred in 12, four, and seven patients, respectively. Upon using the ACS SRC prediction model of the nonintervention group, PNA, DVT and catheter related sepsis was predicted to occur in 24 (paired data OR 5, 95% CI: 1.4-17.2; McNemar's test p = 0.008), 14 (paired data OR 3.5, 95% CI: 1.15-10.6; McNemar's test p = 0.03), and 17 (paired OR 3, 95% CI: 1.09-8.3; McNemar's test p = 0.04) patients, respectively. Patients undergoing tracheostomy creation, therapeutic AC at the time of diagnosis, and gastrostomy tube placement had a reduced risk of aspiration PNA, DVT, and catheter sepsis.

Mechanical Aspiration of a Heavy Thrombus in the Left Anterior Descending Artery using Penumbra Aspiration Catheter

Left anterior descending artery thrombosis is a medical emergency that requires prompt intervention to achieve the best possible clinical outcomes [1]. Early recanalization of obstructed vessels and thrombectomy with subsequent stenting effectively restore blood flow and improve procedural outcomes [2]. However, Manual Aspiration Thrombectomy (MAT) using a flexible aspiration catheter is also an alternative method that can be used to open blocked vessels [3]. Recent advancements in aspiration catheters have improved their trackability and size, making them comparable in efficacy to SBT [4]. As a result, Stent-Based Thrombectomy (SBT) and mechanical aspiration thrombectomy have become the primary treatment options for endovascular therapy in particular cases of coronary artery disease. The concurrent utilization of SBT and MAT as first-line and fallback interventions has been demonstrated to be effective in restoring vascular recanalization [5]. Besides SBT and MAT, a new aspiration catheter device has emerged. It is a relatively new technique for treating a thrombus in LAD that involves using a specialized catheter to remove the blood clot from the culprit artery [6]. This minimally invasive procedure is faster and more effective than traditional treatments such as thrombolytic therapy or Percutaneous Coronary Intervention (PCI) [7]. Penumbra medical technology company (Penumbra Inc, Alameda, CA, USA) introduced the Aspiration System in 2014 [8]. This system is specifically designed to remove blood clots from veins and arteries in the "peripheral vasculature" as well as for the treatment of "pulmonary embolism" [9]. The CAT family of catheters, developed by Penumbra, is known for its robustness, trackability, and atraumatic design, making it well-suited for peripheral anatomy where a thrombus forms [10]. The system comes equipped with the "Penumbra ENGINE aspiration source," which can administer almost untainted and consistent vacuum to catheters. This proficiency enables the extraction of thrombus in vessels of assorted dimensions. Recently, a penumbra aspiration catheter was used in a case report to remove thrombosis in acute coronary syndrome. According to the findings presented in this case report, it can be deduced that the Penumbra CAT RX catheter represents a secure and remarkably efficient alternative for eliminating blood clots in urgent scenarios. Notably, this method mitigates the heightened vulnerability to stroke often associated with the conventional approach of manual aspiration thrombectomy [11]. Previously, penumbra reperfusion catheter and MAT have been used as a "first-line therapy," and SBT with a "Solitaire stent" as a rescue therapy since 2012. This approach showed promising results regarding vessel recanalization and clinical outcomes [12].

Evaluation of vessel injury after simulated catheter use in an endothelialized silicone model of the intracranial arteries.

Neurothrombectomy catheters can disrupt or injure the vessel wall. This potential injury is often studied in animal or cadaver models, but prior work suggests that endothelialized silicone models may be an option for early in vitro assessment. The purpose of this work was to create a complex, clinically-relevant endothelialized neurovascular silicone model, and to determine the utility of the model for evaluating vessel injury due to catheter simulated use. Models of the ICA and MCA were fabricated out of silicone, sterilized, coated with fibronectin, placed in bioreactors, and endothelialized with HUVECs. These silicone vessels were maintained under flow for 3 and 7 days, and cellular linings were assessed. Subsequently, 24 silicone vessels were created and treated with neurovascular catheters. Vessels were accessed with a guidewire, microcatheter, and/or aspiration catheter, either once (1-pass) or three times (3-pass). Vessels were then fixed, and injury was evaluated through quantitative image analysis and a visual scoring system. Complex silicone models were successfully endothelialized and maintained with consistent cell linings. The transparent silicone permitted catheter simulated use without fluoroscopy, and injury to the vessel wall was observed and successfully imaged and characterized. Vessels subjected to 3-passes exhibited more injury than 1-pass, and injury increased with the number and size of devices. These results illustrated expected trends and support use of these models for early assessment of vessel injury. Complex silicone neurovascular models can be endothelialized and used in vitro to assess and compare injury due to the use of neurovascular catheters.

Disconnection of a stent retriever's pushwire caught by an accordion-like deformed aspiration catheter during mechanical thrombectomy: illustrative case.

In mechanical thrombectomy for acute large vessel occlusion, a combined technique of using both a stent retriever and an aspiration catheter has been widely used. The authors report a case in which a stent retriever's pushwire and a microcatheter were caught and disconnected by an accordion-like deformed aspiration catheter. A 74-year-old man underwent mechanical thrombectomy for a left M1 occlusion. A stent retriever was deployed from the left M2 to the left distal M1, and an aspiration catheter was advanced to the left distal M1. When the stent retriever and microcatheter were pulled into the aspiration catheter at the distal M1 without releasing the deflection, traction resistance of the stent retriever occurred, and the aspiration catheter contracted and deformed like an accordion distal to the tip of the guiding catheter. The stent retriever's pushwire and the microcatheter were caught and disconnected. When a stent retriever is pulled into a flexible aspiration catheter in a case with vascular tortuosity, it may be caught by an accordion-like deformed aspiration catheter and disconnected. It is necessary to release the deflection of the aspiration catheter once traction resistance of the stent retriever and deflection of the aspiration catheter occur.

Impact of vessel tortuosity and radiological thrombus characteristics on the choice of first-line thrombectomy strategy: Results from the ESCAPE-NA1 trial.

Despite improvements in device technology, only one-third of stroke patients undergoing endovascular thrombectomy (EVT) achieve first-pass effect (FPE). We investigated the effect of arterial tortuosity and thrombus characteristics on the relationship between first-line EVT strategy and angiographic outcomes. Patients with thin-slice baseline CT-angiography from the ESCAPE-NA1 trial (Efficacy and safety of nerinetide for the treatment of acute ischemic stroke) were included. Tortuosity was estimated using the tortuosity index extracted from catheter pathway, and radiological thrombus characteristics were length, non-contrast density, perviousness and hyperdense artery sign. We assessed the association of first-line EVT strategy (stent-retriever [SR] versus contact aspiration [CA] versus combined SR+CA) with FPE (eTICI score 2c/3 after one pass), final eTICI 2b/3, number of passes and procedure duration using multivariable regression. Interaction of tortuosity and thrombus characteristics with first-line technique were assessed using interaction terms. Among 520 included patients, SR as a first-line modality was used in 165 (31.7%) patients, CA in 132 (25.4%), and combined SR+CA in 223 (42.9%). FPE was observed in 166 patients (31.9%). First-line strategy was not associated with FPE. Tortuosity had a significant effect on FPE only in the CA group (aOR = 0.90 [95% CI 0.83-0.98]) compared with stent-retrievers and combined first-line approach (p interaction = 0.03). There was an interaction between thrombus length and first-line strategy for number of passes (p interaction = 0.04). Longer thrombi were associated with higher number of passes only in the CA group (acOR 1.03 [95% CI 1.00-1.06]). Our study suggests that vessel tortuosity and longer thrombi may negatively affect the performance of first-line contact aspiration catheters in acute stroke patients undergoing EVT.

Bailout technique for entangled stent retriever and carotid stent during tandem large vessel occlusion endovascular therapy.

Endovascular thrombectomy for patients with tandem occlusions could be challenging. Exposure to potential technical complications and bailout rescue techniques are of utmost importance. A 73-year-old woman with tandem internal carotid artery and middle cerebral artery lesions underwent an unsuccessful retrograde revascularization approach in the setting of tortuous anatomy. Antegrade approach revascularization was then pursued. Following cervical internal carotid artery revascularization, a triaxial system of aspiration catheter, microcatheter and micro guidewire was navigated through the stented curved cervical ICA and intracranial stent retriever pass was performed. Upon retrieving the clot-incorporated stent retriever with the intention to retrieve the entire stent retriever into the locally placed aspiration catheter, the triaxial system collapsed into the distal common carotid artery. Large thrombus was recovered from the aspiration catheter aspirate however the proximal end of stent retriever and distal internal carotid artery stent got tangled. After unsuccessful maneuvering to disentangle stent retriever from the internal carotid artery stent, we decided to attempt safe separation of the stent retriever from its pusher wire and leave behind the patent internal carotid artery stent/stent retriever metal construct in place. Gradual pulling pressure was applied to the stent retriever wire while maintaining distal exchange-length microwire access and fully inflated extracranial balloon over the entangled portion to ensure continuous vascular access. The stent retriever wire was then safely separated from the stent retriever and fully retracted outside the body. Delayed angiographic runs continued to demonstrate full patency of the internal carotid artery lumen. No residual dissection, spasm, or thrombus was noted. This case illustrates a novel bailout endovascular salvage technique that could be considered in such cases. These techniques minimize intraoperative complication, focus on patient safety, and promote efficiency for endovascular thrombectomy in unfavorable anatomy.