Society Of Vascular Interventional Neurology Research Articles

Structural Analysis of Aspiration Catheters and Procedural Outcomes: An Analysis of the SVIN Registry

BACKGROUND Rapid expansion of mechanical thrombectomy and swift manufacturing development has translated into significant evolution of large‐bore catheter technology. The objective of this study was to evaluate the association among diverse structural components of large‐bore aspiration catheters on procedural performance. METHODS Retrospective analysis of a prospectively maintained mechanical thrombectomy consortium (SVIN [Society of Vascular Interventional Neurology] Registry) treated with stand‐alone contact aspiration for the first pass in the middle cerebral artery M1 or intracranial internal carotid artery occlusions from 2012 to 2021. Catheters were stratified on the basis of construction materials, tip technology, catheter sizing, and catheter lining. Factors associated with first‐pass effect (first‐pass eTICI 2c–3 reperfusion) as well as speed of clot engagement were analyzed. RESULTS We identified 983 patients with proximal occlusion and aspiration as the first‐pass technique. First‐pass effect was observed in 34% and associated with age (odds ratio [OR], 1.02 [95% CI, 1.01–1.03]), cardioembolic stroke pathogenesis (OR, 1.69 [95% CI, 1.77–2.41]), middle cerebral artery M1 (OR, 2.74 [95% CI, 1.09–1.87]), nongeneral anesthesia (OR, 0.55 [95% CI, 0.39–0.767]), as well as with 0.070‐inch (OR, 2.04 95% CI, 1.01–3.78]), and 0.088‐inch (OR, 3.90 [95% CI, 1.58–9.61]) distal catheter inner diameter in the adjusted analysis. Mean time from arterial access to clot contact was 17 minutes, with faster times observed in younger patients (OR, 0.99 [95% CI, 0.98–0.996]) as well as with the use of aspiration catheters with shorter length of distal outer hydrophilic coating (18–30 cm) on multivariable regression (OR, 0.30 [95% CI, 0.11–0.82]). CONCLUSION Larger aspiration catheter distal inner diameter was associated with higher rates of first‐pass effect. Aspiration catheter construction components were found to influence times from arterial access to clot contact.

Disparities among neurointerventionalists suggest further investigation of conscious sedation versus general anesthesia during thrombectomy for acute stroke.

INTRODUCTION:Prior retrospective and case-control studies have shown that the use of general anesthesia (GA) during endovascular therapy (EVT) for acute ischemic stroke with large vessel occlusion (AIS-LVO) was independently associated with poor clinical outcomes compared with cases performed under conscious sedation (CS). Conversely, recent small randomized clinical trials (RCT) demonstrated a trend toward better outcome in cases performed under GA.METHODS:We submitted an online survey to 193 Society of Vascular Interventional Neurology and 78 American Association of Neurological Surgeons and Congress of Neurological Surgeons – Cerebrovascular Section neuroendovascular practitioners. Questions were aimed at understanding the current state of anesthesia practice during EVT, and to determine if there is clinical equipoise for a large multicenter RCT comparing GA versus CS during EVT.RESULTS:Between March and May of 2017, we received 116 (43%) responses. Anesthesiologists were responsible for managing 96% of the GA cases as compared to only 51% of the CS cases (P < 0.0001). Notable 56% of providers reported performing less than a quarter of their cases under GA. Only 7% performed all cases under GA compared with 17% who used solely CS (P = 0.048). More than half of respondents thought a new RCT was necessary, of whom 61% were interested in participating. Among interested responders, 59% were located in centers with 3 or more neurointerventionalists.CONCLUSION:The significant variation among neuroendovascular providers, added with the lack of consensus among recent trials and meta-analyses, demonstrate clinical equipoise for further studies to explore the effects of anesthesia during EVT in AIS-LVO.

Abstract WP53: Is There Clinicial Equipoise for a Randomized Trial of Anesthesia (Sedation vs. General) During Endovascular Therapy?

Background and Objectives: Retrospective case-control studies found general anesthesia (GA), compared with conscious sedation (CS), was independently associated with poor clinical outcome in acute ischemic stroke (AIS) patients receiving endovascular therapy (EVT). Conversely, recent randomized clinical trials (RCT) not only failed to demonstrate such an association, but also provided a trend toward better outcomes in GA vs. CS. We sought to describe EVT-anesthesia clinical practice and determine if clinical equipoise existed for the purposes of designing a large RCT. Methods: We sent an online survey to 193 SVIN (Society of Vascular Interventional Neurology) and 78 AANS-CV (American Association of Neurological Surgeons - Cerebrovascular section) physicians that routinely perform EVT. Neurointerventionalists were asked a series of questions to describe their clinical practice, determine if clinical equipoise existed for designing a large GA vs. CS RCT and enthusiasm for trial participation. Results: Between 3/17 and 5/17, 116 (60%) responses were received. The majority of centers had at least 3 or more interventionalists and performed at least 50 EVT procedures yearly (Table). Only 13% of respondents reported the use of GA in at least half of their EVT cases (Figure). While anesthesiologists in nearly all cases managed GA, neurointerventionalists administered CS in almost half of cases. 55% vs.45% of respondents thought a RCT was or was not necessary, respectively (Figure). Conclusion: Anesthesia management during EVT varies widely and substantial uncertainty among experts demonstrates clinical equipoise. A large efficacy RCT is warranted, justified and underway (SEdation vs General Anesthesia for Endovascular Therapy in Acute Ischemic Stroke [SEGA Trial] Clinicaltrials.gov NCT-03263117).

Timing, testing, and standardization of endovascular therapy

The Society of Vascular & Interventional Neurology (SVIN) roundtable meeting concerning endovascular therapy highlights the rapid advances in technologic approaches to revascularization in acute stroke patients. Although the new technology is exciting, the road to scientifically proven advances that improve outcomes for patients will depend upon minimizing the time to revascularization, scientific testing of the technology in clinical trials, and standardization of training and delivery of endovascular therapy. One consistent theme from the single-arm clinical trials of endovascular therapy is that the clinical outcome after revascularization is highly dependent upon the time from stroke onset to revascularization. The IMS (Interventional Management of Stroke) I and II Trials,1 the Penumbra Trial,2 and the French Recanalyze Study3 demonstrated a strong relationship between time to revascularization and a good functional outcome, as measured by a modified Rankin Scale score of 0–2 at 3 months. In the IMS I and II pilot trials, revascularization beyond 6 hours resulted in outcomes similar …

Performance and training standards for endovascular acute ischemic stroke treatment

Stroke is the third leading cause of death in the United States, Canada, Europe, and Japan. According to the American Heart Association and the American Stroke Association, there are now 750,000 new strokes that occur each year, resulting in 200,000 deaths, or 1 of every 16 deaths, per year in the United States alone. Endovascular therapy for patients with acute ischemic stroke is an area of intense investigation. The American Stroke Association has given a qualified endorsement of intra-arterial thrombolysis in selected patients. Intra-arterial thrombolysis has been studied in 2 randomized trials and numerous case series. Although 2 devices have been granted FDA phase 3 approval with an indication for mechanical stroke thrombectomy, none of these thrombectomy devices has demonstrated efficacy for the improvement of patient outcomes. The purpose of the present document is to define what constitutes adequate training to perform neuroendovascular procedures in patients with acute ischemic stroke and what performance standards should be adopted to assess outcomes. These guidelines have been written and approved by multiple neuroscience societies that historically have been directly involved in the medical, surgical and endovascular care of patients with acute stroke. These organizations include the Neurovascular Coalition and its participating societies, including the Society of NeuroInterventional Surgery (SNIS), American Academy of Neurology (AAN), American Association of Neurological Surgeons/Cerebrovascular Section (AANS/CNS), and Society of Vascular & Interventional Neurology (SVIN).

The endovascular journey

The Society of Vascular & Interventional Neurology (SVIN) Roundtable on Endovascular Therapy for Acute Ischemic Stroke provides an excellent roadmap not only for how far we have come but also for the long trip remaining on the road to successful acute stroke intervention. The final destination is comprehensive stroke systems integration—health care delivery systems providing rapid access to integrated, innovative, and individualized stroke care from prevention through rehabilitation (daresay “restoration”). The emphasis of the roundtable is on technology, and information technology will be used to improve lifestyle education beginning in early childhood. In Cleveland we have launched the Healthy Brains Healthy Communities initiative in conjunction with the public school system. Fewer patients will need reperfusion therapy if there are fewer strokes. But strokes will still occur, and patients must …