Primary Thrombectomy Research Articles

Abstract WP20: Efficacy and Safety of Mechanical Thrombectomy in Emergent Large Vessel Occlusions with Concomitant Cervical Internal Carotid Artery Occlusion

Introduction: Recently, five published major randomized controlled clinical trials have demonstrated that timely mechanical thrombectomy (MT) of acute ischemic strokes (AIS) with emergent large vessel occlusion (ELVO) is safe and improves functional outcomes. However, data evaluating the efficacy and safety of MT in ELVO patients with concomitant cervical internal carotid artery (cICA) occlusion is limited. The purpose of this study is to evaluate efficacy and safety of MT in ELVO patients with concomitant cICA occlusion Methods: We prospectively analyzed consecutive AIS patients with anterior circulation ELVO who underwent stent-retriever or primary aspiration thrombectomy at two tertiary stroke centers. Outcome measures in our study were 3-month mortality and modified ranking scale (mRS), as well as symptomatic intracranial hemorrhage (sICH). Safety and efficacy outcomes were compared between ELVO patients with and without concomitant cICA occlusion. Results: A total of 137 AIS patients had anterior circulation ELVO and underwent MT (age 63 ± 14, 49% male, median NIHSS 17, IQR [13-20]). ELVO patients with concomitant cICA occlusion (n=19) did not differ in terms of rates of sICH (0% versus 11%, p=0.21), complete recanalization (68 % versus 68%, p=1.00), onset to groin puncture time (minutes [IQR] 268 [211-379] versus 225 [165-312], p=0.47), 3-month mortality (35% versus 26 %, p=0.55), and mRS of 0-2 at 3 months (41% versus 45%, p=0.80) when compared with ELVO patients without concomitant cICA occlusion (n=118). Admission NIHSS was higher among ELVO patients with concomitant cICA occlusion (median [IQR], 18 [15-22] versus 16 [12-19], p=0.01), and they tended to have higher groin puncture to recanalization time (minutes [IQR] 74 [42-97] versus 49 [38-78], p=0.09). The ordinal shift analysis did not show any difference in favorable outcomes in two groups in unadjusted analyses or after adjustment for admission NIHSS and groin to recanalization time (common OR=0.78 [95% CI: 0.27-2.29, p=0.66]). Angioplasty was performed in 11 of 19 ELVO patients with concomitant cICA occlusion. Three patients required stent placement. Discussion: Our study indicates that MT can be performed safely and effectively in ELVO patients with concomitant cICA occlusion.

Experience on Mechanical Thrombectomy for Acute Stroke Treatment in a Brazilian University Hospital

Brazil is a developing country struggling to reduce its extreme social inequality, which is reflected on shortage of health-care infrastructure, mainly to the low-income class, which depends exclusively on the public health system. In Brazil, less than 1% of stroke patients have access to intravenous thrombolysis in a stroke unit, and constraints to the development of mechanical thrombectomy in the public health system increase the social burden of stroke. Report the feasibility of mechanical thrombectomy as part of routine stroke care in a Brazilian public university hospital. Prospective data were collected from all patients treated for acute ischemic stroke with mechanical thrombectomy from June 2011 to March 2016. Combined thrombectomy was performed in eligible patients for intravenous thrombolysis if they presented occlusion of large artery. For those patients ineligible for intravenous thrombolysis, primary thrombectomy was performed as long as there was no evidence of significant ischemia for anterior circulation stroke (Alberta Stroke Program Early CT score >6) within a 6-hour time window, and also for those patients with wake-up stroke or posterior circulation stroke, regardless of the time of symptoms onset. A total of 161 patients were evaluated, resulting in an overall successful recanalization rate of 76% and symptomatic intracranial hemorrhage rate of 6.8%. At 3 months, 36% of the patients had modified Rankin Scale score less than or equal to 2. The overall mortality rate was 23%. Our study, the first ever large series of mechanical thrombectomy in Brazil, demonstrates acceptable efficacy and safety results, even under restricted conditions outside the ideal scenario of trial studies.

458 - The success of thrombectomy does not prevent angiographically visible distal embolization in STEMI patients treated by primary percutaneous coronary intervention and thrombectomy

458 - The success of thrombectomy does not prevent angiographically visible distal embolization in STEMI patients treated by primary percutaneous coronary intervention and thrombectomy

Mechanical thrombectomy in patients with medical contraindications for intravenous thrombolysis: a prospective observational study

Background and purposeThe present study was conducted with the objective of evaluating the safety of primary mechanical thrombectomy (MT) in patients with large vessel occlusion (LVO) stroke and comorbidities that...

OC10_05 The End of Night Mare, Primary Percutaneous Thrombectomy With Right Guide Coronary Judkins 8 French Catheter to Treat of High Risk Acute Pulmonary Embolism

OC10_05 The End of Night Mare, Primary Percutaneous Thrombectomy With Right Guide Coronary Judkins 8 French Catheter to Treat of High Risk Acute Pulmonary Embolism

Outcomes of digital artery revascularization in pediatric trauma

BackgroundDigit amputation is rare in pediatric trauma but can lead to functional morbidity. The true incidence of digital arterial injury is lacking in the literature, and revascularization techniques are not well-described. MethodsRetrospective review of a pediatric trauma registry identified patients with a digital artery injury between July 2008 and December 2013. Isolated vein injuries and arterial injuries proximal to the digits were excluded. Descriptive statistics were used. ResultsTwenty-five subjects met inclusion. Most were male (n=16; 64%) and the median age was 6.8 (IQR: 2.8, 11.1) years. The most common blunt (n=12) trauma was struck/crushed by object (n=4; 33%) and the most common penetrating (n=13) trauma was because of glass (n=9; 69%). All subjects were managed operatively. Initial operations for arterial repair were primary arterial repair (15; 20%), vein graft (7; 28%), thrombectomy (1; 4%), and amputation (1; 4%). Twelve patients (48%) had reported complications at initial follow-up, but only two (8%) had long-term (>24weeks) sequelae. ConclusionDigital artery injury is rare among pediatric traumas. Functional outcomes after digital artery revascularization are favorable. Primary repair can successfully manage these injuries and vein grafting appears to be a suitable alternative when primary repair is not feasible.

Recanalization treatments in basilar artery occlusion-Systematic analysis.

Basilar artery occlusion is a most devastating form of stroke, and the current practice is to reverse it with revascularization therapies. Pharmacological thrombolysis, intravenous or intraarterial, has been adjuncted or replaced with invasive, endovascular thrombectomy procedures. The preferred approach remains unknown and many recanalizations are futile with no clinical benefit. We sought to determine reasons for futility and weigh the existing reports to find whether endovascular mechanical interventions provide superior outcomes over pharmacological thrombolysis alone. After analyzing systematically the reports of outcomes produced by variable basilar artery occlusion recanalization protocols, information was retrieved and reconciled from 15 reports published from year 2005 comprising 803 patients in 17 cohorts. In the largest single-center cohort (162, Helsinki), predictors of futile recanalization (three-month modified Rankin Scale score 4 to 6) were determined. Good outcome was reported by mechanical approaches either alone or on demand more frequently than by pharmacological, intravenous or intraarterial thrombolysis protocols (35.5% versus 24.4%, p < 0.001), accompanied by higher recanalization rates (84.1% versus 70.9%, p < 0.001). Along with superior recanalization rate at 91%, good outcome was reached by primary thrombectomy in 36% at the cost of substantial futile recanalization rate at 60%, which was lower when using modern stentrievers only (52.8%). In the Helsinki cohort, the single most significant predictor was extensive baseline ischemia, increasing the odds of futility 20-fold (95%CI 4.39-92.29, p < 0.001). Other attributes of futility were ventilation support and history of atrial fibrillation or previous stroke. Endovascular mechanical approaches have been reported to provide superior outcomes over pharmacological thrombolysis in basilar artery occlusion. Stricter patient selection, most notably to exclude victims of already extended ischemia, would assist in translating excellent recanalization rates into improved clinical outcomes and more acceptable futility rates.

Clinical and Procedural Predictors of Outcomes From the Endovascular Treatment of Posterior Circulation Strokes

Patients with posterior circulation strokes have been excluded from recent randomized endovascular stroke trials. We reviewed the recent multicenter experience with endovascular treatment of posterior circulation strokes to identify the clinical, radiographic, and procedural predictors of successful recanalization and good neurological outcomes. We performed a multicenter retrospective analysis of consecutive patients with posterior circulation strokes, who underwent thrombectomy with stent retrievers or primary aspiration thrombectomy (including A Direct Aspiration First Pass Technique [ADAPT] approach). We correlated clinical and radiographic outcomes with demographic, clinical, and technical characteristics. A total of 100 patients were included in the final analysis (mean age, 63.5±14.2 years; mean admission National Institutes of Health Stroke Scale score, 19.2±8.2). Favorable clinical outcome at 3 months (modified Rankin Scale score ≤2) was achieved in 35% of patients. Successful recanalization and shorter time from stroke onset to the start of the procedure were significant predictors of favorable clinical outcome at 90 days. Stent retriever and aspiration thrombectomy as primary treatment approaches showed comparable procedural and clinical outcomes. None of the baseline advanced imaging modalities (magnetic resonance imaging, computed tomographic perfusion, or computed tomography angiography assessment of collaterals) showed superiority in selecting patients for thrombectomy. Time to the start of the procedure is an important predictor of clinical success after thrombectomy in patients with posterior circulation strokes. Both stent retriever and aspiration thrombectomy as primary treatment approaches are effective in achieving successful recanalization.

Alberta Stroke Program Early CT Score applied to CT angiography source images is a strong predictor of futile recanalization in acute ischemic stroke.

Reliable predictors of poor clinical outcome despite successful revascularization might help select patients with acute ischemic stroke for thrombectomy. We sought to determine whether baseline Alberta Stroke Program Early CT Score (ASPECTS) applied to CT angiography source images (CTA-SI) is useful in predicting futile recanalization. Data are from the FUN-TPA study registry (ClinicalTrials.gov; NCT02164357) including patients with acute ischemic stroke due to proximal arterial occlusion in anterior circulation, undergoing reperfusion therapies. Baseline non-contrast CT and CTA-SI-ASPECTS, time-lapse to image acquisition, occurrence, and timing of recanalization were recorded. Outcome measures were NIHSS at 24h, symptomatic intracranial hemorrhage, modified Rankin scale score, and mortality at 90days. Futile recanalization was defined when successful recanalization was associated with poor functional outcome (death or disability). Included were 110 patients, baseline NIHSS 17 (IQR 12; 20), treated with intravenous thrombolysis (IVT; 45%), primary mechanical thrombectomy (MT; 16%), or combined IVT + MT (39%). Recanalization rate was 71%, median delay of 287min (225; 357). Recanalization was futile in 28% of cases. In an adjusted model, baseline CTA-SI-ASPECTS was inversely related to the odds of futile recanalization (OR 0.5; 95% CI 0.3-0.7), whereas NCCT-ASPECTS was not (OR 0.8; 95% CI 0.5-1.2). A score ≤5 in CTA-SI-ASPECTS was the best cut-off to predict futile recanalization (sensitivity 35%; specificity 97%; positive predictive value 86%; negative predictive value 77%). CTA-SI-ASPECTS strongly predicts futile recanalization and could be a valuable tool for treatment decisions regarding the indication of revascularization therapies.

Abstract WP21: Primary Thrombectomy Within 3 Hours of Onset in Acute Ischemic Stroke From Large Artery Occlusion (PAST3-LAO)- A Pilot Study

Background: Based on recent trials, AIS due to large artery occlusion (LAO) is resistant to IV thrombolysis and adjunctive stent retriever thrombectomy (SRT) is associated with better recanalization rates and outcomes.Despite the benefit with endovascular therapy 39% to 68% of patients were either disabled or dead.Thrombectomy in AIS with LAO within 3 hours (IV t-PA window) is performed as secondary therapy after IV thrombolysis, which may be associated with delay in enrollment and recanalization. Objective: Primary objective is to evaluate the safety, feasibility and recanalization rate of primary SRT (without IV tPA) within 3 hours in AIS with NIHSS &gt;10 from LAO.Secondary objective is to determine the functional outcome in 30-days and 90-days. Methods: Based on institutionally approved protocol patients with LAO with LCB within 3 hours were offered primary SRT alone as an alternative to IV rtPA, after informed consent.Consecutive patients who underwent primary SRT for LAO within 3 hours from 2012 to 2014 were enrolled.Outcomes were measured using modified Rankin Scale. Results: 18 patients with LAO; mean age 62.8±15.3 years and mean NIHSS 16±5; chose primary SRT after informed consent.Thrombectomy was performed using new generation stent-retriever device in addition to small intra-arterial rtPA (2-10 mg).Number of passes was 1.6±0.9.Near complete (TICI2b in 1) and complete (TICI3 in 17) recanalization was observed in all (100%) patients.Mean time to recanalization from symptoms onset was 188.5±82.7 and from groin puncture was 64.61±40.14 minutes.Immediate post-thrombectomy, 24 hour and 30 day NIHSS score was 4.4±3.7, 1.9±3.2 and 0.3±0.9 respectively.There was no procedure related complication.Asymptomatic perfusion related hemorrhage developed in 6 patients (33%).30 days good outcome was observed in all cases (mRS0= 38.9%, mRS1=44.4%, mRS2=16.7%). 90 days good outcome was observed as follows (mRS0= 50.0%, mRS1=44.4%, mRS2=5.6%). Conclusion: Our pilot study demonstrates that primary SRT in AIS due LAO occlusion with LCB is not only safe and feasible, but associated with complete recanalization and good functional outcome.Larger randomized controlled studies are needed.

Abstract WMP4: Analysis of Outcomes From the Endovascular Treatment of Posterior Circulation Strokes in the Modern Era of Stent Retriever Thrombectomy

Background: Evidence for endovascular treatment of anterior circulation strokes is well developed. However, patients with posterior circulation strokes have been excluded from recent randomized endovascular stroke trials. Objective: To evaluate outcomes of posterior circulation strokes treated with modern endovascular therapy since the FDA approval of stent retrievers, and to identify predictors of clinical outcomes and complications in this specific population of stroke patients. Methods: We performed a multicenter retrospective analysis of consecutive patients with posterior circulation strokes who underwent thrombectomy with stent retrievers or primary aspiration thrombectomy (including the ADAPT approach). We correlated favorable clinical outcomes with demographic, clinical and technical characteristics. Results: A total of 84 patients were included in this study (mean age, 63.5 years; mean admission NIHSS score, 19.2). Favorable clinical outcome at 3 months, defined as mRS score 0-2 was achieved in 34 (40%) patients. NIHSS score &lt; 20, the use of conscious sedation rather than general anesthesia and successful recanalization (TICI 2b/3) were significant predictors of favorable clinical outcome at 90 days. The use of baseline advanced imaging (CT perfusion, multi-phase CTA or MRI) for patient selection was not associated with improved outcomes. In patients with the time of symptom onset to femoral puncture &lt; 6 hours, mRS 0-2 at 3 months was achieved in 51.2% of cases. Treatment initiated beyond the 6-hour window resulted in 30.2% rate of mRS 0-2 at 3 months. Conclusions: Severity of admission NIHSS score, recanalization success and the type of anesthesia strongly correlate with clinical outcomes in endovascular therapy of posterior circulation strokes. The highest rate of long-term favorable outcomes was achieved in patients whose thrombectomy was initiated within the first 6 hours of stroke onset. However, even when started beyond the 6 hours window, endovascular treatment of posterior circulation strokes is feasible.

0200: Predictors of angiographically visible distal embolization in ST elevation myocardial infarction patients treated by primary percutaneous coronary intervention and thrombectomy

Aspiration thrombectomy during primary percutaneous coronary intervention (p-PCI) in ST elevation myocardial infarction (STEMI) has been proposed to restore myocardial reperfusion. But important controversies remain concerning the usefulness of thrombectomy to improve this perfusion. Our objective was to evaluate the impact of manual thrombectomy on the occur-rence of angiographically visible distal embolization (AVDE) during p-PCI in STEMI. 346 consecutive patients admitted for STEMI who underwent p-PCI and thrombectomy were included. Clinical, angiographic and therapeutics characteristics were assessed. AVDE was defined as an abrupt vessel closure occurring at any point during the PCI procedure and that was not present at baseline. Patients were divided into 2 groups: with AVDE (59 patients) and without AVDE 287 patients. Comparing the 2 groups, patients with AVDE were more likely to be older than 60 year-old (67 vs. 50%; p=0.014), with a higher proportion of women (34 vs. 20%; p=0,027), of right coronary artery lesion (57 vs. 34.5%; p=0.001). Conversely, smoking and left anterior descending coronary artery lesion were more frequent in patients without AVDE (respectively 63 vs. 46%; p=0.014 and 50 vs. 30%; p=0.005). Univariate analysis identify age >60 (OR[95% CI]:2.09(1.15-3.78), p=0.015), female gender (OR[95% CI]:2.02(1.09-3.73), p=0,024), culprit coronary diameter >3mm (OR[95% CI] as predictors of AVDE during p-PCI for STEMI. By multivariate analysis, culprit coronary diameter >3mm (OR[95% CI]: 1.90 (1.01-3.56); p=0.048) and and the right coronary artery culprit lesion site (OR[95% CI]:2.48(1.36-4.52); p=0.003) were independent factors associated with AVDE. AVDE complicating p-PCI during STEMI is frequent (17%). Strikingly we found that successful thrombectomy does not prevent from AVDE. Conversely, we highlight that patients with culprit coronary artery diameter >3mm and STEMI due to right coronary artery occlusion are more likely to develop AVDE.

Stent retriever thrombectomy for acute ischemic stroke: Indications, results and management in 2015.

The functional benefit of stent retriever thrombectomy in acute ischemic stroke has been clearly demonstrated in recent positive MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, REVASCAT and THRACE trials. Thrombectomy, in association with intravenous thrombolysis, should now be offered to patients with documented occlusion of the distal internal carotid or proximal middle cerebral arteries, with a relatively normal unenhanced computed tomography (CT), and within 6hours after the onset of symptoms. Thrombectomy results in a mean absolute decrease in handicap of 22% (14 to 31%). Of the 3 up to 8 patients treated, 1 is independent at 3 months according to the initial selection. In case of a contraindication to thrombolysis, early primary thrombectomy should be considered. In acute basilar artery occlusion, thrombectomy should be performed alone or combined with thrombolysis. In an effort to increase the number of patients treated, a very rapid transfer to interventional neuroradiology centers is mandatory. In the future, thrombectomy should be evaluated in patients with distal arterial occlusion, or beyond 6hours after the onset of symptoms, or when the time of symptoms onset is unknown.

Thrombectomie mécanique de l’infarctus cérébral : pourquoi une prise en charge ultrarapide est nécessaire ?

Intravenous thrombolysis was the only proven effective reperfusion therapy for acute ischemic stroke within 4h30 until December 2014. Stroke management has been revolutionized after the publication of the recent positive trials, such as MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, REVASCAT, and THRACE. Each of these demonstrates a clear benefit of stent retriever thrombectomy in association with thrombolysis in acute stroke patients with a documented occlusion of the distal internal carotid or the proximal middle cerebral artery within 6 h of symptoms onset. According to the initial selection, the number of patients to be treated by thrombectomy in order to have one independent patient varies from 3 to 8.To guarantee these results, thrombectomy should be performed by an interventional neuroradiologist within 60–90 min after imaging confirmation, which requires a very fast transfer of patients to hospitals, where interventional neuroradiology is available without delaying thrombolysis. Samu plays a key role in this. In case of contraindication to thrombolysis, early primary thrombectomy should also be considered within 6 h of last seen normal. In acute basilar artery occlusion, thrombectomy should be performed alone or combined with thrombolysis. A close cooperation between all the teams is crucial with the goal of gaining maximum time to the patient.

Abstract T MP9: Primary Thrombectomy Within 3 Hours Of Onset In Acute Ischemic Stroke From Occlusion Of Middle Cerebral Artery- A Pilot Study

Background: Acute ischemic stroke (AIS) due to large artery occlusion (LAO) with high NIHSS (&gt;10), especially in internal carotid artery terminus (ICA-T) are resistant to IV thrombolysis and endovascular thrombectomy is associated with better recanalization rates. IV thrombolysis in large clot burden (&gt;8mm) (LCB) in the middle cerebral artery (MCA) is associated with poor recanalization and may impact outcome. However, thrombectomy in AIS with LAO within 3 hours is performed as secondary therapy after IV thrombolysis. Objectives: To evaluate the feasibility, safety and recanalization rate of primary thrombectomy within 3 hours in AIS with NIHSS &gt;10 from occlusion of MCA with LCB. Additionally, we like to report the functional outcome. Methods: Based on institutionally approved protocol patients with LAO (ICA-T, MCA, vertebral-basilar artery) with LCB within 3 hours were offered primary thrombectomy as an alternative to IV rtPA. They were entered into a stroke database. Patients who underwent primary MCA thrombectomy within 3 hours from 2012 to 2014 were retrospectively analyzed using SAS software. Outcomes were measured using modified Rankin Scale (mRS).Results: 10 patients with MCA occlusion ;mean age 65±15.87 years and mean NIHSS 16±; chose primary thrombectomy after informed consent. Thrombectomy was performed using stent-retriever device in addition to intra-arterial rtPA (2-4 mg). Mean number of passes was 1.4±.7. Near complete (TICI2b) and complete (TICI3) recanalization was observed in all patients. Mean time to recanalization from symptoms onset was 160±37 minutes. Immediate post-thrombectomy, 24 hour and 30 day NIHSS score was 2.6±1.4, 1.9±3.7 and 0 respectively. There was no procedure related complication. Asymptomatic perfusion related hemorrhage developed in 3 patients. 30 day good outcome was observed in all cases (mRS0= 30%, mRS1=50%, mRS2=20%).Conclusion: Our pilot study demonstrates that primary thrombectomy in AIS due to MCA occlusion with LCB is not only feasible and safe, but associated with complete recanalization and good functional outcome. Larger randomized controlled studies are needed.

Abstract W MP10: Outcome and Futile Recanalization in Basilar Artery Occlusion - Systematic Analysis

Background: Basilar artery occlusion (BAO) is a most devastating form of stroke, and the current wisdom is to reverse it with revascularization therapies. Pharmacological thrombolysis have been adjuncted or replaced with endovascular thrombectomy devices. The preferred approach remains unknown and most recanalizations are futile with no clinical benefit. Methods: To determine whether invasive, endovascular interventions are superior to pharmacological thrombolysis alone we analyzed systematically the reported outcomes produced by variable BAO recanalization protocols. Information was retrieved from 15 reports published from 2005 comprising 803 patients in 17 cohorts. In the largest single-center cohort (162, Helsinki), predictors of futile recanalization (FR;3-month modified Rankin Scale [mRS] score 4 to 6) were determined. Results: Good outcome was reported by pharmacological protocols less frequently than by mechanical approaches either alone or on-demand (24.4% vs. 35.5% %, p&lt;0.001), accompanied by lower recanalization rates (70.9% vs. 84.1%, p&lt;0.001)(Figure). Afforded by superior recanalization rate at 91%, good outcome was reached by primary thrombectomy with stent-retrievers in 36%, but at the cost of substantial FR rate at 60%. In the largest single-center cohort, the single most significant predictor was extensive baseline ischemia, increasing the odds of futility 20-fold (95%CI 4.39-92.29, p&lt;0.001). Other attributes of futility were ventilation support and history of atrial fibrillation or previous stroke. Conclusion: Mechanical endovascular approaches have reported superior primary outcome rates over pharmacological thrombolysis in BAO. Stricter patient selection, most notably to exclude victims of already extended ischemia, would assist in translating excellent recanalization rates into improved clinical outcomes and more acceptable futility rates.

Endovascular therapy of wake-up strokes in the modern era of stent retriever thrombectomy

BackgroundEndovascular treatment of wake-up strokes (WUS) has been previously described, mostly with the use of pharmacological thrombolysis or first generation thrombectomy devices.ObjectiveTo describe outcomes of WUS treated with modern endovascular...

Adjuvant Tirofiban Injection Through Deployed Solitaire Stent As a Rescue Technique After failed Mechanical Thrombectomy in Acute Stroke.

PurposeWe present our experiences of intra-arterial tirofiban injection through a deployed Solitaire stent as a rescue therapy after failed mechanical thrombectomy in patients with acute ischemic stroke.Materials and MethodsData on 18 patients treated with adjunctive tirofiban injection through a temporarily deployed Solitaire stent after failed mechanical thrombectomy were retrospectively reviewed. Solitaire stent was used as a primary thrombectomy device in 16 of 18 patients. Two patients received manual aspiration thrombectomy initially. If initial mechanical thrombectomy failed, tirofiban was injected intra-arterially through the deployed Solitaire stent and then subsequent Solitaire thrombectomy was performed.ResultsFourteen patients had occlusions in the middle cerebral artery, 2 in the distal internal carotid artery, and 2 in the basilar artery. Successful recanalization was achieved in 14 patients (77.7%) after intra-arterial injection of tirofiban and subsequent Solitaire thrombectomy. Three patients without successful recanalization after rescue method received angioplasty with stenting. Overall, successful recanalization (TICI grades 2b and 3) was achieved in 17 (94.4%) of 18 patients. Periprocedural complications occurred in 5 patients: distal migration of emboli in 5 patients and vessel perforation in 1. Three patients died. Good functional outcome (mRS ≤ 2) was achieved in 9 patients (50.0%) at 3 months.ConclusionRescue intra-arterial injection of tirofiban through a temporarily deployed Solitaire stent may facilitate further recanalization in cases of failed mechanical thrombectomy in patients with acute ischemic stroke.

Functional Outcome After Primary Endovascular Therapy or IV Thrombolysis Alone for Stroke. An Observational, Comparative Effectiveness Study

Background: Among the acute ischemic stroke patients with large vessel occlusions and contraindications for the use of IV thrombolysis, mainly on oral anticoagulation or presenting too late, primary endovascular therapy is often performed as an alternative to the standard therapy even though evidence supporting the use of endovascular reperfusion therapies is not yet established. Using different statistical approaches, we compared the functional independence rates at 3 months among patients undergoing primary endovascular therapy and patients treated only with IV thrombolysis. Methods: We used data from a prospective, government-mandated and externally audited registry of reperfusion therapies for ischemic stroke (January 2011 to November 2012). Patients were selected if treated with either IV thrombolysis alone (n = 1,582) or primary endovascular thrombectomy (n = 250). A series of exclusions were made to homogenize the clinical characteristics among the two groups. We then carried out multivariate logistic regression and propensity score matching analyses on the final study sample (n = 1,179) to compare functional independence at 3 months, as measured by the modified Rankin scale scores 0-2, between the two groups. Results: The unadjusted likelihood of good outcome was poorer among the endovascular group (OR: 0.69; 95% CI: 0.47-1.0). After adjustment, no differences by treatment modality were seen (OR: 1.51; 95% CI: 0.93-2.43 for primary endovascular therapy). Patients undergoing endovascular thrombectomy within 180-270 min (OR: 2.89; 95% CI: 1.17-7.15) and patients with severe strokes (OR: 1.84; 95% CI: 1.02-3.35) did better than their intravenous thrombolysis counterparts. The propensity score-matched analyses with and without adjustment by additional covariates showed that endovascular thrombectomy was as effective as intravenous thrombolysis alone in achieving functional independence (OR for unadjusted propensity score matched: 1.35; 95% CI: 0.9-2.02, OR for adjusted propensity score matched: 1.45; 95% CI: 0.91-2.32). Conclusion: This comparative effectiveness study shows that in ischemic stroke patients with contraindications for IV thrombolysis, primary endovascular treatment might be an alternative therapy at least as effective as IV thrombolysis alone. Randomized controlled trials are urgently needed.

Abstract T MP5: Primary Aspiration Thrombectomy With the Penumbra Max Catheter System Allows Rapid Recanalization and Cost Efficiency in Acute Stroke Treatment

Introduction: Rapid recanalization remains the goal of acute stroke therapy. Cost effectiveness in stroke treatment is becoming more important. With newer devices such as stentrievers, and improvements upon the older Penumbra aspiration catheters, recanalization rates have improved, but often at the expense of cost containment in stroke treatment. Hypothesis: We assessed the hypothesis that primary aspiration thrombectomy for endovascular acute stroke treatment with the newer Penumbra Max catheter system can be performed effectively and at a reduced cost as compared to other available devices Methods: We retrospectively reviewed prospectively collected data in 124 patients who underwent endovascular treatment for acute ischemic stroke at our institution from 1/1/2011 through 6/30/2013. All devices were freely available for use. However, from 1/1/2013 through 6/30/2013, we agreed to use aspiration with the Penumbra Max catheter system as the primary technique for thrombectomy, with other devices, including the Penumbra Separator and Solitaire device, available if primary aspiration failed. Variables evaluated were techniques/devices used, recanalization rates, procedural fluoroscopy times (as a relative marker of recanalization times between techniques), and procedural costs. Results: Successful recanalization (TICI 2b/3) was achieved in 77% of all cases, with a total ICH rate of 12.1% and sICH of 2.4%. From 1/1/2013 through 6/30/2013 28 patients were treated with primary aspiration using Penumbra Max, with a recanalization rate of 90%. A separator was used in 3 cases and a Solitaire device in 1 patient; with these devices total recanalization was 96%. Primary aspiration using the older Penumbra catheters yielded a recanalization rate of only 59%. Solitaire (n=9) was successful in 70%. TICI 3 recanalization rates were 60% for Penumbra Max, 23% for older Penumbra catheters, and 20% for Solitaire. Average cost/case using the Penumbra Max system was $3243, compared to $5924 as a baseline, yielding a 55% savings. Average fluoroscopy time for Penumbra Max was 22 mins, compared to 36 mins for the older Penumbra catheters and 24 mins for Solitaire. Conclusions: The Penumbra Max system is clinically and cost effective in stroke thrombectomy.