First-pass Recanalization Rates Research Articles

Three years' interventional neurology experience in Turkey with the Thrombite thrombectomy device in large vessel occlusion in the anterior circulation: safety, efficacy, and clinical outcome.

While the Thrombite device differs from the Solitare stent with its Helical open-side structure feature, it shows great similarity with its other features. We assessed the Thrombite device's effectiveness and safety in this study. The study was a retrospective analysis of patients who were included in the Turkish Interventional Neurology database and who had mechanical thrombectomy with the Thrombite device as the first choice between January 2020 and January 2023. The type of study is descriptive research. Using the Thrombite thrombectomy device, 525 patients received treatment. The median baseline National Institutes of Health Stroke Scale (NIHSS) score was 13, the median initial Alberta Stroke Program Early Computed Tomography (ASPECT) score was 8, and the mean patient age was 68.6+11.7 years. Between the groin puncture and the successful recanalization, the median time was 34 minutes (interquartile range [IQR]: 15-45). 48.2% (modified treatment in cerebral infarction; mTICI) 2b/3% and 33.9% (mTICI 2c/3) were the first-pass recanalization rates. In the end, 87.7% of patients had effective recanalization (thrombolysis in cerebral infarction 2b/3). In the "first-pass" subgroup, the favorable functional result (modified Rankin Scale 0-2) was 51.8%, while it was 41.6% for the entire patient population. The rate of embolization into new territory/different territory were 2.1/0.1%. 23 patients (4.5%) had symptomatic hemorrhage. The Thrombite device showed a good safety profile and high overall successful recanalization rates in our experience.

Balloon angioplasty as first-choice recanalization strategy for intracranial atherosclerosis-related emergent large vessel occlusion with small clot burden.

The optimal primary recanalization strategy for intracranial atherosclerosis-related emergent large vessel occlusion (ICAS-ELVO) remains controversial. We aimed to explore the safety and efficacy of balloon angioplasty as the first-choice recanalization strategy for ICAS-ELVO with small clot burden. Consecutive ICAS-ELVO patients presenting with microcatheter "first-pass effect" during endovascular treatment (EVT) were retrospectively analyzed. Patients were divided into preferred balloon angioplasty (PBA) and preferred mechanical thrombectomy (PMT) groups based on the first-choice recanalization strategy. The reperfusion and clinical outcomes between the two groups were compared. Seventy-six patients with ICAS-ELVO involving the microcatheter "first-pass effect" during EVT were enrolled. Compared with patients in the PMT group, those in the PBA group were associated with (i) a higher rate of first-pass recanalization (54.0% vs. 28.9%, p = .010) and complete reperfusion (expanded thrombolysis in cerebral ischemia ≥ 2c; 76.0% vs. 53.8%, p = .049), (ii) shorter puncture-to-recanalization time (49.5min vs. 89.0min, p < .001), (iii) lower operation costs (¥48,499.5 vs. ¥ 99,086.0, p < .001), and (iv) better 90-day functional outcomes (modified Rankin scale:0-1; 44.0% vs. 19.2%, p = .032). Logistic regression analysis revealed that balloon angioplasty as the first-choice recanalization strategy was an independent predictor of 90-day excellent functional outcomes for ICAS-ELVO patients with microcatheter "first-pass effect" (adjusted odds ratio = 6.01, 95% confidence interval: 1.15-31.51, p = .034). Direct balloon angioplasty potentially improves 90-day functional outcomes for ICAS-ELVO patients with small clot burden, and may be a more appropriate first-choice recanalization strategy than mechanical thrombectomy for these patients.

"The microcatheter contrast injection technique": A novel technique to detect the proximal end of a thrombus in mechanical thrombectomy.

Background: An aspiration catheter needs to attach to a thrombus in order to achieve first-pass recanalization by mechanical thrombectomy (MT) for acute ischemic stroke (AIS), particularly that using a direct aspiration first pass technique. The meniscus sign, which is defined as meniscoid contrast opacification indicating the proximal edge of a thrombus, has been suggested to contribute to successful recanalization. In some cases, the meniscus sign is not detected following an injection of contrast medium through a guiding catheter. To precisely identify the location of a thrombus, we use "the microcatheter contrast injection (MCI) technique," which accurately shows the proximal edge of a thrombus. We herein introduce this novel technique and discuss its efficacy in MT. Methods: In cases without the meniscus sign, a microcatheter was advanced to the distal end of contrast opacification, and contrast medium was injected through the microcatheter to detect the meniscus sign. An aspiration catheter was then advanced to the thrombus indicated by the meniscus sign and slowly withdrawn under aspiration. Results: 29 patients underwent MT for AIS using the MCI technique. Even in cases without the meniscus sign on initial angiography, the MCI technique accurately revealed the proximal edge of the thrombus. Moreover, middle cerebral artery occlusion due to atherosclerotic stenosis and displacement of the aspiration catheter and thrombus axis were detected using this technique. Conclusions: The MCI technique may effectively reveal the exact site of a thrombus and increase the success rate of first-pass recanalization.

Abstract 058: General anesthesia versus conscious sedation during endovascular thrombectomy for distal vessel occlusions

Introduction Choice of anesthesia for endovascular thrombectomy in large vessel occlusion of the anterior circulation has been well studied, although practice patterns may still be variable. Anesthesia choice for distal vessel occlusions (DVO) presents unique challenges, however. General anesthesia (GA) may offer advantages over conscious sedation (CS) due to reduced patient movement facilitating catheter navigation, but concerns persist about potential delays and hypotension impacting collateral circulation. In our study, we aim to explore this question further. Methods In our prospectively maintained stroke registry from December 2014 to July 2023, we identified patients with DMVO defined as M2, M3, M4 occlusion, ACA occlusion, and PCA occlusion, who underwent MT for AIS. We compared patients who received CS to those who GA. Our primary outcome measures were length of procedure defined as time from entering angiography suite until final recanalization, access time to recanalization, CS to GA conversion rate, number of passes to reach TICI2b or better and first pass effect. Our secondary outcomes were length of stay, and modified Rankin Scale (mRS) at 5 days, 30 days, and 90 days. Results Total of 290 patients with DVO were identified, the median age was 73 (IQR 19). Of these, 86 patients (29.7%) underwent GA, and 200 (69.0%) received CS. CS to GA conversion was required in 36 patients (12.4%). Females accounted for 47.5% of the CS group and 38.4% of the GA group. No significant differences were found between the two groups in the racial and gender composition (p&gt;0.1). The mean admission NIHSS was significantly higher in the GA group (16.86) compared to the CS group (12.44) as was the rate of IV thrombolysis in the CS (36.2%) group compared to GA (31.4%) group (p&lt;0.01). The type of anesthesia used was not influenced by the laterality of the stroke in the middle cerebral artery territory (left vs right) (χ²=0.39, p=0.53). After adjusting for age, sex, IV thrombolysis, and admission NIHSS, CS usage did not result in an increase in procedural time (β=1.3, p=0.83). Furthermore, CS had no significant effect on the total number of passes (β=‐0.15, p=0.53), nor did it influence the likelihood of achieving first‐pass recanalization (β=0.28, p=0.48). No associations were found between CS use and the modified Rankin Scale (mRS) at 5 days (β=0.17, p=0.65), 30 days (β=0.22, p=0.75), or 90 days (β=0.15, p=0.67). Likewise, the length of stay in the hospital (β=1.71, p=0.77) was not significantly affected by the use of CS. Conclusion In our analysis of DMVO, the use of CS during thrombectomy appeared to be safe and feasible and comparable to GA with regards to procedural length, number of passes, and rate of first pass recanalization. Similarly, the type of anesthesia did not have an impact on clinical outcome. Further studies are needed to build on these findings and inform optimal management strategies.

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.

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.

Impact of stent-retriever tip design on distal embolization during mechanical thrombectomy: a randomized in vitro evaluation

BackgroundRepeated number of passes, clot fragmentation, and distal embolization during mechanical thrombectomy (MT) lead to worse clinical outcomes in acute ischemic stroke. This study aimed to assess the recanalization and...

Direct Aspiration versus Combined Technique for Distal Medium-Vessel Occlusions: Comparison on a Human Placenta Model.

Mechanical thrombectomy appears to be a promising option for distal medium-vessel occlusions, for which intravenous thrombolysis is effective but may be insufficient when used alone. This study aimed to determine the optimal technique for these distal mechanical thrombectomies using the human placenta model. Twenty-four procedures were performed, allowing comparison of direct aspiration (n = 12) versus the combined technique (n = 12). Two positions of the aspiration catheter were tested for each of these techniques: in direct contact with the clot and at a distance from it (5-10 mm). Two types of clots were tested: red blood cell-rich clots and fibrin-rich clots. First-pass recanalization and induced arterial collapse and traction were assessed. The first-pass recanalization was less frequent for direct aspiration than for the combined technique, without reaching statistical significance (41.7% versus 75.0%, P = .098). Full collapse (P < .001) and extended arterial traction (P = .001) were significantly less frequent for direct aspiration. For direct aspiration with the aspiration catheter not in direct contact with the clot, there was not a single first-pass recanalization and there was systematic arterial collapse, resulting in a no-flow in the aspiration syringe. The combined technique appears to be more harmful, and although direct aspiration has a lower rate of first-pass recanalization, it seems appropriate to try direct aspiration as a first-line procedure. However, if the aspiration catheter cannot reach the clot, it is not useful or even risky to try aspiration alone. These results need to be confirmed by clinical studies.

Abstract Number ‐ 151: Impact of Stent‐Retriever Tip Design on Distal Embolization during Mechanical Thrombectomy

Introduction Mechanical thrombectomy (MT) is a widely performed procedure for acute ischemic stroke (AIS) due to large vessel occlusion. Repeated number of passes, clot fragmentation, and distal embolization during MT lead to worse clinical outcomes. We aim to evaluate the impact of different stent‐retriever (SR) distal tip designs on distal emboli generation during MT. Methods Fragment‐prone clot analogs (diameter = 3.53±0.14mm; length = 6.74±0.61mm) were used to create proximal middle cerebral artery (MCA‐M1) occlusions in an in vitro neurovascular model featuring a complete circle of Willis. The anatomical replica was connected to a flow loop with circulating saline at physiological flow rate and temperature; 100‐µm filters were placed at the neurovascular outflow points of the model to collect generated distal emboli. After initial embolization, experiments were randomized into one of the three treatment arms based on SR tip design: open‐end (Open‐SR: Solitaire 6.0×40mm), closed‐end (Closed‐SR: Embotrap II 5.0×33mm), and filter‐end (Filter‐SR: NeVa NET 5.5×37mm). A balloon guide catheter was inflated at the internal carotid artery C1 level immediately after SR deployment, and the SR was pulled out under continuous proximal pump aspiration. A total of 90 cases were performed (30 cases/treatment arm). A single attempt was performed per case and after each pass, distal emboli collected in the outflow filters were analyzed by an image processing algorithm. Successful first pass recanalization (FPR) was confirmed if no residual clot was observed at the initial location or in a distal branch of the model. Primary study endpoints were: FPR rate (%FPR), the size of the largest embolus (largest‐E), the total emboli count (total‐E), the total count of emboli larger than 1mm (total&gt;1mm‐E), and the total area of the filter covered by emboli (area‐E). Results FPR was achieved in 57.8% of cases (52/90): Filter‐SR achieved a non‐significantly higher %FPR (70%) than closed‐SR (50%) and open‐SR (53.3%) (p = 0.244). In comparison to open‐ and closed‐SR, filter‐SR significantly reduced the largest‐E (open‐SR = 1.66±0.68mm vs. closed‐SR = 1.77±0.90mm vs. filter‐SR = 1.22±0.77mm; p = 0.013) as well as the total&gt;1mm‐E (open‐SR = 2.27±2.33 vs. closed‐SR = 3.97±5.68 vs. filter‐SR = 0.93±1.28; p = 0.002), and the area‐E (open‐SR = 18.22±14.47mm2 vs. closed‐SR = 23.98±22.39mm2 vs. filter‐SR = 10.14±8.81mm2; p = 0.013). The differences between distal tip designs were not clearly evidenced in the total‐E (open‐SR = 22.7±10.75 vs. closed‐SR = 23.13±13.16 vs. filter‐SR = 20.63±12.77; p = 0.464). No significant differences were found between open‐ and closed‐SR (p&gt;0.05 in all metrics). Conclusions When facing fragment‐prone clots with low SR engagement, the filter‐SR significantly reduces the number of large clot fragments (&gt;1mm), the size of the largest embolus, and the overall surface area of clot fragments that embolize distally during an MT procedure.

Double stent-retriever as the first-line approach in mechanical thrombectomy: a randomized in vitro evaluation

BackgroundA repeated number of passes during mechanical thrombectomy leads to worse clinical outcomes in acute ischemic stroke. Initial experiences with the simultaneous double stent-retriever (double-SR) technique as the first-line treatment...

In vitro testing of a funnel-tip catheter with different clot types to decrease clot migration in mechanical thrombectomy.

Mechanical thrombectomy is the standard treatment for acute ischemic stroke in patients with large vessel occlusion and can be performed up to 24h after symptom onset. Despite high recanalization rates, embolism in new territories has been reported in 8.6% of the cases. Causes for this could be clot abruption during stent retrieval into the smaller opening of a standard distal access catheter, and antegrade blood flow via collaterals despite proximal balloon protection. A funnel-shaped tip with a larger internal diameter was developed to increase the rate of first-pass recanalization and to improve the safety and efficacy of mechanical thrombectomy. This in vitro study compared the efficacy of a funnel-shaped tip with a standard tip in combination with different clot compositions. Mechanical thrombectomy was performed 80 times for each tip, using two stent retrievers (Trevo XP ProVue 3/20 mm, 4/20 mm) and four different clot types (hard vs. soft clots, 0-24h vs. 72h aged clots). Significantly higher first-pass recanalization rates (mTICI 3) were observed for the funnel-shaped tip, 70.0% versus 30.0% for the standard tip (absolute difference, 32; relative difference 57.1%; P < .001), regardless of the clot type and stent retriever. Recanalization could be increased using harder Chandler loop clots versus softer statically generated clots, as well as 0-24h versus 72h aged clots, respectively. The funnel-shaped tip achieved higher first-pass recanalization rates than the smaller standard tip and lower rates of clot abruption at the tip. Clot compositions and aging times impacted recanalization rates.

A comparison between different endovascular treatment strategies for acute large vessel occlusion due to intracranial artery atherosclerosis: data fromANGEL-ACT Registry.

The aim of our study is to compare the characteristics and clinical outcomes among the different endovascular treatment (EVT) strategies for large vessel occlusion underlying intracranial atherosclerosis (ICAS-LVO) in a recent nationwide registry. Patients with isolated ICAS-LVO were enrolled in our analysis and were categorized into three groups: first-line mechanical thrombectomy (MT) with rescue angioplasty and/or stenting (MT + RS), direct angioplasty and/or stenting without thrombectomy (DA), and MT alone. Baseline and periprocedural characteristics, successful recanalization, and 90-day functional outcomes were compared. Of 396 patients with isolated ICAS-LVO in our study, successful recanalization was achieved in 94.5%, 100%, and 90.9% of patients in the MT + RS, DA, and MT groups, respectively. The 90-day functional independence in the three groups was 50.8%, 59.0%, and 45.1%. The main efficacy and safety outcomes showed no significant differences among the groups. First-pass recanalization (FPR) was more observed in the MT group (43.4%), the recanalization rate per attempt in the MT group gradually decreased until the fourth attempt, and further maneuvers showed recanalization rates of ≈0% per attempt. MT + RS (adjusted odds ratio [aOR] 0.10, p < 0.0001) and DA (aOR 0.18, p = 0.0013) were associated with lower FPR rate than MT alone in the multivariable logistic regression. The technical feasibility and favorable outcomes of several EVT strategies for ICAS-LVO were established in our study. First-line MT with a bailout angioplasty is a reasonable option for ICAS-LVO, and DA is an effective option for the cases when ICAS-LVO is strongly suspected before EVT procedure.

Effects of stroke etiology on angiographic success in patients undergoing mechanical thrombectomy.

In this study, we investigated the relationship between stroke etiology and recanalization success with endovascular treatment in patients with acute ischemic stroke. A total of 109 patients with anterior circulation stroke who underwent mechanical thrombectomy between August 2017 and June 2019 were included in the study retrospectively. Stroke etiologies of the patients were determined according to the TOAST criteria (Trial of Org 10,172 acute stroke treatment), and the relationship between stroke etiology and successful first-pass recanalization rate with endovascular treatment, total successful recanalization rate, and procedure time was evaluated. The data of 109 patients who presented with anterior circulation stroke and underwent mechanical thrombectomy were retrospectively analyzed. Fifty-five (50.5%) of the patients were female and 54 (49.5%) were male, and mean age was 67.3 ± 12.9. When the stroke etiologies of the patients were evaluated, it was found that 47 (43.1%) were due to large vessel ateherosclerotic disease (LVAD), and 62 (56.9%) were cardioembolic-related. Recanalization success and clinical outcomes did not differ significantly in patients with LVAD and those with cardioembolic etiology (p > 0.05). In addition, the number of patients with modified Rankin score (mRS) 6 in the atherosclerotic group was significantly higher than in the cardioembolic group (p = 0.022). Recanalization success and clinical outcomes did not differ significantly in patients with LVAD and those with cardioembolic etiology. However, mortality rate was higher in patients with atherosclerotic etiology, due to the complexity of the procedure and the high rate of reocclusion.

Experimental Evaluation of the Effectiveness of Aspiration-Based Techniques to Treat Different Types of Acute Thromboembolic Occlusions in the Femoropopliteal Vascular System Using an In Vitro Flow Model

PurposeIn this in vitro study, the effectiveness and safety of four aspiration-based techniques for thrombectomy are evaluated for three types of thrombi in a flow model simulating the femoropopliteal segment.Material and MethodsRed, white, and mixed thrombi were produced in a standardized manner and used to simulate occlusion of a superficial femoral artery using a pulsatile flow model. Four techniques were compared: aspiration alone, aspiration + stent retriever, exposing thrombus to laser by an excimer laser system and a laser catheter + aspiration, and aspiration + mechanical fragmentation by a separator. Rate of first-pass recanalization, embolic events, and number of embolized fragments > 1 mm were compared.ResultsAspiration alone, stent retriever, laser, and separator differed in rates of first-pass recanalization (53.3%; 86.6%; 20%; and 100%) and embolic events (40%; 93.3%; 73.3%; and 60%). Number of embolized fragments was lowest with aspiration and higher with separator, laser, and stent retriever. Rates of first-pass-recanalization (75%; 75%; and 45%) and embolic events (65%; 60%; and 75%) differed for red, white, and mixed thrombi. The mixed thrombus caused the highest number of embolized fragments, which was particularly high using the stent retriever.ConclusionAdditional use of mechanical techniques significantly enhances the effectiveness of thrombectomy but simultaneously provokes more embolism. Laser seems to negatively alter the structure of a thrombus and thus diminishes the effectiveness, while provoking embolism. All techniques had lowest effectiveness, but highest embolism with the mixed thrombus. This was particularly striking when a stent retriever was used with the mixed thrombus.

Effect of manual aspiration thrombectomy using large-bore aspiration catheter for acute basilar artery occlusion: comparison with a stent retriever system

BackgroundA large-bore aspiration catheter can be employed for recanalization of acute basilar artery occlusion. Here we compare the results of mechanical thrombectomy using a stent retriever (SR) and manual aspiration thrombectomy (MAT) using a large-bore aspiration catheter system as a first-line recanalization method in acute basilar artery occlusion (BAO).MethodsThe records of 50 patients with acute BAO who underwent mechanical thrombectomy were retrospectively reviewed. Patients were assigned to one of two groups based on the first-line recanalization method. The treatment and clinical outcomes were compared.ResultsSixteen (32%) patients were treated with MAT with a large-bore aspiration catheter and 34 (68%) with a SR as the first-line treatment method. The MAT group had a shorter procedure time (28 vs. 65 min; p = 0.001), higher rate of first-pass recanalization (68.8% vs. 38.2%, p = 0.044), and lower median number of passes (1 vs 2; p = 0.008) when compared with the SR group. There was no significant difference in the incidence of any hemorrhagic complication (6.3% vs. 8.8%; p = 0.754) between the groups. However, there were four cases of procedure-related subarachnoid hemorrhage (SAH) in the SR group and one death occurred due to massive hemorrhage.ConclusionsSelection of MAT using a large-bore aspiration catheter for acute BAO may be a safe and effective first-line treatment method with higher first-pass recanalization rate and shorter procedure time than SR.

Choosing an Effective and Safe Direct Aspiration Setup for Tortuous Anatomy in Acute Ischemic Stroke: In vitro Study in a Physiological Flow Model.

A direct aspiration first pass technique (ADAPT) is an effective thrombectomy option in patients with acute ischemic stroke. Balloon guide catheters (BGC) seem to improve the efficacy of stent retrievers and ADAPT. The last generation 6F aspiration catheters require 9F BGCs, which are rigid devices that are challenging to position in a tortuous anatomy. In this experimental study the efficacy of 6F ADAPT alone and 5F ADAPT combined with 8F BGC was evaluated. Either a fibrin rich (white) clot or an RBC rich (red) clot was placed in the M1 segment of a transparent silicon phantom. Physiological hemodynamic conditions were maintained. The clots were retrieved by 6F aspiration catheter via 8F long sheath or 5F aspiration catheter via a flexible 8F BGC. Thrombectomy was performed under direct visual control. The primary endpoints were the number of passes and the number of distal emboli. Ten experiments were made with each clot model and thrombectomy technique (n = 40). Full recanalization could be achieved in every experiment. First pass mTICI 3 could be achieved by 6F ADAPT in 80 % of red clots and 90 % of white clots. Distal emboli were caused in 10 % and 20 %, respectively. When using 5F ADAPT combined with BGC, a first pass mTICI 3 rate of 90 % in red clots and 100 % in white clots could be achieved. A 10 % rate of distal emboli occurred in both groups. In almost all experiments (both techniques), the thrombi clogged the aspiration catheter. No statistically significant differences could be found between the techniques and clot models. 6F ADAPT without BGC was as effective as 5FADAPT combined with a flexible 8F BGC, with both techniques showing high first-pass recanalization rates and low distal emboli rates. Especially in the case of a tortuous anatomy, these setups should be considered as alternatives to a rigid 9F BGC. The thrombus compositions seemed to be irrelevant in this setting. · 6F ADAPT with no BGC and 5F ADAPT with BGC were very effective and performed equally.. · Both techniques should be considered in tortuous anatomy.. · In this setting the clot composition showed no effect on the recanalization rate.. · Madjidyar J, Nerkada L, Larsen N et al. Choosing an Effective and Safe Direct Aspiration Setup for Tortuous Anatomy in Acute Ischemic Stroke: In vitro Study in a Physiological Flow Model. Fortschr Röntgenstr 2021; 193: 544 - 550.

Transition to Transradial Access for Mechanical Thrombectomy-Lessons Learned and Comparison to Transfemoral Access in a Single-Center Case Series.

Trends in mechanical thrombectomy have emphasized larger bore aspiration catheters that may be difficult to deploy from a radial access point due to size constraints or need to obtain sheathless access. As such, many neurointerventionists are reticent to attempt thrombectomy through transradial access (TRA) for fear of worse outcomes. To explore whether mechanical thrombectomy could be achieved safely and effectively through the transradial route. We retrospectively analyzed the records of patients undergoing mechanical thrombectomy at our academic institute between January 2018 and January 2019, which corresponded to a time when we began to transition to TRA for neurointerventions, including mechanical thrombectomy. We compared the procedural details and clinical outcomes of patients undergoing mechanical thrombectomy using TRA with those using transfemoral access (TFA). During the study period, 44 patients underwent mechanical thrombectomy with TRA and 129 with TFA. There was no statistically significant difference in door-to-access time, door-to-reperfusion time, or first-pass recanalization rate. There was no significant difference in modified Rankin Scale (mRS) score at discharge, mRS score at last follow-up, or length of stay. There were 7 access-site complications in the TFA group and none in the TRA group. One patient in the TRA group required crossover to TFA. Mechanical thrombectomy can be performed safely and effectively from a TRA site without compromising recanalization times or rates. TRA has superior access-site complication profiles compared to TFA.

Favorable first-pass recanalization rates with NeVa™ thrombectomy device in acute stroke patients: Initial clinical experience.

The NeVa™ thrombectomy device (Vesalio LLC, Nashville, USA) has been reported to succeed in large vessel occlusion thrombectomy in animal, in-vitro, and clinical studies. Designed with Drop Zone technology, a closed distal tip, and strong expansive radial force, the device demonstrated particular efficiency in resistant "white" thrombi in preclinical research. Our goal is to determine the safety and performance of this novel stent retriever on first-pass rates and overall recanalization. The Interventional Neurology Database is a prospectively maintained database of anterior and posterior circulation stroke thrombectomy cases. We retrospectively analyzed cases where the NeVa™ thrombectomy device was used as the first-line treatment strategy. Data collection occurred between January 2019 and January 2020. First-pass recanalization, final recanalization, 90-day functional outcome, complication, and bleeding rates are reported. One hundred eighteen patients were treated with the NeVa™ thrombectomy device. The mean patient age was 69 ± 14 years, the median baseline National Institutes of Health Stroke Scale was 14, and the median initial Alberta Stroke Program Early Computed Tomography score was 8. The median time from groin puncture to successful recanalization was 29 min (interquartile range (IQR): 20-40). First-pass recanalization rates were 56.8% (modified treatment in cerebral infarction (mTICI) 2b/3) and 44.9% (mTICI 2c/3). Final successful recanalization rate was 95.8% (thrombolysis in cerebral infarction 2b/3). Favorable functional outcome (modified Rankin Scale 0-2) was 53% in the "first-pass" subgroup and 42.4% in the total patient population. The median number of passes to achieve the final recanalization score was 1 (IQR 1-2). The rate of embolization into new territory was 1.7%. Four patients (3.3%) had symptomatic hemorrhage. In our experience, the NeVa™ device demonstrated high first-pass and overall recanalization rates along with a good safety profile.

Need for rescue treatment and its implication: stent retriever versus contact aspiration thrombectomy

BackgroudThe need for rescue treatment (RT) may differ depending on first-line modality (stent retriever (SR) or contact aspiration (CA)) in endovascular thrombectomy (EVT). We aimed to investigate whether the type...

Effect of balloon guide catheter utilization on contact aspiration thrombectomy.

OBJECTIVEThe role of the balloon guide catheter (BGC) has not been evaluated in contact aspiration thrombectomy (CAT) for acute stroke. Here, the authors aimed to test whether the BGC was associated with recanalization success and good functional outcome in CAT.METHODSAll patients who had undergone CAT as the first-line treatment for anterior circulation intracranial large vessel occlusion were retrospectively identified from prospectively maintained registries for six stroke centers. The patients were dichotomized into BGC utilization and nonutilization groups. Clinical findings, procedural details, and recanalization success rates were compared between the two groups. Whether the BGC was associated with recanalization success and functional outcome was assessed.RESULTSA total of 429 patients (mean age 68.4 ± 11.4 years; M/F ratio 215:214) fulfilled the inclusion criteria. A BGC was used in 45.2% of patients. The overall recanalization and good outcome rates were 80.2% and 52.0%, respectively. Compared to the non-BGC group, the BGC group had a significantly reduced number of CAT passes (2.6 ± 1.6 vs 3.4 ± 1.5), shorter puncture-to-recanalization time (56 ± 27 vs 64 ± 35 minutes), lower need for the additional use of thrombolytics (1.0% vs 8.1%), and less embolization to a distal or different site (0.5% vs 3.4%). The BGC group showed significantly higher final (89.2% vs 72.8%) and first-pass (24.2% vs 8.1%) recanalization success rates. After adjustment for potentially associated factors, BGC utilization remained independently associated with recanalization (OR 4.171, 95% CI 1.523-11.420) and good functional outcome (OR 2.103, 95% CI 1.225-3.612).CONCLUSIONSBGC utilization significantly increased the final and first-pass recanalization rates and remained independently associated with recanalization success and good functional outcome.