Use Of Stent Retriever Research Articles

Endovascular Treatment of Stroke Patients

Stroke patients with proximal occlusions of the main stems of cerebral arteries are no optimal candidates for i. v. thrombolysis. For many years interventional stroke treatment could not be established as alternative. This changed with the introduction of stent retrievers and flexible large lumen aspiration catheters. Randomized trials now proved a significant benefit from intervention for a wide spectrum of severely compromised stroke patients in time windows of up to 8 hrs. However, the randomized trials leave open questions concerning proper patient selection. The benefit for patients with larger infarcts with an ASPECTS between 3 and 5 or patients in time windows above 8 hrs is still uncertain. Especially for critical candidates imaging for reliable detection of the ischemic core and surrounding salvageable brain tissue plays an important role. Technically equivalence between new aspiration techniques as alternative to the use of stent-retrievers is not finally proven. Recanalization of tandem occlusions with the necessity of acute stenting demands better materials for plaque coverage and thrombus withhold. Management of cases with occlusions due to intracranial atherosclerosis is also debatable. The positive trial results provide especially new challenges to establish countrywide neurointerventional services. Even in developed countries recruitment and training of interventional radiologists as well as priority transportation of stroke patients is challenging to organize. This is an abstract presented in the 33rd Iranian congress of radiology (ICR) and the 15th congress of Iranian radiographic science association (IRSA).

Abstract WMP2: Trevo 2000: Real-World Experience in the First 1247 Patients

Objective: The Trevo Registry is designed to assess real world outcomes of the Trevo Retriever in patients experiencing ischemic stroke. This is the largest prospective study for acute stroke intervention, with 1247 patients currently enrolled and 90 day outcomes in 1021 patients. The primary endpoint is revascularization status based on post-procedure TICI score and secondary endpoints include 90-day mRS, 90-day mortality, neurological deterioration at 24 hours and device/procedure related adverse events. Methods: The study is a prospective, open-label, consecutive enrollment, multi-center, international registry of patients undergoing mechanical thrombectomy for acute stroke using the Trevo stent retriever as the initial device. Enrollment is expected to reach 2000 subjects at up to 100 sites. Results: As of August 13, 2016 a total of 1247 patients were enrolled. The median NIHSS at admission was 16 (IQR 11-20). Most patients (66.2%) were treated at >/= 6 hours from last known normal with a median procedure time of 50 minutes (32-77). The occlusion site was M1 or M2 in 74.5%. General anesthesia was employed in 46.6% of procedures. TICI 2b or 3 revascularization was 92.8% with an average of 1.6 passes with the device. Median NIHSS at 24 hours and discharge was 6 and 4 respectively. Fifty-five percent of patients had mRS ≤2 at 3 months and the overall mortality rate was 15.4%. Patients treated after 8 hours of symptom onset had a 94.9% revascularization rate and 52.8% mRS ≤2 at 3 months. The symptomatic ICH rate was 1.2%. Patients who met the revised AHA criteria for thrombectomy were found to have 58.4% mRS 0-2 at 90 days. Conclusions: The Trevo Retriever Registry represents the first real world data with stent retriever use in the era of clinical trials showing the overwhelming benefit of stent retrievers to treat acute ischemic stroke. Due to the fact that this data represents real world use of the Trevo Retriever, (e.g. subjects pre-stroke mRS >1 (16.5%) and those treated 6-24 hours after stroke symptoms (33.8%), this data cannot be compared to the results from recent trials with restricted eligibility criteria. Future subgroup analysis of this large cohort will help to identify areas of future research to enhance outcomes further with this treatment modality.

Multicenter experience with the new SOFIA Plus catheter as a primary local aspiration catheter for acute stroke thrombectomy

IntroductionThe direct aspiration first pass technique (ADAPT) has been introduced as a rapid and safe endovascular treatment strategy in patients with ischemic stroke.ObjectiveTo determine the technical feasibility, safety, and functional...

Intra-arterial Stroke Treatment prior to the Stent-Retriever Era: High Mortality and Lack of Volume–Outcome Association

Mechanical thrombectomy for acute large-vessel occlusive stroke is beneficial when performed with stent-retriever devices; however, little is known about real-world experience with intra-arterial treatment (IAT). We aimed to clarify how hospitals influence outcomes for Medicare thrombectomy patients to inform future delivery of effective mechanical thrombectomy treatment. This is a retrospective cohort study that includes a Medicare fee-for-service patient population. Patients with a primary stroke discharge (ICD-9-CM 433.x1, 434.x1, 436) were included; billing codes were used to identify patients receiving IAT, intravenous thrombolytics (IVT), or a combination of these treatments. Characteristics of treated patients were summarized using descriptive statistics; long-term mortality was summarized via Kaplan-Meier curves; and multilevel logistic regression models with random hospital-level intercept were built to determine hospital influence on outcome and whether a volume-outcome association existed. A total of 4557 patients received IAT at 544 hospitals. The mean age of IAT patients was 76 years. IAT patients had longer hospital stay (9.7 versus 6.8 days), longer stay in the ICU (5.5 versus 3.3 days), and greater probability of intubation (36.7% versus 9.5%) compared with IVT patients. Ninety-day mortality was 46% IAT versus 26% IVT. Hospitals had little influence on outcomes (intraclass correlation coefficient, <.01). No association between procedural volume and outcomes was identified. IAT for 2007-2010 was associated with higher patient mortality than recent and prior clinical trials. Treated Medicare patients were considerably older than clinical trial populations. Hospitals had little influence on mortality, and increased hospital volume was not associated with lower mortality. Future real-world experience should monitor these parameters as use of stent retrievers disseminates.

Internal Carotid Artery S-Shaped Curve as a Marker of Fibromuscular Dysplasia in Dissection-Related Acute Ischemic Stroke

Background and Purpose: Craniocervical fibromuscular dysplasia (FMD) is associated with dissections and with S-shaped curves in the internal carotid artery (ICA). We evaluated the occurrence of S-curves in patients presenting with acute strokes due to ICA steno-occlusive dissections. Methods: This was a retrospective review of the interventional databases of two academic tertiary-care institutions. The presence of ICA S-shaped curves, C-shaped curves, 360-degree loops, as well as classic FMD and atherosclerotic changes at the ICA bulb and curve/loop was determined. Cases of carotid dissections were compared with a control group (consecutive non-tandem anterior circulation strokes). Results: Twenty-four patients with carotid dissections were compared to 92 controls. Baseline characteristics and procedural variables were similar, with the exception of younger age, less frequent history of hypertension, diabetes, atrial fibrillation and stent retriever use in patients with dissections. The rates of mTICI2b-3 reperfusion, parenchymal hematoma, good outcome and mortality were similar amongst groups. The frequency of S-curves (any side without superimposed atherosclerosis) was 29% in the dissection group versus 7% in controls (p < 0.01). S-curves were typically mirror images within the dissection group (85% had bilateral occurrence). The frequency of C-shaped and 360-degree curves was similar between groups. FMD changes within the craniocervical arteries were statistically more common in dissection patients. Ten patients (41%) of the dissection group had S-curves or classic FMD changes. Multivariate analysis indicated that S-curves were independently associated with the presence of dissections. Conclusion: S-shaped ICA curves are predictably bilateral, highly associated with carotid dissections in patients with moderate to severe strokes, and may suggest an underlying presence of FMD.

Treatment of cerebral vasospasm with self-expandable retrievable stents: proof of concept

ObjectiveTo report our preliminary experience with the use of stent retrievers to cause vasodilation in patients with delayed cerebral vasospasm secondary to subarachnoid hemorrhage.MethodsFour patients from two different high volume...

E.09 Predictors of optimal endovascular therapy results among patients with acute ischemic stroke

Background: Several studies have demonstrated the safety and efficacy of endovascular therapy for patients with acute ischemic stroke. However, patient, imaging and treatment factors associated with the optimal functional outcome require better definition. Methods: We pooled data from 8 randomized controlled trials (SYNTHESIS, MR RESCUE, IMS III, MR CLEAN, ESCAPE, EXTEND-IA, SWIFT-PRIME, and REVASCAT). We conducted subgroup and sensitivity analyses to evaluate predictors of optimal functional results (modified Rankin scale, mRS) at 90 days. Results: Meta-analysis of 8 trials including 2,423 patients yielded that endovascular therapy resulted in 44.6% functional independence (mRS 0-2) versus 31.8% in the usual care group (OR 1.71, 95% CI 1.18-2.49, P=0.005). This treatment effect was significantly greater among patients with confirmed angiographic imaging of proximal arterial occlusion (OR 2.24, 95% CI 1.72-2.90, P&lt;0.001), in patients who received the combined therapy of intravenous tPA and endovascular intervention (OR 2.07, 95% CI 1.46-2.92, P&lt;0.001), and when using stent retriever for mechanical thrombectomy (OR 2.39, 95% CI 1.88-3.04, P&lt;0.001). Conclusions: The relative functional benefit associated with endovascular therapy among patients with acute ischemic stroke was increased when combined with intravenous tPA, with confirmed proximal arterial occlusion on angiographic imaging, and with use of stent retrievers for mechanical thrombectomy.

Comparison of non-stent retriever and stent retriever mechanical thrombectomy devices for the endovascular treatment of acute ischemic stroke.

OBJECTIVE Mechanical thrombectomy is standard of care for the treatment of acute ischemic stroke. However, limited data are available from assessment of outcomes of FDA-approved devices. The objective of this study is to compare clinical outcomes, efficacy, and safety of non-stent retriever and stent retriever thrombectomy devices. METHODS Between January 2008 and June 2014, 166 patients treated at Jefferson Hospital for Neuroscience for acute ischemic stroke with mechanical thrombectomy using Merci, Penumbra, Solitaire, or Trevo devices were retrospectively reviewed. Primary outcomes included 90-day modified Rankin Scale (mRS) score, recanalization rate (thrombolysis in cerebral infarction [TICI score]), and incidence of symptomatic intracranial hemorrhages (ICHs). Univariate analysis and multivariate logistic regression determined predictors of mRS Score 3-6, mortality, and TICI Score 3. RESULTS A total of 99 patients were treated with non-stent retriever devices (Merci and Penumbra) and 67 with stent retrievers (Solitaire and Trevo). Stent retrievers yielded lower 90-day NIH Stroke Scale scores and higher rates of 90-day mRS scores ≤ 2 (22.54% [non-stent retriever] vs 61.67% [stent retriever]; p < 0.001), TICI Score 2b-3 recanalization rates (79.80% [non-stent retriever] vs 97.01% [stent retriever]; p < 0.001), percentage of parenchyma salvaged, and discharge rates to home/rehabilitation. The overall incidence of ICH was also significantly lower (40.40% [non-stent retriever] vs 13.43% [stent retriever]; p = 0.002), with a trend toward lower 90-day mortality. Use of non-stent retriever devices was an independent predictor of mRS Scores 3-6 (p = 0.002), while use of stent retrievers was an independent predictor of TICI Score 3 (p < 0.001). CONCLUSIONS Stent retriever mechanical thrombectomy devices achieve higher recanalization rates than non-stent retriever devices in acute ischemic stroke with improved clinical and radiographic outcomes and safety.

Endovascular therapy including thrombectomy for acute ischemic stroke: A systematic review and meta-analysis with trial sequential analysis

One of the primary strategies for the management of acute ischemic stroke is intravenous (IV) thrombolysis with tissue plasminogen activator (t-PA). Over the past decade, endovascular therapies such as the use of stent retrievers to perform mechanical thrombectomy have been found to improve functional outcomes compared to t-PA alone. We aimed to reassess the functional outcomes and complications of IV thrombolysis with and without endovascular treatment for acute ischemic stroke using conventional meta-analysis and trial sequential analysis. Pooled relative risks (RR) and 95% confidence intervals (CI) were calculated for the effect of IV thrombolysis with and without endovascular therapy on functional outcome, mortality and symptomatic intracranial hemorrhage (SICH). Trial sequential analysis was done to strengthen the meta-analysis. We analyzed six randomized controlled trials involving 1943 patients. Patients who received IV thrombolysis with endovascular treatment showed significantly higher rates of excellent functional outcomes (modified Rankin Scale [mRS] 0–1) (RR, 1.75 [95% CI, 1.29–2.39]) compared to those who received IV thrombolysis alone. A similar association was seen for good functional outcomes (mRS 0–2) (RR, 1.56 [95% CI, 1.24–1.96]). Trial sequential analysis demonstrated endovascular treatment increased the RR of a good functional outcome by at least 30% compared to IV thrombolysis alone. There was no significant difference in all-cause mortality for mechanical thrombectomy compared to IV thrombolysis alone or the incidence of SICH at 3month follow-up. Endovascular treatment is more likely to result in a better functional outcome for patients compared to IV thrombolysis alone for acute ischemic stroke.

Stent Retrievers for the Treatment of Acute Ischemic Stroke: A Systematic Review and Meta-analysis of Randomized Clinical Trials.

Stent retrievers are a promising alternative for the treatment of acute ischemic stroke (AIS). Several recently completed clinical trials have examined the use of stent retrievers with intravenous recombinant tissue plasminogen activator (rtPA) compared with rtPA alone. To conduct a systematic review and meta-analysis of randomized clinical trials to quantify the benefits and risks of using stent retrievers in addition to rtPA for the treatment of AIS. The MEDLINE, EMBASE, and Cochrane Library of Clinical Trials databases were searched from inception to July 2015 for the keywords stent*, retriev*, Solitaire, Trevo, Revive, and stroke. Trial registries were also searched. A total of 326 publications were identified and 213 potentially relevant records were screened. Randomized clinical trials that examined stent retrievers with rtPA vs rtPA alone were included in the meta-analysis. Two independent reviewers extracted study data and performed quality assessment using the Cochrane Risk of Bias Tool. DerSimonian and Laird random-effects models were used to estimate relative risks (RRs), risk differences (RDs), and numbers needed to treat. The primary outcome was the proportion of patients achieving functional independence (defined as a score of 0-2 on the modified Rankin Scale, with 0 indicating no disability and 6 indicating death) at 90 days. Risks of all-cause mortality, intracranial hemorrhage, and parenchymal hematoma at 90 days were also assessed. Five randomized clinical trials met our inclusion criteria (n = 1287 patients). Patients randomized to stent-retriever therapy with rtPA had significantly improved rates of functional independence at 90 days compared with those randomized to rtPA alone (RR, 1.72; 95% CI, 1.48-1.99; RD, 0.19; 95% CI, 0.13-0.25). When data were pooled across trials, the effect of stent-retriever therapy on all-cause mortality at 90 days was inconclusive (RR, 0.82; 95% CI, 0.60-1.11; RD, -0.04; 95% CI, -0.08 to 0.1). There were similarly no detectable differences in the risks of intracranial hemorrhage (RR, 1.15; 95% CI, 0.67-1.97; RD, 0.00; 95% CI, -0.02 to 0.03) or parenchymal hematoma (RR, 1.18; 95% CI, 0.71-1.94; RD, 0.01; 95% CI, -0.01 to 0.04), although the 95% CIs were wide. Fixed-effects sensitivity analyses produced similar results for all outcomes. The use of stent retrievers in conjunction with rtPA vs rtPA alone is associated with significant improvement of functional independence 90 days after AIS.

Abstract WP32: When and Where ADAPT in Anterior Circulation Ischemic Strokes Really Works?

Introduction: The ADAPT (a direct aspiration first pass technique for acute stroke thrombectomy), using large bore aspiration catheters, has been reported to be a fast, safe, simple and effective method of mechanical thrombectomy (MT) that has facilitated the treatment of acute ischemic strokes. Hypothesis: An attempt to determinate the favorable factors leading to a satisfactory reperfusion (TICI 2b/3) with ADAPT in anterior circulation ischemic stroke patients with confirmed large vessel occlusions. Methods: Based on our prospectively gathered database we extracted patients who were admitted for MT in anterior circulation ischemic strokes since August 2013 and for whom ADAPT was used as the first MT option. Patient demographics, initial NIHSS, localization and lateralization of the occlusion, DWI-ASPECTS, IV thrombolysis prior to MT, time from stroke onset to femoral puncture, final TICI score and 3-month mRS were analyzed. Results: ADAPT was effective in achieving a TICI2b/3 in 54.7% of 309 patients. Two factors influenced positively the success of reperfusion with ADAPT as a stand alone procedure: an isolated MCA occlusion (p&lt;0.0001) and a shorter time from stroke onset to femoral puncture (p=0.0156). Age, Gender, initial NIHSS, DWI-ASPECTS and IV thrombolysis prior to MT did not influence the success of the ADAPT procedure. The additional use of stent retrievers improved the TICI 2b/3 revascularization rate to 84.1% (p&lt;0.0001). When ADAPT was the sole technique used to achieve satisfactory reperfusion, 3-month mRS≤2 was achieved in 70.4% of the patients, while only 41.7% of mRS≤2 at 3-month was achieved in patients for whom ADAPT then stent retrievers were used (p=0.0001). Conclusions: ADAPT is very effective in case of isolated MCA occlusion ischemic strokes. The relevance of ADAPT over stent retrievers in other anterior circulation localizations (carotid siphon and tandem occlusions) has to be evaluated with a randomized study.

Abstract TP18: S-shaped Internal Carotid Artery Curve in Dissection-related Acute Ischemic Stroke

Background and Purpose: Craniocervical fibromuscular dysplasia (FMD) has been associated with dissections. Recently, the presence of an S-shaped curve in the ICA has been described as a marker of FMD. We evaluated the occurrence of S-shaped curves in acute ischemic stroke (AIS) patients presenting with ICA steno-occlusive dissections. Methods: This was a retrospective review of the interventional database of two academic tertiary care institutions. Cases of carotid dissections were compared with a control group (consecutive non-tandem anterior circulation strokes). The presence of ICA S-shaped curves, C-shaped curves, 360° loops, as well as, FMD changes and atherosclerotic changes at the ICA bulb and curve/loop was determined by evaluation of conventional-angiogram and CTA. Results: Twenty-four patients with carotid dissections were identified and compared to 92 controls. The baseline characteristics were similar, with the exception of expected younger age and less prevalent history of hypertension, diabetes and atrial fibrillation in the dissection group. Procedural variables were also similar, with the exception of a large percentage of the use of stentretrievers in the control group. The occurrence of parenchymal hemorrhages, good outcomes and mortality were similar amongst the two groups. The frequency of S-shaped curves on either side was 29% in the dissection group vs. 7% in the control group (p&lt;0.01). The S-shaped ICA curves were typically mirror images within the dissection group (85% of the patients with an S-shaped curves had bilaterally occurrence). The frequency of C-shaped and 360 degree curves was statistically similar between groups. FMD changes within the craniocervical arteries were statistically more common in the patients with dissections. Ten patients of the dissection group had either FMD changes or an S-Shaped curve (41%). Multivariate analysis indicated that S-shaped curves were independently associated with the presence of dissections. Conclusion: S-shaped ICA curves are predictably bilateral, independently associated with carotid dissections in patients undergoing thrombectomy for acute ischemic stroke, and may indicate the underlying presence of FMD.

Outcomes of endovascular treatment of basilar artery occlusion in the stent retriever era: a systematic review and meta-analysis

BackgroundStent retriever thrombectomy has recently been found to be effective for anterior circulation strokes, but its efficacy for basilar artery occlusion (BAO) is unclear.ObjectiveTo carry out a systematic review and...

Mechanical thrombectomy with the Trevo ProVue device in ischemic stroke patients: does improved visibility translate into a clinical benefit?

PurposeTo investigate the efficacy and safety of the Trevo ProVue (TPV) stent retriever in stroke patients with large artery occlusions, with particular attention to the full structural radiopacity of the...

Rapid learning curve for Solitaire FR stent retriever therapy: evidence from roll-in and randomised patients in the SWIFT trial

BackgroundIn light of recent positive trial data for endovascular therapy in acute ischemic stroke (AIS), stent retriever use by practitioners without prior experience with these devices may become more common.ObjectiveTo...

Abstract T MP7: Single Center Experience With A Direct Aspiration Technique (adapt) For Endovascular Treatment Of Acute Ischemic Stroke

Background: We report our single center experience of endovascular treatment of stroke by the technique of direct clot aspiration. Methods: From September 2013 to July 2014, from our prospectively gathered database, we reviewed 114 patients presenting with large vessels occlusion in the settings of acute ischemic stroke and treated with the ADAPT technique in first intention. Results: Hundred and fourteen patients (55 female and 54 male patients (mean age: 64 y.o) presented with a median NIHSS score of 15,9 (1-26). The localisation of arterial occlusion was the MCA in 52/114 (45%), the ICA in 16/114 (14%), a tandem occlusion in 35/114 (30,7%) and the vertebro basilar territory in 11/114 (9,65%). Procedures were performed under sedation in 66% of cases and general anesthesia in 33%. The aspiration technique alone was successful in achieving TICI 2b/3 in 48,2% of cases (55/114) with a mean of 2 passes. The additional use of stent retrievers improved the TICI 2b/3 revascularization rate to 87,5%. With aspiration alone, the average time from groin puncture to at least TICI 2b recanalization was 37 min (from clot contact to recanalisation: 17 min). Ninety day functional outcomes was available for 87/114 patients with 50% of good functional outcomes (mRS≤ 0-2) and 15% death (mRS 6). For the overal series there were 10 cases (8,7%) of procedural complications (one non occlusive dissection, 4 distal emboli, and 5 Subarachnoid hemorrhages) and 2 symptomatic intracerebral hemorrhages (2,5%). Discussion: The aspiration technique utilizing large bore aspiration catheters technique alone was effective in 48% of the cases being fast, safe and simple, but to achieve a recanalization rate of 87,5% it add to be completed by the use of stentrievers in the other cases. The relevance of this technique needs to studied in larger prospective multicentric studies.

Intra-arterial Administration of Papaverine during Mechanical Thrombectomy for Acute Ischemic Stroke

The use of stent retrievers for mechanical thrombectomy in acute ischemic stroke may induce significant vasospasm, which at the early phases of reperfusion may be crucial for rethrombosis of the recanalized vessel. We aimed to study whether the use of intra-arterial papaverine in selected cases of vasospasm was associated with improved cerebral perfusion, arterial reocclusion, or increased hemorrhagic complications. We retrospectively studied 9 consecutive patients with large artery acute occlusion, treated with stent retriever and intra-arterial papaverine. Onset to administration of intravenous recombinant tissue-plasminogen activator time, baseline National Institute of Health Stroke Scale, time to reperfusion, number of passes of the stent retriever, modified Rankin Scale score at discharge, postprocedural hemorrhage, onset to reperfusion time, papaverine dose, and thrombolysis in cerebral infarction grade were recorded in all patients. After papaverine administration, the caliber of the infused arteries and their flow was increased in all cases. In none of the treated cases a reocclusion occurred after papaverine infusion. In one of the studied patients (11%), a parenchymal bleeding occurred 36 hours postoperatively. This small study suggests that intra-arterial infusion of papaverine for the treatment of cerebral vasospasm after mechanical thrombectomy in acute ischemic stroke is effective and safe.

Acute stroke patients treated with stent retrievers in carotid "T" occlusions have improved recanalization and outcome.

Recanalization rates and patient outcomes in acute occlusion of the carotid terminus have previously been poor. The use of stent-retrievers has resulted in better recanalization and patient outcomes. We sought to compare outcomes in patients treated with stent-retrievers to outcomes in older techniques. We retrospectively compared a stent-retriever cohort to a historical cohort. We evaluated recanalization rates and good outcomes (defined as mRS < 2 at 30 days or 10 point drop in NIHSS). There were twenty patients treated with stent-retrievers versus nine without. The recanalization rate in patients treated with stent retrievers was significantly higher than that of other modalities (90% vs 33%, p=0.004). Good outcomes were significantly higher in the stent retriever cohort (70% vs 22%, p=0.041). The use of stent-retrievers in patients with carotid "T" occlusions shows promise in comparison to older techniques. A randomized trial comparing stent-retriever therapy to IV thrombolysis is warranted to determine the efficacy of this new generation of devices.

P-031 Single Center Experience with the ADAPT Technique for Acute Ischemic Stroke

BackgroundWe report our single center experience of endovascular treatment of stroke by a technique of direct aspiration with large bore catheter.MethodsFrom September 2013 to March 2014 we included prospectively on...

ADAPT FAST study: a direct aspiration first pass technique for acute stroke thrombectomy

BackgroundThe development of new revascularization devices has improved recanalization rates and time, but not clinical outcomes. We report a prospectively collected clinical experience with a new technique utilizing a direct...