MeVO SAVE technique: initial experience with the 167 cm long NeuroSlider 17 for a combined approach in medium vessel occlusions (MeVOs)

Goyal et al described occlusions in M2/3, A2/3 and P2/3 as medium vessel occlusions (MeVOs); the only available controlled data of mechanical thrombectomy (MT) in MeVOs is limited to the middle cerebral artery M2 segment, suggesting that MT may be effective and safe with high functional independence and recanalization rates. The Stent retriever Assisted Vacuum-locked Extraction (SAVE) technique in mechanical thrombectomy consists of the simultaneous use of a stent retriever and a distal aspiration catheter (DAC), with the removal of both as a unit when performing the thrombectomy pass; however, so far the low-profile (0.035 inch distal inner diameter) DACs were longer (160 cm) than conventional 0.017 inch microcatheters for MeVOs. We present a case of a combined approach MT in MeVO with the use of the new 167 cm long NeuroSlider 17 (Acandis, Pforzheim, Germany) 0.0165 inch microcatheter and 3MAX (Penumbra, Alameda, CA) through the SAVE technique—the MeVO SAVE technique. (video 1).video 1.

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Applications of the Columbus steerable guidewire

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-018120 ◽

2021 ◽

pp. neurintsurg-2021-018120

Author(s):

Alexander von Hessling ◽

Tomás Reyes del Castillo ◽

Lutz Lehmann ◽

Justus Erasmus Roos ◽

Grzegorz Karwacki

Keyword(s):

Cerebral Artery ◽

Posterior Cerebral Artery ◽

Curvature Radius ◽

Content Type ◽

Complex Aneurysm ◽

Media Player ◽

First Case ◽

Great Support ◽

Basilar Tip Aneurysm ◽

Video Player

The Columbus steerable guidewire (Rapid Medical, Israel) is a 0.014 inch guidewire with a remotely controlled deflectable tip intended for neuronavigational purposes. 1 The tip can be shaped by pulling or pushing the handle. Pulling the handle decreases the radius (from 4 mm to 2 mm) and curves the tip, while pushing the handle increases the curvature radius and straightens the tip until it bends in the opposite direction. The amount of deflection is at the discretion of the operator. Video 1 The response of the Columbus guidewire to rotational movements is inferior to that of standard wires, and the tip is very soft and malleable but brings great support when bent. We present two cases where the Columbus guidewire was used. In the first case, the Columbus enabled us to probe a posterior cerebral artery arising from a giant basilar tip aneurysm without wall contact. In the second case, the Columbus was used as a secondary wire to help cannulate the pericallosal artery in a patient with a recurrent anterior complex aneurysm; this subsequently permitted successful stent-assisted coiling of the aneurysm.Video 1

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Mechanical Thrombectomy in Acute Ischemic Stroke: A Meta-analysis of Stent Retrievers Versus Direct Aspiration Versus a Combined Approach

Neurosurgery ◽

10.1093/neuros/nyz310_166 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Author(s):

Pavlos Texakalidis ◽

Stefanos Giannopoulos ◽

Theofilos Karasavvidis ◽

Leonardo Rangel-Castilla ◽

Dennis J Rivet ◽

...

Keyword(s):

Mechanical Thrombectomy ◽

Meta Analysis ◽

Stent Retriever ◽

Combined Approach ◽

First Line ◽

Symptomatic Intracerebral Hemorrhage ◽

Rescue Treatment ◽

Combined Use ◽

Stent Retrievers ◽

Event Rates

Abstract INTRODUCTION Recent randomized control trials (RCTs) established that mechanical thrombectomy is superior to medical therapy for patients with stroke. Stent retriever thrombectomy, direct aspiration and combined use of a stent retriever and aspiration have been alternatively used.The aim of this study was to compare the safety and efficacy profile of the different mechanical thrombectomy strategies. METHODS This study was performed according to the PRISMA guidelines. A random-effects model meta-analysis was conducted. RESULTS In all 21 studies with a total of 3059 patients were included. No differences were identified between the stent retriever and aspiration group in terms of modified thrombolysis in cerebral infarction (mTICI) 2b/3, mTICI 3 recanalization rates and favorable outcome (mRS = 2). Adverse event rates including 90-d mortality, symptomatic intracerebral hemorrhage (sICH), subarachnoid hemorrhage (SAH), parenchymal hematoma, new territory emboli, arterial dissection and perforation were similar between the stent retriever and direct aspiration group. Use of the stent retriever was associated with a higher risk of vasospasm (OR:2.59; 95% CI: 1.00-6.74; I2:0%) compared to direct aspiration. When compared with the direct aspiration group, the subgroup of patients who underwent mechanical thrombectomy with the combined approach as a first-line strategy had a higher likelihood of successful mTICI 2b/3 (OR: 1.76; 95% CI:1.23-2.52; I2: 5.5%) and mTICI 3 recanalization (OR: 2.29; 95% CI: 1.08-4.88; I2: 58%) although with a higher risk of SAH (OR: 4.33; 95% CI: 1.15-16.32; I2: -). In addition, patients who had thrombectomy with the combined approach as a rescue treatment after failure of first-line aspiration were at a significantly higher risk of sICH (OR: 3.49; 95% CI: 1.20-10.19; I2: 21.7%). CONCLUSION Stent retriever thrombectomy and direct aspiration were equally safe and effective. When compared with direct aspiration, the combined use of a stent retriever and aspiration as a first-line strategy was associated with higher mTICI 2b/3 and mTICI 3 recanalization rates although with a higher risk of 24-hr SAH.

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Use of Walrus balloon-guide catheter through sheathless radial approach for mechanical thrombectomy of right middle cerebral artery occlusion

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-017985 ◽

2021 ◽

pp. neurintsurg-2021-017985

Author(s):

Rimal H Dossani ◽

Muhammad Waqas ◽

Hamid H Rai ◽

Andre Monteiro ◽

Faisal Almayman ◽

...

Keyword(s):

Radial Artery ◽

Mechanical Thrombectomy ◽

Artery Occlusion ◽

Femoral Access ◽

Content Type ◽

Radial Approach ◽

Guide Catheter ◽

Ct Angiogram ◽

History Of ◽

Video Player

The literature demonstrates a favorable first pass effect with balloon-guide catheter (BGC) for mechanical thrombectomy. An 8F BGC is routinely used with femoral access. We present the first video report of 8F BGC advanced through the radial artery using a sheathless technique (video 1). An approximately 70-year-old patient presented with left-sided hemiplegia, neglect, and dysarthria. A CT angiogram demonstrated right M1 occlusion, and the patient underwent urgent mechanical thrombectomy. Radial approach was preferred owing to patient history of anticoagulation. A 6F Sim Select intermediate catheter was used to minimize the step off as the 8F BGC was advanced into the radial artery over an 035 exchange-length Advantage Glidewire. A skin nick over the Glidewire Advantage facilitated the introduction of the 8F BGC into the radial artery. Standard mechanical thrombectomy using a combination of stent retriever and aspiration catheter (Solumbra technique) was performed, and thrombolysis in cerebral infarction 3 recanalization was achieved after a single pass. The National Institutes of Health Scale score improved from 12 to 4, with mild left facial droop, dysarthria, and decreased speech fluency. The patient was discharged from the hospital on postoperative day 2. Ultrasound should be used for immediate assessment of radial artery size and conversion to femoral access without delay if the radial artery is less than 2.5 mm.Video 1

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Nautilus-assisted coil embolization for a complex AcomA wide-necked aneurysm in the setting of acute subarachnoid hemorrhage

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-017670 ◽

2021 ◽

pp. neurintsurg-2021-017670

Author(s):

Alexander Sirakov ◽

Svetozar Matanov ◽

Pervinder Bhogal ◽

Stanimir Sirakov

Keyword(s):

Subarachnoid Hemorrhage ◽

Coil Embolization ◽

Cerebral Aneurysms ◽

Anterior Communicating Artery ◽

New Approach ◽

Content Type ◽

Acute Subarachnoid Hemorrhage ◽

Inner Diameter ◽

Aneurysmal Neck ◽

Video Player

Numerous devices and sophisticated strategies have been developed to further increase the number of aneurysms amenable to endovascular treatment.1–4 Despite the superfluity of available neurovascular armamentarium, wide-necked bifurcation aneurysms can still pose a significant technical challenge to the treating clinician.5–7 Neck bridging is a conceptually new approach, which provides increased occlusion rates with lower recurrence and complications rates.8–10 The Nautilus (EndoStream Medical) is an intrasaccular bridging device intended to assist in coil embolization of wide-necked cerebral aneurysms. This CE-marked device, available in various sizes, consists of flexible-layers, and is a nitinol-based, detachable implant. The device is delivered through a standard microcatheter with a minimal 0.0165" inner diameter and is fully radiopaque and completely resheathable.Owing to its unique ‘tornado’ like shape the device entirely reconstructs the aneurysmal neck, which facilitates the following coil embolization. In this video 1, we demonstrate the use of Nautilus - assisted coil embolization for a complex anterior communicating artery (AcomA) wide-necked aneurysm in the setting of acute subarachnoid hemorrhage.Video 1

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Initial Experience With the Trevo NXT Stent Retriever

Frontiers in Neurology ◽

10.3389/fneur.2021.704329 ◽

2021 ◽

Vol 12 ◽

Author(s):

Manina M. Etter ◽

Markus Möhlenbruch ◽

Charlotte S. Weyland ◽

Carlos Pérez-García ◽

Manuel Moreu ◽

...

Keyword(s):

Mechanical Thrombectomy ◽

High Volume ◽

Stent Retriever ◽

Initial Experience ◽

First Line ◽

Pooled Data ◽

Primary Endpoints ◽

Time Period ◽

First Pass ◽

Secondary Endpoints

Background: The application of a new coating to the delivery wire of the Trevo retriever has the potential to improve its handling. We therefore report our initial experience with this new stent retriever for mechanical thrombectomy of large and medium vessel occlusions.Methods: We pooled data of four high-volume European stroke centers over the time period from October 2020 to February 2021. Patients were included in our study if the Trevo NXT stent retriever was used as a first-line device. Primary endpoints were first-pass near-complete or complete reperfusion, defined as mTICI score of ≥2c. Secondary endpoints were final reperfusion, National Institutes of Health Stroke Scale (NIHSS) at 24 h and discharge, device malfunctions, complications during the procedure, and subjective ratings of the interventionalists regarding device functionality.Results: Eighty patients (39 women, mean age 74 ± 14 years) were eligible for our study. Median NIHSS at admission was 15 (IQR, 8–19), and median Alberta Stroke Program Early CT Score at baseline was 9 (IQR, 8–10). In 74 (93%) patients a primary combined approach was used as first-line technique. First-pass near-complete reperfusion was achieved in 43 (54%) and first-pass complete reperfusion in 34 (43%) patients. Final near-complete reperfusion was achieved in 66 (83%) patients after a median of 1.5 (1–3) passes, while final successful reperfusion was observed in 96% of our cases. We observed no device malfunctions. Median NIHSS at discharge was 2 (IQR, 0–5), and 3 patients (4%) suffered a symptomatic intracranial hemorrhage.Conclusions: Based on our initial data, we conclude that the Trevo NXT is an effective and safe tool for mechanical thrombectomy especially when used for combined approaches.

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First-in-man experience of the Versi Retriever in acute ischemic stroke

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2018-014040 ◽

2018 ◽

Vol 11 (3) ◽

pp. 296-299 ◽

Cited By ~ 1

Author(s):

Nobuyuki Sakai ◽

Hirotoshi Imamura ◽

Hidemitsu Adachi ◽

Shoichi Tani ◽

So Tokunaga ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Stent Retriever ◽

Initial Experience ◽

Related Complication ◽

Anterior Circulation ◽

Clinical Trial Registration ◽

Institutional Review ◽

Angiographic Result

ObjectiveTo describe our initial experience with the Versi Retriever for mechanical thrombectomy in patients with acute ischemic stroke.MethodsThis study is a single-center, single-arm, first-in-man registry under institutional review board control to evaluate the efficacy and safety of the new stent retriever, the Versi Retriever. Patients with acute ischemic stroke were consecutively enrolled between September and November 2017. The clinical and procedural data were retrospectively analyzed. The angiographic result after the procedure was self-graded based on the Thrombolysis in Cerebral Infarction (TICI) scale by each operator.ResultsEleven patients with a mean age of 69.4 years were treated with the Versi Retriever. Median National Institutes of Health Stroke Scale score on admission was 16 (IQR 10–34). The occluded vessel was located in the anterior circulation in 81.8%. Revascularization rates of TICI 2b–3 and TICI 3 at final angiogram were achieved in 100% and 63.6%, respectively. A favorable functional outcome (modified Rankin Scale 0–2) at 90 days was obtained in 72.7%. No symptomatic intracranial hemorrhage occurred and no procedure-related complication was observed.ConclusionsOur initial experience suggests that the Versi Retriever is a safe and effective stent retriever for mechanical thrombectomy in patients with acute ischemic stroke.Clinical trial registrationNCT03366818

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Thrombectomy Technique Predicts Outcome in Posterior Circulation Stroke—Insights from the STAR Collaboration

Neurosurgery ◽

10.1093/neuros/nyaa179 ◽

2020 ◽

Vol 87 (5) ◽

pp. 982-991 ◽

Cited By ~ 2

Author(s):

Ali M Alawieh ◽

Maya Eid ◽

Mohammad Anadani ◽

Mithun Sattur ◽

Ilko L Maier ◽

...

Keyword(s):

International Study ◽

Star Collaboration ◽

Functional Independence ◽

Posterior Circulation ◽

Stent Retriever ◽

Combined Approach ◽

Clinical Predictors ◽

Anterior Circulation ◽

Lower Odds ◽

Basilar Occlusion

Abstract BACKGROUND Randomized controlled trials evaluating mechanical thrombectomy (MT) for acute ischemic stroke predominantly studied anterior circulation patients. Both procedural and clinical predictors of outcome in posterior circulation patients have not been evaluated in large cohort studies. OBJECTIVE To investigate technical and clinical predictors of functional independence after posterior circulation MT while comparing different frontline thrombectomy techniques. METHODS In a retrospective multicenter international study of 3045 patients undergoing MT for stroke between 06/2014 and 12/2018, 345 patients had posterior circulation strokes. MT was performed using aspiration, stent retriever, or combined approach. Functional outcomes were assessed using the 90-d modified Rankin score dichotomized into good (0-2) and poor outcomes (3-6). RESULTS We included 2700 patients with anterior circulation and 345 patients with posterior circulation strokes. Posterior patients (age: 60 ± 14, 46% females) presented with mainly basilar occlusion (80%) and were treated using contact aspiration or ADAPT (39%), stent retriever (31%) or combined approach (19%). Compared to anterior strokes, posterior strokes had delayed treatment (500 vs 340 min, P < .001), higher national institute of health stroke scale (NIHSS) (17.1 vs 15.7, P < .01) and lower rates of good outcomes (31% vs 43%, P < .01). In posterior MT, diabetes (OR = 0.28, 95%CI: 0.12-0.65), admission NIHSS (OR = 0.9, 95%CI: 0.86-0.94), and use of stent retriever (OR = 0.26, 95%CI: 0.11-0.62) or combined approach (OR = 0.35, 95%CI: 0.12-1.01) vs ADAPT were associated with lower odds of good outcome. Stent retriever use was associated with lower odds of good outcomes compared to ADAPT even when including patients with only basilar occlusion or with successful recanalization only. CONCLUSION Despite similar safety profiles, use of ADAPT is associated with higher rates of functional independence after posterior circulation thrombectomy compared to stent retriever or combined approach in large “real-world” retrospective study.

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Abstract WMP10: Comparison of 6 mm Diameter and 3-4 mm Diameter Stent Retrievers for Mechanical Thrombectomy in Acute Ischemic Stroke Patients. Is Bigger Better?

Stroke ◽

10.1161/str.48.suppl_1.wmp10 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Ameer E Hassan ◽

Christina Sanchez ◽

Asad Ahrar ◽

Saqib A Chaudhry ◽

Adnan I Qureshi

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Functional Independence ◽

Stent Retriever ◽

Optimal Size ◽

Stroke Patients ◽

Nihss Score ◽

Significant Difference ◽

Stent Retrievers

Background: There is controversy regarding the optimal size of stent retriever for achieving timely recanalization in acute ischemic stroke patients. Objective: To determine the relationship between stent retriever diameter and procedure time, and rates of recanalization, and functional independence among acute ischemic stroke patients undergoing mechanical thrombectomy. Methods: We analyzed data from consecutive acute ischemic stroke patients treated with mechanical thrombectomy derived from a prospective database. Baseline demographic and clinical characteristics, NIHSS score on admission and discharge, intracranial hemorrhage occurrence, and mRS at discharge were analyzed. Thrombolysis In Cerebral Infarction (TICI) scale was used to grade pre and post procedure angiographic recanalization. Procedural time was defined by the time interval between microcatheter placement and recanalization. We compared the rates of thrombectomy attempts, complete recanalization (TICI grade of 3), and functional independence (defined by mRS 0-2) between patients treated with 6 mm and 3-4 mm diameter stent retrievers. Results: A total of 230 acute ischemic stroke patients (mean age 71.8 ±12.5; 46.6% women) were treated with stent retrievers. Thrombectomy was performed with a 6mm diameter stent retriever in 107 patients and 3 or 4 mm diameter stent retriever in 123 patients. There were no statistically significant differences in demographics or baseline characteristics, or admission NIHSS score between the two groups. There was a trend towards a fewer number of thrombectomy attempts required with a 6mm diameter stent retriever (p=0.06). There was a higher rate of complete recanalization in patients treated with 6mm diameter stent retriever compared with 3 or 4 mm diameter stent retriever (72% vs 57.7% p=0.02). There was no statistically significant difference in rates of functional independence between the two groups (24.3% vs 25.2% p=0.84) at discharge. Conclusion: Among acute ischemic stroke patients undergoing mechanical thrombectomy, use of a 6 mm diameter stent retriever was associated with a higher rate of complete recanalization and a lower number of thrombectomy attempts compared with 3-4 mm diameter stent retrievers.

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Abstract TP15: A Multicenter Study Comparing Solumbra to Standard Aspiration and Stent Retriever Thrombectomy

Stroke ◽

10.1161/str.51.suppl_1.tp15 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

David J McCarthy ◽

Vasu Saini ◽

Stephanie Chen ◽

Evan Luther ◽

Dallas Sheinberg ◽

...

Keyword(s):

Linear Regression ◽

Mechanical Thrombectomy ◽

Star Collaboration ◽

Functional Independence ◽

Stent Retriever ◽

P Value ◽

Regression Analyses ◽

Procedure Time ◽

Aspiration Thrombectomy ◽

Lower Likelihood

Background: Standard mechanical thrombectomy (MT) techniques utilized include aspiration thrombectomy (ADAPT), stent retriever (SR), and a combination of both (Solumbra). Many studies compare outcomes between ADAPT and SR; however, there has yet to be a large multicenter investigation comparing ADAPT and SR to Solumbra. Methods: All patients from the participating STAR collaboration who underwent MT from 2015-2019 were included. Patients were analyzed by first MT technique utilized (ADAPT, SR, or Solumbra). Univariable and multivariable linear regression was utilized to analyze the MT technique association to number of thrombectomy attempts and procedure time. Univariable and multivariable logistic regression was utilized to determine the association between MT technique and the following outcomes: recanalization, symptomatic hemorrhage, 90-day functional independence, or 90-day mortality. P value less than 0.5 was considered significant. Results: A total of 2515 MT for stroke were identified: 1155 (46%) ADAPT, 735 (29%) SR, 625 (25%) Solumbra. Patients who received Solumbra MT were older (p<0.001), had higher IV-tPA administration rates (p<0.01), and lower onset-groin times (p<0.01). Separate multivariable linear regression analyses revealed that Solumbra technique had significantly high procedure times (OR 10.2, p<0.001) but less thrombectomy attempts (OR -0.8, p<0.001) compared to other MT techniques. There was no difference in recanalization success between techniques (ADAPT 85%, SR 84%, Solumbra 86%). Compared to Solumbra, ADAPT and SR thrombectomy had significantly lower incidence of symptomatic hemorrhage (ADAPT OR 0.32, p=0.009; SR OR 0.39, p=0.039) and ADAPT had a significantly lower likelihood of mortality (OR 0.50, p<0.001). There was no difference in 90-day functional independence (mRS≤2) rates between MT techniques. Conclusion: Compared to standard ADAPT and SR thrombectomy, the Solumbra technique for MT is a longer procedure that results in an increased likelihood of hemorrhage and 90-day mortality.

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Mechanical thrombectomy using a Solitaire stent retriever in the treatment of pediatric acute ischemic stroke

Journal of Neurosurgery Pediatrics ◽

10.3171/2018.9.peds18242 ◽

2019 ◽

Vol 23 (3) ◽

pp. 363-368 ◽

Cited By ~ 1

Author(s):

Bing Zhou ◽

Xiao-Chuan Wang ◽

Jun-Yi Xiang ◽

Ming-Zhao Zhang ◽

Bo Li ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Balloon Dilation ◽

Stent Retriever ◽

National Institutes Of Health ◽

Clinical Prognosis ◽

Nihss Score ◽

Grade 3

OBJECTIVEMechanical thrombectomy using a Solitaire stent retriever has been widely applied as a safe and effective method in adult acute ischemic stroke (AIS). However, due to the lack of data, the safety and effectiveness of mechanical thrombectomy using a Solitaire stent in pediatric AIS has not yet been verified. The purpose of this study was to explore the safety and effectiveness of mechanical thrombectomy using a Solitaire stent retriever for pediatric AIS.METHODSBetween January 2012 and December 2017, 7 cases of pediatric AIS were treated via mechanical thrombectomy using a Solitaire stent retriever. The clinical practice, imaging, and follow-up results were reviewed, and the data were summarized and analyzed.RESULTSThe ages of the 7 patients ranged from 7 to 14 years with an average age of 11.1 years. The preoperative National Institutes of Health Stroke Scale (NIHSS) scores ranged from 9 to 22 with an average of 15.4 points. A Solitaire stent retriever was used in all patients, averaging 1.7 applications of thrombectomy and combined balloon dilation in 2 cases. Grade 3 on the modified Thrombolysis In Cerebral Infarction scale of recanalization was achieved in 5 cases and grade 2b in 2 cases. Six patients improved and 1 patient died after thrombectomy. The average NIHSS score of the 6 cases was 3.67 at discharge. The average modified Rankin Scale score was 1 at the 3-month follow-up. Subarachnoid hemorrhage after thrombectomy occurred in 1 case and that patient died 3 days postoperatively.CONCLUSIONSThis study shows that mechanical thrombectomy using a Solitaire stent retriever has a high recanalization rate and excellent clinical prognosis in pediatric AIS. The safety of mechanical thrombectomy in pediatric AIS requires more clinical trials for confirmation.

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