scholarly journals Endovascular thrombectomy 2020: open issues

2020 ◽  
Vol 22 (Supplement_M) ◽  
pp. M13-M18
Author(s):  
Peter Lanzer ◽  
Petr Widimsky ◽  
Diana A Gorog ◽  
Mikael Mazighi ◽  
David Liebeskind ◽  
...  
Keyword(s):  
Mechanical Thrombectomy ◽  
Posterior Circulation ◽  
Large Artery ◽  
First Line ◽  
Anterior Circulation ◽  
Endovascular Thrombectomy ◽  
Optimal Outcomes ◽  
Perfusion Defects ◽  
First Line Treatment ◽  
Open Issues

Abstract Mechanical thrombectomy is now well - established first - line treatment for selected patients with large artery occlusions of the anterior circulation. However, number of technical and procedural issues remains open to assure optimal outcomes in majority of patients including those suffering from posterior circulation perfusion defects. This brief review addresses some of the open issues and refers to the ongoing trials to close the existing knowledge gaps.

scholarly journals P.115 Saskatchewan experience with mechanical thrombectomy under general anaesthesia

2019 ◽  
Vol 46 (s1) ◽  
pp. S44
Author(s):  
A Persad ◽  
Z Tymchak ◽  
S Ahmed ◽  
A Gardner ◽  
R Whelan ◽  
...  
Keyword(s):  
Acute Stroke ◽  
General Anesthesia ◽  
Mechanical Thrombectomy ◽  
Posterior Circulation ◽  
The Body ◽  
Anatomical Location ◽  
Viable Option ◽  
Anterior Circulation ◽  
Endovascular Thrombectomy ◽  
Overall Mortality

Background: While recent clinical trials have demonstrated immense efficacy of mechanical thrombectomy (MT) in the setting of acute stroke, there remains debate over the safety in performing this procedure under general anesthesia (GA). In the Saskatchewan Acute Stroke Pathway, all patients presenting with LVO have endovascular thrombectomy performed under GA. Methods: Data was retrospectively reviewed on 108 consecutive LVO in 2016-2017. All MT were done under GA. Anatomical location of LVO, pre-MT ASPECTS score, post-MT TICI scores and 90-day NIHSS and mRS were recorded. Results: Of 108 LVO, 103 went on to have MT. 44 were right anterior circulation, 50 were left anterior circulation and 9 were posterior circulation. Of 94 anterior circulation strokes, 47 (50.0%), 43 (45.7%) and 4 (4.3%) had good, moderate and poor collateral circulation respectively, and the average pre-MT ASPECTS was 8.6. The average pre-MT NIHSS was 14.7. 81/90 (90.0%) achieved thrombolysis in cerebral infarction (TICI) perfusion scale grade of 2b/3 after recanalization. Average documented 90-day NIHSS was 2.4 and mRS was 2.5. Overall mortality was 21/103 (20.4%). Conclusions: In the Saskatchewan acute stroke pathway, general anesthesia is a safe modality for MT. This adds to the body of evidence supporting GA as a viable option for sedation in MT.

scholarly journals Added Value of Rescue Devices in Intra-Arterial Thrombectomy: When Should We Apply Them?

2021 ◽  
Vol 12 ◽  
Author(s):  
Cheng-Fu Ni ◽  
Sho-Jen Cheng ◽  
Cheng-Yu Chen ◽  
Tu-Hsueh Yeh ◽  
Kevin Li-Chun Hsieh
Keyword(s):  
Functional Outcomes ◽  
Mechanical Thrombectomy ◽  
Rescue Therapy ◽  
Functional Independence ◽  
Posterior Circulation ◽  
First Line ◽  
Anterior Circulation ◽  
First Line Therapy ◽  
Line Therapy ◽  
Reperfusion Rate

Introduction: Recent trials have demonstrated the superior efficacy of mechanical thrombectomy over other medical treatments for acute ischemic stroke; however, not every large vessel occlusion (LVO) can be recanalized using a single thrombectomy device. Rescue devices were proved to increase the reperfusion rate, but the efficacy is unclear.Objective: In this retrospective study, we evaluated the efficacy of rescue therapy in different locations of LVO.Methods: We analyzed the outcomes of mechanical thrombectomy from a prospective registry of consecutive 82 patients in Taipei Medical University Hospital. The reperfusion rate and the functional outcome were compared in patients who received first-line therapy only and patients who need rescue therapy.Results: An 84.1% reperfusion rate was achieved in our cohort. We applied first-line stent retriever (SR) treatment in 6 patients, among which 4 (66.6%) achieved successful reperfusion. We applied a direct-aspiration first-pass technique (ADAPT) as the first-line treatment in 76 patients, among which 46 (60.5%) achieved successful reperfusion. Successful reperfusion could not be achieved in 30 cases (39.5%); therefore, we applied a second-line rescue SR for 28 patients, and reperfusion was established in 18 (64.3%) of them. These results revealed that the LVO in anterior circulation has a higher chance to respond to SR rescue therapy than posterior circulation lesions (68 vs. 33.3%, P < 0.001). Patients who received only first-line therapy exhibited significantly better functional outcomes than those who were also treated with rescue SR therapy (41.2 vs. 16.7%, P = 0.001). In addition, patients with LVO in the anterior circulation were found to have a higher probability of achieving functional independence than patients with posterior circulation lesions (10.7 vs. 0.0%, P < 0.001). The adjusted multivariate analysis revealed that successful reperfusion and treatment type (first-line or rescue therapy) were significantly related to a modified Rankin Scale (mRS) score at 90 days.Conclusion: This study reveals that rescue SR therapy improves the reperfusion rate. Patients who require rescue SR therapy have a lower likelihood of functional independence. LVO in the anterior circulation responds better to rescue SR therapy and results in better functional outcomes than posterior circulation lesions.

Mechanical thrombectomy as a first-line treatment for arterial occlusion

2001 ◽  
Vol 14 (2) ◽  
pp. 123-131 ◽  
Author(s):  
Karthikeshwar Kasirajan ◽  
John M. Marek ◽  
Mark Langsfeld
Keyword(s):  
Mechanical Thrombectomy ◽  
Arterial Occlusion ◽  
Line Treatment ◽  
First Line ◽  
First Line Treatment

scholarly journals Stroke thrombectomy complication management

2021 ◽  
pp. neurintsurg-2021-017349
Author(s):  
Sara M Pilgram-Pastor ◽  
Eike I Piechowiak ◽  
Tomas Dobrocky ◽  
Johannes Kaesmacher ◽  
Juergen Den Hollander ◽  
...  
Keyword(s):  
Treatment Efficacy ◽  
Mechanical Thrombectomy ◽  
Complication Management ◽  
Line Treatment ◽  
Large Vessel Occlusion ◽  
First Line ◽  
Invasive Treatment ◽  
Vessel Occlusion ◽  
Endovascular Mechanical Thrombectomy ◽  
First Line Treatment

Endovascular mechanical thrombectomy (EVT) is widely accepted as the first-line treatment for acute ischemic stroke in patients with large vessel occlusion. Being an invasive treatment, this method is associated with various preoperative, perioperative, and postoperative complications. These complications may influence peri-interventional morbidity and mortality and therefore treatment efficacy and clinical outcome. The aim of this review is to discuss the most common types of complications associated with EVT, the probable mechanisms of injury, and effective methods to manage and prevent complications.

Abstract T P18: Incidence and Management of Intracranial Wire Perforation During Acute Stroke Endovascular Therapy

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Deepak Gulati ◽  
Amin Aghaebrahim, ◽  
Amer Malik ◽  
Andrew Ducruet ◽  
Brian Jankowitz ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Posterior Circulation ◽  
Preventive Strategies ◽  
Anterior Choroidal Artery ◽  
Balloon Inflation ◽  
Anterior Circulation ◽  
Endovascular Thrombectomy ◽  
Intracranial Stenting ◽  
Anterior Choroidal ◽  
Choroidal Artery

BACKGROUND: Wire perforation during endovascular thrombectomy for acute stroke is a rare but devastating complication. Understanding the incidence and mechanism of this adverse event may further identify preventive strategies and improvements in management during perforation. METHODS: Retrospective review of a prospectively maintained database of acute stroke interventions at our institute identified 1035 patients. Of these, 46 patients were noted to have contrast extravastion during the procedure concerning for wire perforation (4%). RESULTS: A majority of the cases involved the anterior circulation (76%). Sites of perforation included: ICA (12), MCA (23), ophthalmic (1), anterior choroidal (2), PCA (4), PICA (1), SCA (1) and vertebral artery (2). Successful hemostasis was achieved with onyx embolization (39%), coil embolization (13%), onyx/coil combined embolization (5%), microcatheter occlusion (2%) and balloon inflation (7%). Thirty one percentage of the cases occurred during intracranial stenting or angioplasty. Despite high rates of mortality (72%), rapid recognition of extravasation and hemostasis led to good outcomes in 9% of patient. CONCLUSION: Intra-procedural wire perforation with leakage of contrast is associated with catheterization of small caliber vessels such as distal MCA branches (M3), anterior choroidal artery and diminutive posterior circulation vessels as well as intracranial angioplasty/stenting. Devastating outcomes can potentially be averted with appropriate hemostatic control.

A human brain test bed for research in large vessel occlusion stroke

2021 ◽  
pp. 1-9
Author(s):  
Daniel Gebrezgiabhier ◽  
Yang Liu ◽  
Adithya S. Reddy ◽  
Evan Davis ◽  
Yihao Zheng ◽  
...  
Keyword(s):  
Human Brain ◽  
Mechanical Thrombectomy ◽  
Posterior Circulation ◽  
Large Vessel ◽  
Suction Catheter ◽  
Large Vessel Occlusion ◽  
Test Bed ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Human Brains

OBJECTIVEEndovascular removal of emboli causing large vessel occlusion (LVO)–related stroke utilizing suction catheter and/or stent retriever technologies or thrombectomy is a new standard of care. Despite high recanalization rates, 40% of stroke patients still experience poor neurological outcomes as many cases cannot be fully reopened after the first attempt. The development of new endovascular technologies and techniques for mechanical thrombectomy requires more sophisticated testing platforms that overcome the limitations of phantom-based simulators. The authors investigated the use of a hybrid platform for LVO stroke constructed with cadaveric human brains.METHODSA test bed for embolic occlusion of cerebrovascular arteries and mechanical thrombectomy was developed with cadaveric human brains, a customized hydraulic system to generate physiological flow rate and pressure, and three types of embolus analogs (elastic, stiff, and fragment-prone) engineered to match mechanically and phenotypically the emboli causing LVO strokes. LVO cases were replicated in the anterior and posterior circulation, and thrombectomy was attempted using suction catheters and/or stent retrievers.RESULTSThe test bed allowed radiation-free visualization of thrombectomy for LVO stroke in real cerebrovascular anatomy and flow conditions by transmural visualization of the intraluminal elements and procedures. The authors were able to successfully replicate 105 LVO cases with 184 passes in 12 brains (51 LVO cases and 82 passes in the anterior circulation, and 54 LVO cases and 102 passes in the posterior circulation). Observed recanalization rates in this model were graded using a Recanalization in LVO (RELVO) scale analogous to other measures of recanalization outcomes in clinical use.CONCLUSIONSThe human brain platform introduced and validated here enables the analysis of artery-embolus-device interaction under physiological hemodynamic conditions within the unmodified complexity of the cerebral vasculature inside the human brain.

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

BMC Neurology ◽  
2020 ◽  
Vol 20 (1) ◽  
Author(s):  
Jin Wook Choi ◽  
Miran Han ◽  
Jung Hyun Park ◽  
Woo Sang Jung
Keyword(s):  
Basilar Artery ◽  
Mechanical Thrombectomy ◽  
Treatment Method ◽  
Artery Occlusion ◽  
Basilar Artery Occlusion ◽  
Procedure Time ◽  
First Line ◽  
Aspiration Thrombectomy ◽  
First Pass ◽  
First Line Treatment

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

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

2019 ◽  
Vol 11 (10) ◽  
pp. 979-983 ◽  
Author(s):  
Dong-Hun Kang ◽  
Jin Woo Kim ◽  
Byung Moon Kim ◽  
Ji Hoe Heo ◽  
Hyo Suk Nam ◽  
...  
Keyword(s):  
Stent Retriever ◽  
First Line ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Aspiration Thrombectomy ◽  
Endovascular Thrombectomy ◽  
Negatively Associated ◽  
Good Outcome ◽  
Rescue Treatment ◽  
First Pass

BackgroudThe need for rescue treatment (RT) may differ depending on first-line modality (stent retriever (SR) or contact aspiration (CA)) in endovascular thrombectomy (EVT). We aimed to investigate whether the type of first-line modality in EVT was associated with the need for RT.MethodsWe identified all patients who underwent EVT for anterior circulation large-vessel occlusion from prospectively maintained registries of 17 stroke centers. Patients were dichotomized into SR-first and CA-first. RT involved switching to the other device, balloon angioplasty, permanent stenting, thrombolytics, glycoprotein IIb/IIIa antagonist, or any combination of these. We compared clinical characteristics, procedural details, and final recanalization rate between the two groups and assessed whether first-line modality type was associated with RT requirement and if this affected clinical outcome.ResultsA total of 955 patients underwent EVT using either SR-first (n=526) or CA-first (n=429). No difference occurred in the final recanalization rate between SR-first (82.1%) and CA-first (80.2%). However, recanalization with the first-line modality alone and first-pass recanalization rates were significantly higher in SR-first than in CA-first. CA-first had more device passes and higher RT rate. The RT group had significantly longer puncture-to-recanalization time (93±48 min versus 53±28 min). After adjustment, CA-first remained associated with RT (OR, 1.367; 95% CI, 1.019 to 1.834). RT was negatively associated with good outcome (OR, 0.597; 95% CI, 0.410 to 0.870).ConclusionCA was associated with requiring RT, while recanalization with first-line modality alone and first-pass recanalization rates were higher with SR. RT was negatively associated with good outcome.

Leukoaraiosis and acute ischemic stroke: 90-day clinical outcome following endovascular recanalization, with proposed “L-ASPECTS”

2020 ◽  
pp. neurintsurg-2020-015957 ◽  
Author(s):  
John Benson ◽  
Seyed Mohammad Seyedsaadat ◽  
Ian Mark ◽  
Deena M Nasr ◽  
Alejandro A Rabinstein ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Area Under The Curve ◽  
Primary Outcome Measure ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Endovascular Recanalization ◽  
Poor Outcomes

BackgroundTo assess if leukoaraiosis severity is associated with outcome in patients with acute ischemic stroke (AIS) following endovascular thrombectomy, and to propose a leukoaraiosis-related modification to the ASPECTS score.MethodsA retrospective review was completed of AIS patients that underwent mechanical thrombectomy for anterior circulation large vessel occlusion. The primary outcome measure was 90-day mRS. A proposed Leukoaraiosis-ASPECTS (“L-ASPECTS”) was calculated by subtracting from the traditional ASPECT based on leukoaraiosis severity (1 point subtracted if mild, 2 if moderate, 3 if severe). L-ASEPCTS score performance was validated using a consecutive cohort of 75 AIS LVO patients.Results174 patients were included in this retrospective analysis: average age: 68.0±9.1. 28 (16.1%) had no leukoaraiosis, 66 (37.9%) had mild, 62 (35.6%) had moderate, and 18 (10.3%) had severe. Leukoaraiosis severity was associated with worse 90-day mRS among all patients (P=0.0005). Both L-ASPECTS and ASPECTS were associated with poor outcomes, but the area under the curve (AUC) was higher with L-ASPECTS (P<0.0001 and AUC=0.7 for L-ASPECTS; P=0.04 and AUC=0.59 for ASPECTS). In the validation cohort, the AUC for L-ASPECTS was 0.79 while the AUC for ASPECTS was 0.70. Of patients that had successful reperfusion (mTICI 2b/3), the AUC for traditional ASPECTS in predicting good functional outcome was 0.80: AUC for L-ASPECTS was 0.89.ConclusionsLeukoaraiosis severity on pre-mechanical thrombectomy NCCT is associated with worse 90-day outcome in patients with AIS following endovascular recanalization, and is an independent risk factor for worse outcomes. A proposed L-ASPECTS score had stronger association with outcome than the traditional ASPECTS score.

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