Recanalization Rate Research Articles

Abstract 130: Endovascular Therapy for Cerebral Venous Sinus Thrombosis: A Systematic Review of 267 patients

Introduction Cerebral venous sinus thrombosis (CVST) is a rare form of stroke that usually affects young females especially during pregnancy and the postpartum period. Several risk factors can contribute to the development of cerebral venous sinus thrombosis including hypercoagulable states, dehydration, infections, head or neck injuries, cancer, and some rheumatological diseases (1). The symptoms of cerebral venous sinus thrombosis can vary depending on the location and extent of the clot. Common signs and symptoms may include severe headaches, visual disturbances, seizures, focal neurological deficits, altered mental status, and in severe cases, coma. The initial treatment for CVST is systemic anticoagulation (2‐3). However, endovascular treatment (EVT) of CVST is typically reserved for cases associated with significant thrombus burden and lack of clinical improvement or worsening of symptoms despite systemic anticoagulation therapy without current conclusive evidence of its benefit. The aim of this study is to evaluate the evidence of EVT in patients with CVST. Methods A systemic literature search was conducted via PubMed to identify relevant studies. Only studies with sample sizes larger than 10 were included. We excluded small case series, meta‐analyses, systematic reviews, and studies that lack the main outcomes of interest. Our main outcomes included functional outcome defined as modified Rankin Scale score (mRS 0‐3), mortality, new or expanded ICH and recanalization rates. Results We finally included 10 studies (4‐13) in our qualitative synthesis. Only one study was a small, randomized clinical trial while the rest were observational studies. In our included studies, 267 patients underwent EVT for CVST. Among them, the median age was ranging from 12 to 75 and 162 (60 %) of patients were females. Patients were followed up for a mean ranging from 3 to 12 months. Recanalization was observed in 161 patients, out of which 111 were complete recanalization (68.9%) and 50 were partial recanalization (31.1%). Good functional outcome defined as mRS 0‐3 was achieved in a total of 181 patients. Additionally, 26 (9.7%) patients had a new onset or expanded ICH while 26 patients had died (9.7%). Conclusion EVT for CVST was associated with improved clinical outcomes with acceptable safety profile in severe cases. There is a lack of evidence from large randomized clinical trials so more prospective studies are needed to confirm these results.

Abstract 200: ICA Lesion Etiology does not affect the Outcomes after Endovascular Treatment of Acute Tandem LVO

Introduction Tandem lesions (TLs) are present in up to 15% of patients with stroke due to acute large vessel occlusions.(1) Nevertheless, published research on endovascular treatment outcomes in this population is scarce. Although TLs are most commonly of atherosclerotic etiology, some patients present with dissection of the ICA.(2, 3) In this study, we compared the clinical outcomes of TL patients with the two etiologies. Methods A retrospective analysis was performed on a multicenter cohort of patients with TLs who underwent endovascular treatment. The patients were categorized into two groups according to the etiology of the ICA lesion: atherosclerosis and dissection. Patients were matched by baseline characteristics. Clinical outcomes, including recanalization success, functional independence and hemorrhagic events were assessed with multivariable analyses. Results Of 691 patients from the database, 526 met the inclusion criteria of this study. 467 (88.8%) patients presented with atherosclerosis of the ICA, and 59 (11.2%) patients presented dissection. Univariable differences were found in median age (69 y. [IQR 61 ‐ 76] vs. 52 y. [IQR 44 ‐ 63], p<.001), rates of hypertension (74.5% vs. 52.5%, p<0.001), hyperlipidemia (49.2% vs. 27.1%, p=.001), diabetes (29.8% vs. 15.3%, p=.019), and prior antiplatelets use (36.8% vs. 22.8%, p=.037). After matching and adjusting for confounders, we did not find differences between both groups for the main outcomes: Successful reperfusion (89.1% vs. 79.7%, aOR 0.46, 95% CI 0.20 – 1.08, p=.074), mRS 0‐2 at 90 days (47.5% vs. 47.4%, aOR 0.80, 95% CI 0.44 – 1.48, p=.381), and sICH (4.3% vs. 6.8%, aOR 0.96, 95% CI 0.17 – 5.58, p=0.965). Similarly, no differences were found for the secondary outcomes: Excellent recanalization (51.1% vs. 40.7%, aOR 0.86, 95% CI 0.46 – 1.60, p=.632), early neurological improvement (41% vs. 36.2%, aOR 0.76, 95% CI 0.40 – 1.43, p=.392), parenchymal hematoma type 2 (7.8% vs. 8.5%, aOR 0.59, 95% CI 0.17 – 2.03, p=.400), mortality at 90 days (17.4% vs. 14%, aOR 1.17, 95% CI 0.49 – 2.81, p=.726), and intrahospital mortality (9.6% vs. 8.6%, aOR 0.91, 95% CI 0.31 – 2.62, p=.859). Conclusion In our cohort, patients with lesions of atherosclerotic etiology achieved higher rates of successful and excellent recanalization, but the effect disappeared when matching the groups and adjusting for confounders. The results of this study show that the etiology of the ICA lesion does not affect the clinical outcomes of endovascular treatment in tandem lesions.

Abstract 208: Optimal Catheter Position and Aspiration Technique Improves Safety and Efficacy Using Next Generation Funnel Catheter

Introduction The Advanced Neurovascular Access (ANA5, Anaconda Biomed) is a novel stroke thrombectomy catheter comprising a distal self‐expanding covered funnel designed to locally restrict blood flow in the Internal Carotid Artery (ICA) and, when used in conjuction with available stent retreiver, reduce clot fragmentation during clot ingestion. The ANAIS study aimed to investigate the safety and efficacy of the ANA5 device (‘Funnel’) in different deployment locations and aspiration conditions. Methods Prospective, single‐arm, multi‐center study to assess the safety and performance of ANA5 in combination with a stent retriever in patients with Acute Ischemic Stroke (ANAIS). An independent imaging corelab and Clinical Events Committee assessed the different predefined outcomes. Patients with anterior circulation vessel occlusion admitted within 24 hours from symptom onset were eligible. The primary efficacy endpoint was successful recanalization, defined as mTICI ≥2b in the target vessel within three passes of the Funnel device. The primary safety endpoint was a composite of symptomatic Intracranial Hemorrhage within 24 hours and any device related severe adverse event. The impact of the funnel deployment location in the different ICA segments (C1 to C4 or above) and the condition of the aspiration on angiographical outcome was also evaluated. Results A total of 39 subjects who complied with all inclusion/exlusion criteria were treated by 10 different physicians in 3 stroke centers. Mean age was 69.9 ±13.2 years, 52.5% women, and the median National Institutes of Health Stroke Scale on admission was 16.0 [12.5‐19.5]. Initial occlusion location was: TICA 25.0%, M1‐MCA 52.5% and M2‐MCA 22.5%. The rate of succesful reperfusion within 3 passes was 74.4% (29/39) (primary efficacy endpoint). First pass effect (FPE) mTICI 2b‐3 and 2c‐3 was 56.4% (22/39) and 48.7% (19/39), respectively. Zero sICHs at 24h or SADE at 5 days were reported (primary safety endpoint). At 90 days, the rate of modified Rankin Scale score 0‐2 was: 57.9% (22/38). The efficacy of the thrombectomy procedure using the Funnel increases when: 1. The funnel was deployed in the higher ICA segments (below ophtalmic artery) with diameter between 3.5‐5.0mm, ensuring full apposition of the funnel to the vessel wall: C1(n=10): 40.0% vs. C2 or higher (n=29): 86.2% (p < 0.002). 2. Continuous aspiration was applied during the full retrieval of the stentriever in the Funnel (89.3% (n=28) vs. 36.4% (n=11), p < 0.0005). 3. When both continuous aspiration and appropriate ICA location were achieved, the Clinical efficacy endpoint improved to 95.5% (n=22), and FPE mTICI 2b‐3 and 2c‐3 were 72.7% and 59.1% respectively. Conclusion The use of the next generation Funnel Device in the ANAIS study results in a high rate of successful recanalization with an optimal safety profile and favorable 90 days clinical outcomes. The performance improved when the Funnel was deployed above the C1 cervical segment of the ICA, and continuous aspiration was applied during the full stent retrieval.

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>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<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.

Abstract 249: In‐silico Versus In‐Vitro Evaluation of a New Stent‐Retriever Design: A Novel Approach to Pre‐clinical Development

Introduction In‐vitro evaluation (analysis in a bench top flow model) is the gold standard and a regulatory requirement for pre‐clinical investigation of devices being developed for endovascular thrombectomy (EVT). In‐silico evaluation (computer simulated analysis in a virtual stroke model) has the potential to test and optimize large number of stent‐retriever design variations in a relatively time and cost‐effective manner. Further, new design concepts can be tested across multiple anatomical scenarios. We aim to validate the utility of in‐silico evaluation when compared with in‐vitro evaluation for the SuperNova Stent‐retriever. Methods In‐silico analysis was performed using a virtual thrombectomy model, built using data from a fine‐grained finite‐element model, to estimate the probability of successful recanalization and emboli in new/distal territory. Neurovascular anatomy of the virtual model was built based on digital subtraction angiography of an in‐vitro model (Sim Agility, Mentice, Inc). Gravity Medical Technology’s SuperNova Stent‐retriever was the device under investigation‐ physical device for in‐vitro analysis and virtual replica for in‐silico analysis (built using finite element analysis incorporating various physical metrics of the stent‐retriever). Experiments performed for in‐vitro analysis were replicated for in‐silico analysis. Multiple thrombectomy scenarios were defined and validation analysis was performed. Data was analyzed using SPSS 23 (IBM, Armonk, NY) Results We defined multiple thrombectomy scenarios including 1 cm red blood clot in M1 artery, 2 cm bifurcation M1‐M2 red blood clot (Y‐shaped clot), 1 cm white blood clot in M1 artery, and 1 cm white blood clot in superior M2 artery. The figure below demonstrates a pictorial representation of the first scenario‐ 1 cm red blood clot in M1 artery followed by mechanical thrombectomy simulation using the SuperNova stent‐retriever. Per our in‐vitro analysis (10 thrombectomy experiments), the rate of first pass effect and the rate of complete recanalization after a maximum of 3 passes using SuperNova stent‐retriever was 50% and 90%, respectively. Complete data from in‐silico analysis is being generated and will be presented at the conference. Preliminary data suggests high degree of concordance. Conclusion In‐silico analysis has the potential to improve and expedite pre‐clinical thrombectomy device development. Further studies are required to better understand the scope and potential of this technology.

Abstract 173: A Case Series of Basilar Tip Aneurysm Endovascular Treatment – The Barrow Neurological Institute Experience

Introduction Basilar‐tip aneurysm (BTA) is the most common aneurysm found in the posterior circulation, representing 5–8% of total intracranial aneurysms. Endovascular techniques are first‐line for treatment of the vast majority of posterior circulation artery aneurysms because of their deep location and the high mortality and morbidity associated with microsurgical clipping. Coil embolization (CE) is safer and more efficacious in the treatment of BTAs compared to open surgery but has increased rate of recanalization. Two adjunctive modifications of CE ‐ balloon remodeling techniques (BRT) and stent‐assisted coiling (SAC) ‐ have been utilized to facilitate occlusion of BTAs of variable anatomies/morphologies, sizes, and rupture status. We aimed to compare the clinical utility, safety and efficacy of these adjuvant therapies for treating BTAs. Methods A retrospective secondary analysis of a prospectively collected database at our institution was performed, including all patients with endovascularly treated basilar tip aneurysms database from January 1996 through January 2019 (n=121; CE=26; BRT=51; SAC=44). This project was approved by the local institutional review board. Patient data on demographics, aneurysmal characteristics and management, post‐operative outcomes, ICU management, and withdrawal of care were abstracted from the medical record of eligible patients. Univariate statistics used Welch’s two‐sample t‐test for continuous data and chi‐squared test for frequency‐based variables. Multivariate analysis used multivariate Poisson and Firth’s logistic regression. Results Aneurysms treated with CE were found to be smaller compared to BAC and SAC, with a median difference of 4 mm. For ruptured aneurysms, Adjuvant therapy (BAC or SAC) was used to treat larger dimension aneurysms compared to CE (p = 0.046). Adjusted for other factors, aneurysm dimension was an independent factor influencing recanalization or recurrence (OR = 1.16, p = 0.006), retreatment (OR = 1.165, p = 0.005), and obliteration (Raymond Roy Grade, continuous, β = 0.033, p = 0.043). Ruptured aneurysms were most frequently treated with CE (80.8%), followed by BAC (47.1%), and least frequently with SAC (6.8%) (p < 0.001). We also found an association with time of approval to retreatment. Stents approved by FDA after 2014 (used in 13 cases) had a greater rate of retreatment (46.2% vs. 10.7%). Adjusted for other factors, BAC had 3 times greater odds of recanalization or recurrence compared to SAC. CE demonstrated a 1.19‐month greater time to retreatment than BAC and a 1.89‐month longer time to retreatment than SAC. Overall, CE had a 1.28‐month greater time to retreatment than adjuvant therapy (SAC or BAC). Conclusion CE and its adjuvant therapies have similar safety profile but pose variable efficacy in terms of obliteration, recurrence, retreatment, and durability over time. This study represents one of the largest data sets on endovascular adjuvant therapy of BTAs and has the potential to inform clinical decision making when considering CE with BRT vs. SAC for BTA of specific size and morphology. In the future, inclusion of BTAs treated with WEB device and more novel flow divertor devices in this data set can further inform clinical decision making.

Abstract 221: EARLY EXPERIENCE OF EMBOGUARD BALLOON GUIDE CATHETER IN LARGE VESSEL OCCLUSION THROMBECTOMY

Introduction Endovascular thrombectomy (EVT) is the standard of care in acute ischemic stroke secondary to large vessel occlusion in selective patients within the first 24 hours. With the evolving technology and newer generation of catheters and devices, the interest in improving the technical and procedural factors that can help better the recanalization success, clinical outcomes, and efficiency is ever‐growing. Proximal flow arrest with balloon guide catheters (BGC) has been shown to optimize revascularization success and functional outcome in stroke EVT. We aim to evaluate the performance of the Emboguard BGC (Cerenovus, Irvine, CA, USA) in anterior circulation large vessel occlusion (LVO) acute ischemic strokes. Methods A prospectively maintained EVT database was reviewed for 12 months between May 2022 to May 2023 to identify all patients at our institution with intracranial vessel occlusion who underwent EVT using Emboguard BGC. Included patients were ≥18 years with large‐vessel occlusion who presented within 24 hours of time from last‐known‐well and had baseline National Institutes of Health Stroke Scale (NIHSS) score ≥ 6. Non‐dominant M2, M3, and A2 occlusions were excluded. We collected baseline demographic, clinical, and radiographic characteristics including age, sex, co‐morbidities, baseline NIHSS score, baseline modified Rankin Score (mRS), ASPECTS score, site of occlusion, imaging at our site, and use of intravenous and/or intra‐arterial thrombolytics. Outcomes included complications, NIHSS at discharge, final modified TICI (thrombolysis in cerebral ischemia) scores including the first‐pass effect (FPE, defined as mTICI 2c/3 after first pass), modified‐FPE (defined as, mTICI 2b‐3 after first pass), symptomatic intracranial hemorrhage (SITS‐MOST definition), and death at discharge. Data were analyzed using descriptive statistics, with frequency/percent for qualitative data and median/ interquartile range (IQR) for quantitative data. Results A total of 57 patients underwent EVT using Emboguard BGC. Among them, 54.4% were female and the median age was 72 years [IQR 66‐80]. Most of the patients had MCA occlusion (68.4% with 50.9% M1 and dominant/co‐dominant M2s 17.5%) with median ASPECTS 9 [IQR 8‐10]). About one‐third of our patients received intravenous thrombolytics. Following EVT, successful recanalization defined as modified TICI (thrombolysis in cerebral ischemia) scores of 2b/3 was achieved in 56 cases (98.2%) with 1 being the median number of passes (IQR 1‐2). The first pass effect (defined as one pass with mTICI of 2c/3) was achieved in 45.6% of cases. The median National Institutes of Health Stroke Scale (NIHSS) reduced significantly from 16 (IQR 12‐22) at baseline to 4 (IQR 1.5–12) at discharge (Table). Symptomatic intracranial hemorrhage was reported in 6 cases (10.5%), death at discharge was reported in 9 cases (15.8%), and access site complications were reported in 3 cases (5.3%). Conclusion Emboguard BGC showed promising results evident by a high rate of FPE, smaller number of EVT passes and improved recanalization rates with reasonable safety profile. Comparative prospective studies are needed to confirm these results.

Abstract 048: The Tigertriever 13 for Primary Distal Vessel Occlusions (DVO) ‐ Multicenter Experience

Introduction Objective: To evaluate the safety and efficacy of the Tigertriever 13 stent retriever in acute ischemic stroke (AIS) patients with primary distal and medium vessel occlusions (DMVO). Tigertriever 13 is a low profile stentriever that enables using a small microcatheter for safer procedures. Methods This is a retrospective data analysis of consecutive 59 cases performed between 04/19‐12/22 in two German comprehensive stroke centers. These patients were either ineligible or failed thrombolysis. Mean age was 75 and pre‐procedure NIHSS was 8,2 (SD 5,1), 55,9% Male, 37,2% were treated and failed thrombolysis treatment. These patients were admitted with disabling deficits that localize to the territory of the distal vessels. The occluded locations were 58,0% MCA M3, 0,0% MCA M4, 22,0% ACA, 20,0% PCA. All patients were treated with Tigertiever 13 with a mean of 1,7 passes where 100% under general anesthesia. Successful recanalization of the occluded vessel was measured by TICI score and intraoperative complications were recorded for safety evaluation. Results The mean time from symptoms onset to groin puncture was 200 minutes, and a successful recanalization rate of TICI 2b‐3 was observed in 72,8% of the patients while NIHSS was improved from 8,2 at baseline to 5,7 at discharge. There were 11,8% asymptomatic intracranial hemorrhages (ICH) and 0,5% symptomatic ICH. Conclusion The Tigertriever 13 device with operator controllability and high fluoroscopy visibility and its small size can potentially provide a safe and effective clot removal in patients with distal vessels occlusion. The effectiveness and safety profile in these patients with distal occlusions is comparable to those of patients with proximal occlusions.

Efficacy of Urinary Kallidinogenase Plus Intravenous Recombinant Tissue Plasminogen Activator for Stroke Patients With Extended Window: A Retrospective Analysis.

To assess the outcome of human urinary kallidinogenase (HUK) plus recombinant tissue plasminogen activator (rT-PA) intravenous thrombolysis for stroke patients with an extended time window(4.5 to 9 h). A total of 92 acute ischemic stroke patients who fulfilled the criteria were included in this study. All patients received basic treatment and intravenous rT-PA, and 49 patients received additional injections of HUK (HUK group) once a day for 14 consecutive days. Outcomes were indicated by the thrombolysis in cerebral infarction score as the primary endpoint and the National Institute of Health Stroke Scale, modified Rankin Scale, and Barthel Index as the secondary endpoints. The safety outcomes were the rate of symptomatic intracranial hemorrhage, bleeding, angioedema, and mortality. The National Institute of Health Stroke Scale scores were significantly lower in the HUK group at hospital discharge (4.55 ± 3.78 vs 7.88 ± 7.31, P = 0.009) and day 90 (4.04 ± 3.51 vs 8.12 ± 9.53, P = 0.011). The improvements in the Barthel Index scores were more obvious in the HUK group. Patients in the HUK group achieved favorable functional independence (67.35% vs 46.51%; odds ratio: 2.37; 95% CI: 1.01-5.53) at 90 days. The recanalization rate of the HUK group was 64.10%, whereas that was 41.48% in the control group (P = 0.050). The complete reperfusion rates were 42.9% and 23.3% in the HUK group and the control group, respectively. No significant differences were observed for adverse events between the two groups. Combination therapy of HUK plus rT-PA in patients with acute ischemic stroke with an extended time window can safely improve their functional outcomes.

Evaluation of effectiveness and safety of the multizone NeVaTM stent retriever for mechanical thrombectomy in ischemic stroke

PurposeThis study aimed to evaluate the effectiveness and safety of the NeVaTM stent retriever as first- and second-line device for mechanical thrombectomy in acute ischemic stroke.MethodsIn this retrospective single-center study, all consecutive patients that underwent mechanical thrombectomy with NeVaTM stent retriever as first- or second-line device due to intracranial vessel occlusion with acute ischemic stroke between March and November 2022 were included.ResultsThirty-nine patients (m=18, f=21) with a mean age of 69.9 ± 13.3 years were treated with the NeVaTM stent retriever. NeVaTM stent retriever was used as first-line device in 24 (61.5%) of patients and in 15 (38.5%) as second-line device. First-pass rate (≥mTICI 2c) of NeVaTM stent retriever was both 66.7% when used as first- or second-line device. Final recanalization rate including rescue strategies was 92.3% for ≥mTICI2c and 94.9% for ≥mTICI2b. No device-related minor or major adverse events were observed. A hemorrhage was detected in 33.3% of patients at 24h post-thrombectomy dual-energy CT, of which none was classified as symptomatic intracerebral hemorrhage. NIHSS and mRS improved significantly at discharge compared to admission (p<0.05).ConclusionThe NeVaTM stent retriever has a high effectivity and good safety profile as first- and second-line device for mechanical thrombectomy in acute ischemic stroke.

Mechanical thrombectomy in low Alberta stroke program early CT score (ASPECTS) in hyperacute stroke-a systematic review and meta-analysis.

Major randomized controlled trials of mechanical thrombectomy (MT) for acute ischemic stroke (AIS) failed to include a substantial number of patients presenting with low baseline Alberta Stroke Program Early CT Score (ASPECTS:0-5). Patients experiencing hyperacute strokes (last known well ≤ 6 h) can potentially benefit most from MT. We conducted a systematic review and meta-analysis to report presentation severity and radiographic and clinical outcomes for hyperacute stroke patients presenting with low-ASPECTS. Our comprehensive literature search of PubMed, Embase, and Cochrane databases up to August 31, 2022 included articles reporting patients presenting hyperacutely who underwent MT for anterior circulation large vessel occlusion AIS with an ASPECTS ≤ 5 on baseline imaging. Pooled averages were calculated for age and presenting National Institutes of Health Stroke Scale (NIHSS). Fixed- and random-effects meta-analyses for weighted estimation of overall rates were performed. Forest plots were generated for proportions and estimated overall outcome rates. 18 studies (1958 patients) were included (mean age = 64.1 years; presenting NIHSS = 18.4). Final modified thrombolysis in cerebral infarction 2b-3 grade was achieved in 76.4%, with symptomatic intracranial hemorrhage in 12.1%. Good (modified Rankin Scale [mRS] 0-2) and ambulatory (mRS 0-3) 3-month outcomes were achieved by 27.4 and 46.7%, respectively; 90-day mortality was 26.4%. MT in low-ASPECTS hyperacute stroke patients may result in ambulatory clinical outcomes with acceptable hemorrhage risk. Recanalization rates achieved were similar to those in patients presenting with ASPECTS ≥ 6; this did not fully translate to better clinical outcomes. MT should be considered for hyperacute strokes with low presenting ASPECTS.

Exploring indicators of success in chronic total occlusion percutaneous coronary intervention with Stingray system-based antegrade dissection re-entry: Insights from retrospective analysis.

The predictors of success of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) through antegrade dissection and re-entry (ADR) using the Stingray system (Stingray ADR) remain elusive, mainly owing to the lack of consecutive angiographic and procedural records of patients. This study aimed to identify indicators that can determine the success of CTO PCI performed using the Stingray ADR technique. The clinical data of 115 patients who underwent CTO PCI through Stingray ADR at the same cardiac center were retrospectively and consecutively collected. Multivariate logistic regression analysis was performed to investigate the indicators of the success of ADR attempts. The technical success rate of Stingray ADR in CTO PCI was 72.2%. The overall technical success rate of CTO recanalization was 78.3% in all CTO PCIs having used Stingray Low Profile balloon. Vessel calcification (odds ratio [OR]: 4.03; 95% confidence interval [CI]: 1.49-11.88; p = 0.008), and retrograde puncture indicator (OR: 4.89; 95% CI: 1.51-17.11; p = 0.009) were identified as independent positive predictors. Blunt/no stump proximal to the occlusion segment (OR: 0.22; 95% CI: 0.06-0.64; p = 0.009), decision time before Stingray ADR (per 1 h increase) (OR: 0.54; 95% CI: 0.31-0.92; p = 0.026), operation duration of Stingray ADR (per 10 min increase) (OR: 0.62; 95% CI: 0.40-0.94; p = 0.028), and puncture site at the intraplaque region (OR: 0.24; 95% CI: 0.06-0.84; p = 0.026) were identified as the four negative independent predictors. This study revealed independent predictors of the success of CTO PCI performed using the Stingray ADR technique. As for CTO characteristics, the presence of calcification in the CTO segment and a tapered stump proximal to the lesion site can facilitate successful Stingray ADR. As for the procedures, the success rate of Stingray ADR can be improved by initiating the technique decisively and promptly, operating the system quickly and accurately and creating a puncture in the distal cap region of CTO under retrograde guidance.

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.

Mechanical thrombectomy with a new intermediate balloon catheter combining the BGC and DAC features: Initial clinical experience with the iNedit device.

The iNedit balloon distal access catheter is a novel thrombectomy device. It has an inner diameter of 0.058″, proximal outer diameter of 2.13 mm, and distal outer diameter of 1.67mm. It is compatible with a 0.088″ guide catheter and includes a balloon located 5 cm from the catheter tip, enabling proximal flow restriction and combined therapy with stent retrievers. We investigate the appraisal of the use, safety, and efficacy of the iNedit catheter in the first-in-human study. In the preliminary cases that demanded training on the product previous to a multicentric study, prospective data were collected on 22 consecutive patients treated with the iNedit catheter to perform thrombectomy for acute ischemic stroke due to large vessel occlusion within 24 h. The outcome measures consisted of several evaluations of user experience rated on a 5-point scale ranging from 1 (bad) to 5 (excellent), as well as assessments of procedural safety outcomes such as artery perforation and arterial occlusion, procedural efficacy outcomes including first-pass effect (Thrombolysis In Cerebral Infarction [TICI] 2c/3) and final recanalization (TICI 2b/3), and clinical efficacy outcomes such as a 3-month 0-2 modified Rankin Scale (mRS). The mean age was 72 ± 12 years old; median National Institute Health Stroke Scale was 17 (11-19). Sites of primary occlusion were: 2 internal carotid artery, 12 M1-MCA, 7 M2-MCA, and one P1. Median score evaluation of the appraisal of use was 4- IQR [4-5]. The median number of passes was 1 [IQR 1-2]. First pass complete recanalization rate was 50% and the final recanalization rate was 94.45%. No artery perforation and arterial occlusion. Good functional outcome mRS 0-2 was achieved in 50% of patients. In this initial clinical experience, iNedit device achieved a high rate of first-pass effect and final recanalization rate with no safety concerns, thus favoring a high percentage of good clinical outcomes.

Intravenous thrombolysis with tenecteplase versus alteplase combined with endovascular treatment of anterior circulation tandem occlusions: A pooled analysis of ETIS and TETRIS.

Tandem occlusions are a singular large vessel occlusion entity involving specific endovascular and perioperative antithrombotic management. In this context, data on safety and efficacy of prior intravenous thrombolysis (IVT) with tenecteplase is scarce. We aimed to compare IVT with tenecteplase or alteplase in patients with acute tandem occlusions intended for endovascular treatment. A retrospective pooled analysis of two large observational registries (ETIS (Endovascular Treatment of Ischemic Stroke) and TETRIS (Tenecteplase Treatment in Ischemic Stroke)) was performed on consecutive patients presenting with anterior circulation tandem occlusion treated with IVT using either alteplase (ETIS) or tenecteplase (TETRIS) followed by endovascular treatment between January 2015 and June 2022. Sensitivity analyses on atherosclerosis related tandem occlusions and on patient treated with emergent carotid stenting were conducted. Propensity score overlap weighting analyses were performed. We analyzed 753 patients: 124 in the tenecteplase and 629 in the alteplase group. The overall odds of favorable outcome (3-month modified Rankin score 0-2) were comparable between both groups (49.4% vs 47.1%; OR = 1.10, 95%CI 0.85-1.41). Early recanalization, final successful recanalization and mortality favored the use of tenecteplase. The occurrence of any intracranial hemorrhage (ICH) was more frequent after tenecteplase use (OR = 2.24; 95%CI 1.75-2.86). However, risks of symptomatic ICH and parenchymal hematoma remained similar. In atherosclerotic tandems, favorable outcome, mortality, parenchymal hematoma, early recanalization, and final successful recanalization favored the tenecteplase group. In the carotid stenting subgroup, PH were less frequent in the tenecteplase group (OR = 0.18; 95%CI 0.05-0.69). In patients with tandem occlusions, IVT with tenecteplase seemed reasonably safe in particular with increased early recanalization rates. These findings remain preliminary and should be further confirmed in randomized trials.

Impact of Balloon Guide Catheters in Elderly Patients Treated with Mechanical Thrombectomy: Insights from the ROSSETTI Registry.

Several nonrandomized studies have demonstrated the effectiveness of balloon guide catheters in treating patients with anterior circulation large-vessel occlusion. However, their impact on the elderly populations has been underreported. We aimed to analyze the effect of balloon guide catheters in a cohort of elderly patients (80 years of age or older) with anterior circulation large-vessel occlusion. Consecutive patients from June 2019 to June 2022 were collected from the ROSSETTI Registry. Demographic and clinical data, angiographic endovascular technique, and clinical outcome were compared between balloon guide catheter and non-balloon guide catheter groups. We studied the association between balloon guide catheters and the rate of complete recanalization after a single first-pass effect modified TICI 2c-3, as well as their association with functional independence at 3 months. A total of 808 patients were included during this period, 465 (57.5%) of whom were treated with balloon guide catheters. Patients treated with balloon guide catheters were older, had more neurologic severity at admission and lower baseline ASPECTS, and were less likely to receive IV fibrinolytics. No differences were observed in terms of the modified first-pass effect between groups (45.8 versus 39.9%, P = .096). In the multivariable regression analysis, balloon guide catheter use was not independently associated with a modified first-pass effect or the final modified TICI 2c-3, or with functional independence at 3 months. In our study, balloon guide catheter use during endovascular treatment of anterior circulation large-vessel occlusion in elderly patients did not predict the first-pass effect, near-complete final recanalization, or functional independence at 3 months. Further studies, including randomized clinical trials, are needed to confirm these results.

Distal placement of balloon guide catheter facilitates stent-retriever mechanical thrombectomy for acute ischemic stroke in the anterior circulation.

Although balloon guide catheters (BGCs) have been demonstrated to improve recanalization and functional outcomes by enabling proximal flow control and forced aspiration during mechanical thrombectomy (MT), the significance of the BGC location has been overlooked. We evaluated the impact of BGC location during MT for anterior circulation acute ischemic stroke (AIS). Patients were divided into the proximal and distal BGC groups according to the BGC tip location relative to the lower margin of the C1 vertebral body. Endovascular and clinical outcomes were compared between the two groups, including subgroup analyses of the two types of extracranial internal carotid artery (ICA) anatomy, categorized based on cerebral angiography. A total of 124 patients were analyzed, with 62 each in the proximal and distal BGC placement groups. The distal BGC group had higher rates of first-pass recanalization (FPR) (38.7% vs. 17.7%, P = 0.009) and favorable outcomes (64.5% vs. 46.8%, P = 0.047) with shorter procedure time (47.5min vs. 65min, P = 0.001) and fewer distal embolization (3.2% vs. 12.9%, P = 0.048) than the proximal BGC group. FPR was also more frequently achieved in the distal BGC group of patients with tortuous ICA (37.0% vs. 12.5%, P = 0.029). Multivariate analysis showed that distal BGC placement was an independent predictor of FPR (odds ratio, 3.092; 95% confidence interval, 1.326-7.210; P = 0.009). Distal BGC placement facilitates MT for AIS in the anterior circulation. Therefore, we suggest distal BGC placement to maximize the effect of thrombectomy, even for tortuous extracranial ICA.

Recanalization of chronic long-segment occlusion of the internal carotid artery with endovascular and hybrid surgery

To investigate the effect of endovascular and/or hybrid surgical recanalization on chronic long-segment occlusion of the internal carotid artery (ICA) and the effect of occlusion location on the recanalization rate and prognosis, 87 patients with chronic ICA occlusion treated with endovascular approach only or hybrid surgery were retrospectively enrolled. The duration of ICA occlusion ranged from 21 to 360 days (median 30). Type I occlusion (from the neck to below the cavernous segment) consisted of 46 (52.8%) patients while type II (from the neck to above the clinoid segment) of 41 (47.1%). Hybrid surgery was performed in 44 (50.6%) patients while endovascular recanalization only was conducted in the other 43 (49.4%). In all patients, the success rate of recanalization was 93.0% (40/43) for the endovascular approach and 95.5% for the hybrid surgical approach. In patients with type I occlusion, endovascular recanalization only was performed in 22 (47.8%) patients and hybrid surgery in 24 (52.2%), resulting in successful recanalization in all patients (100%). In patients with type II occlusion, the success rate of recanalization was 85.7% (18/21) for the endovascular approach only but 90% (18/20) for the hybrid surgery. The total success rate of recanalization was 94.3% (82/87) for all patients, 100% for type I occlusion, and 87.8% for type II occlusion. No significant (P = 0.12) differences existed in the recanalization rate between groups I and II. Clinical follow-up was performed in 82 (94.3%) patients 6–39 months (mean 16) after the surgery. Re-occlusion occurred in 0 in group I but in four (9.8%) in group II. The mRS was good with 0–2 in 38 (82.6%) patients in group I and in 27 (75%) patients in group II, with no significant (P = 0.78) difference. In conclusion, chronic long-segment ICA occlusion can be safely and efficiently recanalized with the endovascular and hybrid surgery. The location of ICA occlusion may have a critical role in determining the recanalization rate, and careful evaluation of the occlusion location may be helpful in increasing the prognosis of recanalization.

Systematic review and meta-analysis of the efficacy and safety of adjunctive use of tirofiban in patients treated with endovascular therapy for acute ischemic stroke at different embolic sites.

The use of tirofiban as an adjunct to endovascular therapy (EVT) for acute ischemic stroke has been controversial. We aimed to assess the differences in safety and efficacy of EVT adjuvant to tirofiban in patients with anterior circulation stroke (ACS) and posterior circulation stroke (PCS). We systematically searched Pubmed, Embase, Cochrane Library, and Web of Science. Cohort studies and randomized controlled trials that compared treatment with tirofiban combined with EVT and EVT alone were included in our meta-analysis. The safety outcomes were symptomatic intracranial hemorrhage, and 3-month mortality. The efficacy outcomes were good functional outcome, excellent functional outcome, and successful recanalization (mTICI ≥ 2b). We performed subgroup analyses of anterior and posterior circulation strokes. We included 15 studies with 4608 patients. For safety outcomes, tirofiban significantly reduced 3-month mortality in the ACS subgroup (odd ratio [OR] = 0.80, 95% confidence interval [CI] = 0.65-0.98, P = .03) without increasing the rate of symptomatic intracranial hemorrhage (OR = 1.12, 95% CI = 0.88-1.44, P = .35). In the PCS subgroup, tirofiban significantly reduced 3-month mortality (OR = 0.63, 95% CI = 0.50-0.80, P = .0001) and symptomatic intracranial hemorrhage (OR = 0.60, 95% CI = 0.37-0.95, P = .03). For efficacy outcomes, in the ACS subgroup, tirofiban significantly improved good functional outcome (OR = 1.24, 95% CI = 1.06-1.45, P = .008) but did not improve recanalization (OR = 1.17, 95% CI = 0.93-1.47, P = .17) and excellent functional outcome (OR = 1.19, 95% CI = 0.97-1.46, P = .10). In the PCS subgroup, tirofiban significantly improved recanalization rate (OR = 1.94, 95% CI = 1.43-2.65, P < .0001) and did not improve good functional outcome (OR = 1.03, 95% CI = 0.81-1.30, P = .81) and excellent functional outcome (OR = 0.84, 95% CI = 0.58-1.20, P = .34). In acute ischemic stroke patients undergoing EVT, tirofiban improves good functional outcomes in ACS patients and increases recanalization rates in PCS patients on the 1 hand, reduces mortality, and does not increase the risk of symptomatic intracranial hemorrhage on the other. Tirofiban is safe and effective in both anterior circulation stroke and posterior circulation stroke patients undergoing EVT. More large multicentre randomized controlled studies are needed in the future.

The Efficacy and Safety of Tirofiban Use in Endovascular Thrombectomy for Intravenous Thrombolysis Applicable Patients with Large Vessel Occlusion Stroke-a Post Hoc Analysis from the Direct-MT Trial.

The purpose of the study was to evaluate the efficacy and safety of tirofiban use in endovascular thrombectomy for intravenous thrombolysis applicable patients of large vessel occlusion stroke with data from Direct-MT trial. Direct-MT was the first randomized controlled trial to prove the non-inferiority of thrombectomy alone to bridging therapy (intravenous thrombolysis before thrombectomy) for large vessel occlusion stroke. Patients who underwent endovascular procedure were included and divided into thrombectomy-alone group and bridging therapy group. The effect of tirofiban use on 90days MRS distribution, MRS 0-2 and mortality, successful reperfusion, the ASPECTS and outcome lesion volume of index stroke, re-occlusion of the treated vessel, futile recanalization and safety outcomes were further evaluated in both groups after adjustment for relevant confounding factors. The interaction between tirofiban and rt-PA was also assessed. Of 639 patients included in this analysis, 180 patients underwent thrombectomy with tirofiban use (28.2%). Patients with tirofiban use had lower percentage of bridging therapy (41.1% vs 54.3%, P = 0.003), higher proportion of large artery atherosclerosis (P < 0.001) and more emergent stenting (30.56% vs 6.97%, P < 0.001). After adjustment for confounding factors, the 90-day modified Rankin Scale distribution, successful final recanalization rate, outcome lesion volume of index stroke on CT and intracranial hemorrhage risk showed no difference after tirofiban use in thrombectomy-alone group and in bridging therapy group. No interaction effect between tirofiban and rt-PA was detected. Based on data from Direct-MT trial, tirofiban is a safe medication for intravenous thrombolysis applicable patients with large vessel occlusion stroke undergoing thrombectomy. Level 3, cohort study of randomized trial.