Stent retrievers with segmented design improve the efficacy of thrombectomy in tortuous vessels

IntroductionTortuous vascular anatomy is one of the greatest challenges in mechanical thrombectomy. This study examines the impact of vascular tortuosity on the performance of stent retrievers and evaluates the efficacy of the newer generation stent retrievers with segmented design.Materials and methodsModels with mild, moderate, and severe tortuosity with an internal carotid artery (ICA) and a middle cerebral artery (MCA) were created. An elastic and cohesive clot was placed in the MCA lying from distal M1 and proximal M2. We assessed the revascularization rates of two commonly used stent retrievers (Trevo XP and Solitaire FR) and two newer stent retrievers with segmented design (Embotrap and Versi) in each vascular model.ResultsBoth the type of stent retriever and the severity of vessel tortuosity significantly affected the successful recanalization rate. Post-hoc tests showed that the rate of revascularization was significantly less in severe tortuosity than in mild or moderate tortuosity (P<0.001). The Versi resulted in higher success rates than the Solitaire (P<0.01) and the Trevo (P<0.05). The success rates of the Embotrap were higher than the Solitaire and Trevo stent retrievers, although the difference was not statistically significant.ConclusionsSevere tortuosity reduces the performance of mechanical thrombectomy. The segmented design in stent retrievers could improve the efficacy of mechanical thrombectomy in tortuous vessels.Trial registrationESCAPE NCT01778335;SWIFT PRIME >NCT01657461; REVASCAT >NCT01692379; All post-results.

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Impact of Baseline Central Retinal Thickness on Outcomes in the VIVID-DME and VISTA-DME Studies

Journal of Ophthalmology ◽

10.1155/2018/3640135 ◽

2018 ◽

Vol 2018 ◽

pp. 1-9 ◽

Cited By ~ 1

Author(s):

Edoardo Midena ◽

Mark Gillies ◽

Todd A. Katz ◽

Carola Metzig ◽

Chengxing Lu ◽

...

Keyword(s):

Treatment Effect ◽

Retinal Thickness ◽

Continuous Variable ◽

Central Retinal Thickness ◽

Link Type ◽

Intravitreal Aflibercept ◽

Laser Control ◽

Post Hoc ◽

The Impact ◽

Anatomical Outcomes

Purpose. To report the impact of baseline central retinal thickness (CRT) on outcomes in patients with diabetic macular edema (DME) in VIVID-DME and VISTA-DME. Methods. Post hoc analyses of two randomized controlled trials in which 862 DME patients were randomized 1 : 1 : 1 to treatment with intravitreal aflibercept 2.0 mg every 4 weeks (2q4), intravitreal aflibercept 2.0 mg every 8 weeks after five initial monthly doses (2q8), or macular laser photocoagulation at baseline and as needed. We compared visual and anatomical outcomes in subgroups of patients with baseline CRT < 400 μm and ≥400 μm. Results. At weeks 52 and 100, outcomes with intravitreal aflibercept 2q4 and 2q8 were superior to those in laser control-treated patients regardless of baseline CRT. When looked at in a binary fashion, the treatment effect of intravitreal aflibercept versus laser was not significantly better in the ≥400 μm than the <400 μm group; when looked at as a continuous variable, baseline CRT seemed to have an impact on the treatment effect of intravitreal aflibercept versus laser. Conclusions. Post hoc analyses of VIVID-DME and VISTA-DME demonstrated the benefits of intravitreal aflibercept treatment in DME patients with baseline CRT < 400 μm and ≥400 μm. This trial is registered with NCT01331681 and NCT01363440.

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Impact of thrombus length on recanalization and clinical outcome following mechanical thrombectomy in acute ischemic stroke

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2016-012591 ◽

2016 ◽

Vol 9 (10) ◽

pp. 937-939 ◽

Cited By ~ 16

Author(s):

Fatih Seker ◽

Johannes Pfaff ◽

Marcel Wolf ◽

Silvia Schönenberger ◽

Simon Nagel ◽

...

Keyword(s):

Clinical Outcome ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Neurological Outcome ◽

Mechanical Thrombectomy ◽

Binary Logistic Regression ◽

Artery Occlusion ◽

Good Clinical Outcome ◽

Stent Retrievers ◽

The Impact

PurposeThe impact of thrombus length on recanalization in IV thrombolysis for acute intracranial artery occlusion has been well studied. Here we analyzed the influence of thrombus length on the number of thrombectomy maneuvers needed for recanalization, intraprocedural complications, recanalization success, and clinical outcome after mechanical thrombectomy.MethodsWe retrospectively analyzed angiographic and clinical data from 72 consecutive patients with acute occlusion of the M1 segment of the middle cerebral artery who were treated with mechanical thrombectomy using stent retrievers. Successful recanalization was defined as a Thrombolysis in Cerebral Infarction score of 2b or 3. Good neurological outcome was defined as a modified Rankin Scale score of ≤2 at 90 days after stroke onset.ResultsMean thrombus length was 13.4±5.2 mm. Univariate binary logistic regression did not show an association of thrombus length with the probability of a good clinical outcome (OR 0.95, 95% CI 0.84 to 1.03, p=0.176) or successful recanalization (OR 0.92, 95% CI 0.81 to 1.05, p=0.225). There was no significant correlation between thrombus length and the number of thrombectomy maneuvers needed for recanalization (p=0.112). Furthermore, thrombus length was not correlated with the probability of intraprocedural complications (p=0.813), including embolization in a new territory (n=3).ConclusionsIn this study, thrombus length had no relevant impact on recanalization, neurological outcome, or intraprocedural complications following mechanical thrombectomy of middle cerebral artery occlusions. Therefore, mechanical thrombectomy with stent retrievers can be attempted with large clots.

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Early experience with stent retrievers and comparison with previous-generation mechanical thrombectomy devices for acute ischemic stroke

Journal of Neurosurgery ◽

10.3171/2014.2.jns131372 ◽

2014 ◽

Vol 121 (1) ◽

pp. 12-17 ◽

Cited By ~ 12

Author(s):

Eric M. Deshaies ◽

Amit Singla ◽

Mark R. Villwock ◽

David J. Padalino ◽

Sameer Sharma ◽

...

Keyword(s):

Patient Outcomes ◽

Mechanical Thrombectomy ◽

Functional Independence ◽

Limited Information ◽

Arterial Tree ◽

Specific Patient ◽

Thrombectomy Device ◽

Stent Retrievers ◽

Solitaire Fr ◽

Therapy Studies

Object There is limited information regarding patient outcomes following interventions for stroke during the window for endovascular therapy. Studies have suggested that recently approved stent retrievers are safer and more effective than earlier-generation thrombectomy devices. The authors compared cases in which the Solitaire-FR device was used to those in which a MERCI or Penumbra device was used. Methods This study is a single-center retrospective review of 102 consecutive cases of acute stroke in which patients were treated with mechanical thrombectomy devices between 2007 and 2013. Multivariate models, adjusted for confounding factors, were used to investigate functional independence (modified Rankin Scale [mRS] score ≤ 2, and successful reperfusion (thrombolysis in cerebral infarction [TICI] score ≥ 2b). Results Thrombectomy device had a significant impact on functional independence (mRS score ≤ 2) at discharge from the hospital (p = 0.040). Solitaire-FR treatment resulted in significantly more patients being discharged as functionally independent in comparison with MERCI treatment (p = 0.016). A multivariate model found the use of Solitaire-FR to improve the odds of good clinical outcome in comparison with prior-generation devices (OR 6.283, 95% CI 1.785–22.119, p = 0.004). Additionally, the use of Solitaire-FR significantly increased the odds of successful reperfusion (OR 3.247, 95% CI 1.160–9.090, p = 0.025). Conclusions The stent retriever Solitaire-FR significantly improved the odds of functional independence and successful revascularization of the arterial tree. New interventional technology for stroke continues to mature, but randomized trials are needed to establish the actual benefit to specific patient populations.

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Clinical implication of using up both fluoropyrimidine (FU) and paclitaxel (PTX) in patients with severe peritoneal metastases (SPM) of gastric cancer (GC).

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.3_suppl.221 ◽

2021 ◽

Vol 39 (3_suppl) ◽

pp. 221-221

Author(s):

Hiroyuki Arai ◽

Eisuke Inoue ◽

Kensei Yamaguchi ◽

Narikazu Boku ◽

Hiroki Hara ◽

...

Keyword(s):

Clinical Implication ◽

Prognostic Score ◽

Glasgow Prognostic Score ◽

Best Supportive Care ◽

Combination Strategy ◽

Factors Affecting ◽

The Difference ◽

Post Hoc ◽

The Impact ◽

Selection Of

221 Background: JCOG1108/WJOG7312G trial showed favorable but not significantly better outcomes of 5-FU/ l-leucovorin ( l-LV) /PTX combination (FLTAX) compared to 5-FU/ l-LV (FL) in untreated patients with SPM of GC. However, a half of patients treated with FL could not sequentially use PTX which is a key drug for peritoneal metastasis. We conducted a post hoc analysis to investigate the clinical implication of using up both FU and PTX in either combination or sequential strategy for GC patients with SPM. Methods: Among 101 patients enrolled in the trial (FL: N = 51; FLTAX: N = 50), overall survival (OS) was compared between three subgroups: patients treated with FL followed by PTX (FL/PTX: N = 25), those treated with FL followed by best supportive care (BSC) (FL/BSC: N = 21), and those treated with FLTAX (per protocol population, N = 48). To identify the factors affecting the likelihood of using sequential PTX (LUSP), we compared baseline characteristics between the FL/PTX and FL/BSC subgroups. Each baseline covariate was tested for the impact on LUSP by logistic regression model. The difference of treatment efficacy between FL and FLTAX was assessed in subgroups stratified by the factors identified to affect LUSP. Results: Patients in the FL/PTX subgroup showed significantly better OS than those in the FL/BSC subgroup (median OS, 7.8 vs 2.0 months; hazard ratio [HR] 0.24, 95% confidence interval [CI] 0.12-0.48, p < 0.01) and equivalent OS compared to those in the FLTAX subgroup (median OS, 7.8 vs 8.0 months; HR 0.83, 95% CI 0.50-1.39, p = 0.49). Compared with patients in the FL/BSC subgroup, those in the FL/PTX subgroup had a trend for lower frequency of Glasgow prognostic score (GPS) 2 (40.0% vs 66.7%, p = 0.17) and unresectable type (76.0% vs 95.2%, p = 0.07). GPS 2 and unresectable type were identified as factors with a worse impact on LUSP compared to GPS 0 and recurrent type, with odds ratio (OR) of 0.29 (95% CI 0.05-1.78, p = 0.18) and that of 0.16 (95% CI 0.02-1.44, p = 0.10), respectively. Among all patients enrolled in the trial, 43 patients had both GPS2 and unresectable type (score 2), 45 had either (score 1), 11 had neither (score 0), and two lacked the data of GPS. Median OS in the patients with score 2, 1, and 0 was 4.7, 7.8, and 18.8 months, respectively (score 2 vs 0, HR 4.37, 95% CI 1.84-10.42; score 1 vs 0, HR = 2.80, 95% CI 1.19-6.64). Compared to FL, FLTAX showed better OS in patients with score 2 (HR = 0.60, 95% CI 0.32-1.13) and in those with score 1 (HR = 0.77, 95% CI 0.42-1.42), but worse OS in those with score 0 (HR = 4.74, 95% CI 0.49-45.85). Conclusions: Combination or sequential use of active two drugs, 5-FU and PTX, might contribute to better OS of GC patients with SPM. However, because selection of patients suitable to sequential use is difficult, the combination strategy FLTAX is a favorable treatment option.

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Risk of distal embolization with stent retriever thrombectomy and ADAPT

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2014-011491 ◽

2014 ◽

Vol 8 (2) ◽

pp. 197-202 ◽

Cited By ~ 98

Author(s):

Ju-Yu Chueh ◽

Ajit S Puri ◽

Ajay K Wakhloo ◽

Matthew J Gounis

Keyword(s):

Mechanical Thrombectomy ◽

Cerebral Arteries ◽

Treatment Strategies ◽

Stent Retriever ◽

Distal Embolization ◽

Guide Catheter ◽

Catheterization Technique ◽

Stent Retrievers ◽

Poor Outcomes ◽

Solitaire Fr

BackgroundThere is a discrepancy in clinical outcomes and the achieved recanalization rates with stent retrievers in the endovascular treatment of ischemic stroke. It is our hypothesis that procedural release of embolic particulate may be one contributor to poor outcomes and is a modifiable risk. The goal of this study is to assess various treatment strategies that reduce the risk of distal emboli.MethodsMechanical thrombectomy was simulated in a vascular phantom with collateral circulation. Hard fragment-prone clots (HFC) and soft elastic clots (SECs) were used to generate middle cerebral artery (MCA) occlusions that were retrieved by the Solitaire FR devices through (1) an 8 Fr balloon guide catheter (BGC), (2) a 5 Fr distal access catheter at the proximal aspect of the clot in the MCA (Solumbra), or (3) a 6 Fr guide catheter with the tip at the cervical internal carotid artery (guide catheter, GC). Results from mechanical thrombectomy were compared with those from direct aspiration using the Penumbra 5MAX catheter. The primary endpoint was the size distribution of emboli to the distribution of the middle and anterior cerebral arteries.ResultsSolumbra was the most efficient method for reducing HFC fragments (p<0.05) while BGC was the best method for preventing SEC fragmentation (p<0.05). The risk of forming HFC distal emboli (>1000 µm) was significantly increased using GC. A non-statistically significant benefit of direct aspiration was observed in several subgroups of emboli with size 50–1000 µm. However, compared with the stent-retriever mechanical thrombectomy techniques, direct aspiration significantly increased the risk of SEC fragmentation (<50 µm) by at least twofold.ConclusionsThe risk of distal embolization is affected by the catheterization technique and clot mechanics.

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Anchor technique: Use of stent retrievers as an anchor to advance thrombectomy catheters in internal carotid artery occlusions

Interventional Neuroradiology ◽

10.1177/1591019915609170 ◽

2015 ◽

Vol 21 (6) ◽

pp. 707-709 ◽

Cited By ~ 8

Author(s):

Jasmeet Singh ◽

Stacey Q Wolfe ◽

Rashid M Janjua ◽

Hirad Hedayat ◽

Christofer Burnette

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Mechanical Thrombectomy ◽

Stent Retriever ◽

Alternative Plan ◽

Stent Retrievers ◽

Technical Details ◽

Difficult Cases

In three recent cases of acute complete internal artery occlusions, we used stent retriever deployed through the mechanical aspiration/distal access catheters to achieve recanalization. In all cases the stent retriever was used as an anchor and supplemented mechanical thrombectomy. This report describes the technical details of the procedure and presents an alternative plan of action in difficult cases when standard thrombectomy techniques do not work.

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Ultra-distal access of the M1 segment with the 5 Fr Navien distal access catheter in acute (anterior circulation) stroke: is it safe and efficient?

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2016-012370 ◽

2016 ◽

Vol 9 (7) ◽

pp. 650-653 ◽

Cited By ~ 1

Author(s):

H Janssen ◽

M Killer-Oberpfalzer ◽

M Patzig ◽

G Buchholz ◽

J Lutz

Keyword(s):

Acute Stroke ◽

Mechanical Thrombectomy ◽

Catheter Placement ◽

Success Rates ◽

Anterior Circulation ◽

Distal Catheter ◽

Stroke Treatment ◽

Stent Retrievers ◽

Placement Success ◽

Anchoring Technique

Background and aimThe importance of mechanical thrombectomy in acute stroke treatment has grown over recent years. Mechanical thrombectomy comprises many different techniques. Technical improvements in the catheter material have led to the development of large-bore distal access catheters which can enter tortuous intracranial vessels. This has promising applications for endovascular stroke treatment. This study evaluated the safety and success rate of ultra-distal access of the middle cerebral artery (MCA) M1 segment with the 5 Fr Navien 58 distal access catheter in the treatment of acute stroke in combination with stent retrievers.MethodsWe retrospectively analyzed 81 patients with an acute stroke of the anterior circulation in whom ultra-distal access to the M1 segment was carried out using the Navien 58 catheter with an anchoring technique with a stent retriever for mechanical thrombectomy. Technical complications, success rates of catheter placement, success rates of thrombectomy using the modified Thrombolysis In Cerebral Infarction (mTICI) score, and the procedure times were evaluated.ResultsUltra-distal access with the Navien 58 was successful in 75% (61/81) of cases. Recanalization success with a mTICI score of 2b and better was achieved in 83% overall (67/81), in 90% (55/61) of cases with successful ultra-distal access and in 60% (12/20) of cases without ultra-distal access. No severe adverse effects such as dissections or perforations occurred as a result of the ultra-distal catheter placement in the M1 segment. In 4% (3/81) of the cases a reversible MCA vasospasm occurred.ConclusionsUltra-distal placement of the Navien 58 distal access catheter into the M1 segment in acute anterior circulation stroke can be achieved consistently, is safe in practice, and results in good recanalization success rates.

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Abstract WP58: Admission Blood Pressure and Infarct Volume in Patients With Large Vessel Occlusions. Insights From the ASTER Trial

Stroke ◽

10.1161/str.51.suppl_1.wp58 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Mohammad Anadani ◽

Bertrand Lapergue ◽

Michel Piotin ◽

Maéva Kyheng ◽

Julien Labreuche ◽

...

Keyword(s):

Blood Pressure ◽

Diffusion Weighted Imaging ◽

Mechanical Thrombectomy ◽

Infarct Volume ◽

Significant Negative Correlation ◽

Functional Independence ◽

Post Hoc Analysis ◽

Post Procedure ◽

The Difference ◽

Post Hoc

Background: Higher systolic blood pressure (SBP) has been shown to be associated with worse outcome after mechanical thrombectomy. However, it is still unknown if higher admission SBP is just an epiphenomenon of higher infarct volume leading to the worse outcome or if the SBP association with the outcome is independent of infarct volume. In this study, we aimed to study the correlation between admission SBP and both admission infarct volume and 24 change in infarct volume. Methods: This is a post hoc analysis of the ASTER randomized trial. Cuff admission SBP was measured on presentation prior to thrombectomy. Diffusion-weighted imaging (DWI) infarct volume was measured on admission and at 24-hours post-procedure. Delta volume was measured by calculating the difference between the admission and 24-hour DWI lesions. Results: A total of 126 patients (mean age was 68.9 ± 14.8 years, median NIHSS was 17 (IQR, 11 to 20), 66% received tPA and 87% achieved mTICI 2b-3 at the end of the procedure) had MRI on admission and were included in this study. There was weak and not statistically significant negative correlation between admission SBP and infarct volume (R=-0.15; P=0.08). We did not find any correlation between admission SBP and 24 hours delta infarct volume. On generalized logistic regression analysis adjusting for infarct volume, SBP was associated with 90-day functional independence (modified Rankin Scale <3) (OR,0.84; 95% CI, 0.70-0.99; p=0.049). Conclusion: We did not find a significant correlation between infarct volume on admission and admission SBP. Moreover, the association between admission SBP and functional outcome was independent of infarct volume.

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Abstract P517: The Effect of Unfavorable Vascular Anatomy on Mechanical Thrombectomy for Middle Cerebral Artery Occlusion Strokes Preliminary Evaluation of the AIM2 Score System

Stroke ◽

10.1161/str.52.suppl_1.p517 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Okkes Kuybu ◽

Mahmoud Mohammaden ◽

Diogo C Haussen ◽

Alhamza R Al-bayati ◽

Samir R Belagaje ◽

...

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Mechanical Thrombectomy ◽

Vascular Anatomy ◽

Preliminary Evaluation ◽

Vessel Occlusion ◽

Simple Method ◽

Score System ◽

Significant Difference ◽

The Impact

Background: Time to reperfusion remains one of the strongest predictors of outcome in large vessel occlusion strokes (LVOS). Herein, we aim to assess the impact of unfavorable vascular anatomy on mechanical thrombectomy (MT) number of passes and procedural times. Methods: Retrospectively review of a prospective MT database spanning January-July 2018 including acute LVOS involving the middle cerebral artery-M1 segment and available baseline CT angiography. The AIM2 score (Table 1) was applied with patients categorized as favorable (AIM2: 0-2) versus unfavorable (AIM2: >=3) anatomy. The primary outcome was the rate of <3 device passes. Secondary outcomes included procedural times and the rates of successful reperfusion (mTICI2b-3) and 90-day mRS 0-2. Safety measures included rates of sICH and 90-day mortality. Results: Patients with unfavorable anatomy (n=15) were significantly younger (52±19, p=0.02) and had lower rates of hypertension (46% vs 80%, p=0.01) and smoking (0% vs 39%, p<0.001) versus those with favorable anatomy (n=50). Successful reperfusion with <3 passes was more often achieved with AIM2 scores 0-2 vs. ≥3 (84% vs 60%, p=0.04). There were no significant difference in other outcome measures (Table 2). Conclusions: The AIM2 score system represents a simple method for the systematically evaluation of vascular anatomy in MT and correlates significantly with increased number of MT passes.

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