Safety and effectiveness of mechanical thrombectomy for primary isolated distal vessel occlusions: retrospective observational comparative study

In patients undergoing mechanical thrombectomy, achieving complete (Thrombolysis in Cerebral Infarction 3) rather than incomplete successful reperfusion (Thrombolysis in Cerebral Infarction 2b) is associated with better functional outcome. Despite technical improvements, incomplete reperfusion remains the final angiographic result in 40% of patients according to recent trials. As most incomplete reperfusions are caused by distal vessel occlusions, they are potentially amenable to rescue strategies. While observational data suggest a net benefit of up to 20% in functional independence of incomplete versus complete reperfusions, the net benefit of secondary improvement from Thrombolysis in Cerebral Infarction 2b to 3 reperfusion might differ due to lengthier procedures and delayed reperfusion. Current strategies to tackle distal vessel occlusions consist of distal (microcatheter) aspiration, small adjustable stent retrievers, and administration of intra-arterial thrombolytics. While there are promising reports evaluating those techniques, all available studies show relevant limitations in terms of selection bias, single-center design, or nonconsecutive patient inclusion. Besides an assessment of risks associated with rescue maneuvers, we advocate that the decision-making process should also include a consideration of potential outcomes if complete reperfusion would successfully be achieved. These include (1) a futile angiographic improvement (hypoperfused territory is already infarcted), (2) an unnecessary angiographic improvement (the patient would not have developed infarction if no rescue maneuver was performed), and (3) a successful rescue maneuver with clinical benefit. Currently there is paucity of data on how these scenarios can be predicted and the decision whether to treat or to stop in a patient with incomplete reperfusion involves many unknowns. To advance the status quo, we outline current knowledge gaps and avenues of potential research regarding this clinically important question.

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A comparative study on endovascular treatment of (sub)acute critical limb ischemia: mechanical thrombectomy vs thrombolysis

Drug Design Development and Therapy ◽

10.2147/dddt.s131503 ◽

2017 ◽

Vol Volume 11 ◽

pp. 1233-1241 ◽

Cited By ~ 20

Author(s):

Mariya Kronlage ◽

Ilka Printz ◽

Britta Vogel ◽

Erwin Blessing ◽

Oliver Müller ◽

...

Keyword(s):

Comparative Study ◽

Endovascular Treatment ◽

Critical Limb Ischemia ◽

Mechanical Thrombectomy ◽

Limb Ischemia

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EP45* Beyond proximal large vessel occlusions: outcome of mechanical thrombectomy in distal vessel occlusions in the EXCELLENT registry – Interim analysis

10.1136/neurintsurg-2021-esmint.44 ◽

2021 ◽

Author(s):

OO Zaidat ◽

RG Nogueira ◽

AH Siddiqui ◽

AJ Yoo ◽

RA Hanel ◽

...

Keyword(s):

Interim Analysis ◽

Mechanical Thrombectomy ◽

Large Vessel ◽

Distal Vessel

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Abstract 1122‐000157: Safety and Effectiveness of MT for Primary Isolated Distal Vessel Occlusions: A Retrospective Comparative Study

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.01.suppl_1.000157 ◽

2021 ◽

Vol 1 (S1) ◽

Author(s):

Ossama Y Mansour ◽

Mahmoud Elhorany ◽

Nader A Sourour ◽

Frédéric Clarençon

Keyword(s):

Medical Treatment ◽

Mechanical Thrombectomy ◽

Secondary Analysis ◽

Intravenous Thrombolysis ◽

Vessel Occlusion ◽

Best Medical Treatment ◽

Significant Difference ◽

Retrospective Comparative Study ◽

Distal Vessel ◽

Historic Cohort

Introduction : Distal vessel occlusions represent about 25–40% of acute ischemic stroke (AIS), either as primary occlusion or secondary occlusion complicating mechanical thrombectomy (MT) for large vessel occlusion. Our aim was to evaluate safety and effectiveness of MT associated with the best medical treatment (BMT) in the management of AIS patients with distal vessel occlusion in comparison with the BMT alone. Methods : Retrospective analysis was conducted on AIS patients treated by MT+BMT for primary distal vessel occlusion between 2015 and 2020, and were compared with a historic cohort managed by BMT alone between 2006 and 2015 selected based on the same inclusion criteria. A secondary analysis was conducted using propensity score matching (PSM) including the following: NIHSS, age and treatment with intravenous thrombolysis (IVT) as covariates. Results : Of 650 patients screened, 44 patients with distal vessel occlusions treated by MT+BMT were selected and compared with 36 patients who received BMT alone. After PSM, 28 patients in each group were matched without significant difference. Good clinical outcome defined as mRS≤2 was achieved by 53.6% of the MT+BMT group and 57% of the BMT group (OR, 0.87; 95%CI, 0.3–2.4; P = 1.00). The mortality rate was comparable in both groups (7% vs 10.7% in MT+BMT and BMT patients, respectively; OR = 0.64; 95%CI, 0.1‐4; P = 1.00). Symptomatic intracranial haemorrhage (ICH) was seen in only one patient treated by MT+BMT (3.6%). Conclusions : Mechanical thrombectomy seems to be comparable with the best medical treatment regarding the effectiveness and safety in the management of patients with distal vessel occlusions.

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Abstract TP19: Thrombectomy in Medium Arteries Works for Distal Vessel Occlusions in Acute Ischemic Stroke - STRATIS

Stroke ◽

10.1161/str.51.suppl_1.tp19 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

David S Liebeskind ◽

Michael T Froehler ◽

Osama O Zaidat ◽

M A Aziz-Sultan ◽

Richard P Klucznik ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Arterial Diameter ◽

Systematic Analysis ◽

Anatomical Nomenclature ◽

Arterial Recanalization ◽

Device Deployment ◽

The Relationship ◽

Distal Vessel

Background: Mechanical thrombectomy is established for large vessel occlusions in acute ischemic stroke, but the potential role in distal vessel occlusions of medium arteries is largely unknown. Such distal arterial segments have not been measured with respect to thrombectomy devices used during endovascular therapy. We conducted a systematic analysis of arterial size, segmental anatomy and stent retriever device performance during thrombectomy. Methods: The STRATIS angiography core lab adjudicated the exact location of the occlusion, proximal and distal device deployment, relationship to arterial bifurcations and anatomical nomenclature. Arterial diameters were measured at all of these sites. Statistical analyses examined the relationship between these variables, arterial recanalization and eTICI reperfusion. Results: Thrombectomy was performed with various device sizes, including Solitaire 4x40 in 36.3% (306/844), Solitaire 6x30 in 31.4% (265/844), Solitaire 4x20 in 26.4% (223/844), unspecified in 3.8% (32/844), Solitaire 6x20 in 1.3% (11/844) and Solitaire 4x15 in 0.8% (7/844). Arterial diameter at the occlusion site was median 2.17mm (1.40-3.59) in the distal M1, 1.67mm (0.81-2.98) in the proximal M2, 1.50mm (0.92-1.99) in the distal M2, 1.24mm (0.67-2.00) in the M3 and 1.88mm (1.49-1.94) in the P1. Considerable overlap was noted between arterial sizes at occlusion sites carrying different segmental arterial nomenclature or vessel names. During device deployment in STRATIS, median arterial diameter at the occlusion site was 2.4mm (IQR 1.9, 3.4), 2.9mm (IQR 2.2, 3.6) at the proximal stent marker and 1.4mm (IQR 1.2, 1.7) at the distal stent marker. Substantial eTICI reperfusion (2b-3) was achieved in all distal vessel occlusions (Table 1). Conclusions: Substantial reperfusion may be achieved with currently available mechanical thrombectomy devices for distal vessel occlusions in medium arteries.

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Distal Vessel Imaging via Intra-arterial Flat Panel Detector CTA during Mechanical Thrombectomy

American Journal of Neuroradiology ◽

10.3174/ajnr.a6906 ◽

2020 ◽

Author(s):

T. Nozaki ◽

M. Noda ◽

T. Ishibashi ◽

K. Otani ◽

M. Kogiku ◽

...

Keyword(s):

Mechanical Thrombectomy ◽

Flat Panel ◽

Flat Panel Detector ◽

Vessel Imaging ◽

Distal Vessel

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Frontline ADAPT therapy to treat patients with symptomatic M2 and M3 occlusions in acute ischemic stroke: initial experience with the Penumbra ACE and 3MAX reperfusion system

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2017-013233 ◽

2017 ◽

Vol 10 (5) ◽

pp. 434-439 ◽

Cited By ~ 30

Author(s):

Jens Altenbernd ◽

Oliver Kuhnt ◽

Svenja Hennigs ◽

Ruediger Hilker ◽

Christian Loehr

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Functional Independence ◽

National Institutes Of Health ◽

Complication Rates ◽

Vessel Occlusion ◽

First Pass ◽

Symptomatic Intracranial Hemorrhage ◽

Distal Vessel

BackgroundAfter a series of positive studies for mechanical thrombectomy in large vessel occlusion acute ischemic stroke, the question remains, can symptomatic patients with distal vessel occlusion benefit from mechanical thrombectomy?PurposeTo assess the safety and efficacy of the 3MAX reperfusion system as frontline therapy for M2 and M3 occlusions.MethodsThis study retrospectively collected data on 58 patients treated for M2 and M3 occlusions between January and September 2016. Of these 58 patients, 31 had an isolated M2 or M3 occlusion. Eligible patients were treated with 3MAX by adirect first pass aspiration (ADAPT) technique within 6 hours following stroke onset. Effectiveness was defined by functional independence (90-day modified Rankin Scale core 0–2) and revascularization to modified Thrombolysis in Cerebral Infarction (mTICI) 2b–3 scores adjudicated by a core laboratory, while complication rates were used to determine safety of the device and the procedure.ResultsPatients with an isolated M2 or M3 occlusion had a mean age of 68.6±13.3 years (range 18–90 years), a median National Institutes of Health Stroke Score of 15 (IQR 9–19), and ASPECTS score of 9 (IQR 8–10). After intervention, 100% (31/31) of patients were revascularized to mTICI 2b–3; 77.4% (24/31) of patients showed revascularization to mTICI 3. Aspiration alone led to revascularization in 83.9% (26/31) of patients. At 90 days, 96.8% (30/31) of patients had achieved functional independence. The incidence of symptomatic intracranial hemorrhage was 0% (0/31).ConclusionsResults suggest that the 3MAX reperfusion system is safe and effective in achieving successful revascularization and functional independence for patients with acute ischemic stroke secondary to M2 and M3 occlusions using ADAPT, either as frontline monotherapy, or in combination with adjunctive devices.

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