Carotid artery direct access for mechanical thrombectomy: the Carotid Artery Puncture Evaluation (CARE) study

2021 ◽  
pp. neurintsurg-2021-017935
Author(s):  
Victor Dumas ◽  
Johannes Kaesmacher ◽  
Julien Ognard ◽  
Géraud Forestier ◽  
Cyril Dargazanli ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Vascular Access ◽  
Mechanical Thrombectomy ◽  
High Rate ◽  
Direct Access ◽  
Closure Device ◽  
Vessel Occlusion ◽  
Multicentric Study ◽  
Complication Risk ◽  
Care Study

BackgroundIn acute ischemic stroke due to anterior large vessel occlusion (AIS-LVO), accessing the target occluded vessel for mechanical thrombectomy (MT) is sometimes impossible through the femoral approach. We aimed to evaluate the safety and efficacy of direct carotid artery puncture (DCP) for MT in patients with failed alternative vascular access.MethodsWe retrospectively analyzed data from 45 stroke centers in France, Switzerland and Germany through two research networks from January 2015 to July 2019. We collected physician-centered data on DCP practices and baseline characteristics, procedural variables and clinical outcome after DCP. Uni- and multivariable models were conducted to assess risk factors for complications.ResultsFrom January 2015 to July 2019, 28 149 MT were performed, of which 108 (0.39%) resulted in DCP due to unsuccessful vascular access. After DCP, 77 patients (71.3%) had successful reperfusion (modified Thrombolysis In Cerebral Infarction (mTICI) score ≥2b) and 28 (25.9%) were independent (modified Rankin Scale (mRS) score 0–2) at 3 months. 20 complications (18.5%) attributed to DCP occurred, all of them during or within 1 hour of the procedure. Complications led to extension of the intubation time in the intensive care unit in 7 patients (6.4%) and resulted in death in 3 (2.8%). The absence of use of a hemostatic closure device was associated with a higher complication risk (OR 3.04, 95% CI 1.03 to 8.97; p=0043).ConclusionIn this large multicentric study, DCP was scantly performed for vascular access to perform MT (0.39%) in patients with AIS-LVO and had a high rate of complications (18.5%). Our results provide arguments for not closing the cervical access by manual compression after MT.

Abstract WP20: Efficacy and Safety of Mechanical Thrombectomy in Emergent Large Vessel Occlusions with Concomitant Cervical Internal Carotid Artery Occlusion

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Nitin Goyal ◽  
Georgios Tsivgoulis ◽  
Abhi Pandhi ◽  
Yasser M Khorchid ◽  
Abhishek Ojha ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Mechanical Thrombectomy ◽  
Large Vessel ◽  
Efficacy And Safety ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Aspiration Thrombectomy ◽  
Cervical Internal Carotid Artery

Introduction: Recently, five published major randomized controlled clinical trials have demonstrated that timely mechanical thrombectomy (MT) of acute ischemic strokes (AIS) with emergent large vessel occlusion (ELVO) is safe and improves functional outcomes. However, data evaluating the efficacy and safety of MT in ELVO patients with concomitant cervical internal carotid artery (cICA) occlusion is limited. The purpose of this study is to evaluate efficacy and safety of MT in ELVO patients with concomitant cICA occlusion Methods: We prospectively analyzed consecutive AIS patients with anterior circulation ELVO who underwent stent-retriever or primary aspiration thrombectomy at two tertiary stroke centers. Outcome measures in our study were 3-month mortality and modified ranking scale (mRS), as well as symptomatic intracranial hemorrhage (sICH). Safety and efficacy outcomes were compared between ELVO patients with and without concomitant cICA occlusion. Results: A total of 137 AIS patients had anterior circulation ELVO and underwent MT (age 63 ± 14, 49% male, median NIHSS 17, IQR [13-20]). ELVO patients with concomitant cICA occlusion (n=19) did not differ in terms of rates of sICH (0% versus 11%, p=0.21), complete recanalization (68 % versus 68%, p=1.00), onset to groin puncture time (minutes [IQR] 268 [211-379] versus 225 [165-312], p=0.47), 3-month mortality (35% versus 26 %, p=0.55), and mRS of 0-2 at 3 months (41% versus 45%, p=0.80) when compared with ELVO patients without concomitant cICA occlusion (n=118). Admission NIHSS was higher among ELVO patients with concomitant cICA occlusion (median [IQR], 18 [15-22] versus 16 [12-19], p=0.01), and they tended to have higher groin puncture to recanalization time (minutes [IQR] 74 [42-97] versus 49 [38-78], p=0.09). The ordinal shift analysis did not show any difference in favorable outcomes in two groups in unadjusted analyses or after adjustment for admission NIHSS and groin to recanalization time (common OR=0.78 [95% CI: 0.27-2.29, p=0.66]). Angioplasty was performed in 11 of 19 ELVO patients with concomitant cICA occlusion. Three patients required stent placement. Discussion: Our study indicates that MT can be performed safely and effectively in ELVO patients with concomitant cICA occlusion.

scholarly journals Thrombectomy by primary aspiration technique in a patient with critical internal carotid artery stenosis

2021 ◽  
Author(s):  
Yasmim Nadime José Frigo ◽  
Hendrick Henrique Fernandes Gramasco ◽  
Igor Oliveira Fonseca ◽  
Mateus Felipe dos Santos ◽  
Rodrigo Bazan ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Mechanical Thrombectomy ◽  
Large Vessel ◽  
Neurological Deficits ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Clinical Prognosis ◽  
Aspiration Technique

Context: Stroke is one of the main leaders of death and disability in the world. Currently, mechanical thrombectomy with stent retrievers is the technique of choice for large vessel occlusion, however, the primary aspiration technique has been proposed as a fast and safe alternative. Case report: J.E.M, male, 57 years old, hypertensive, atrial fibrillation. Started claudication of neurological deficits, with intermittent paresthesia in left upper limb for 2 days. Admitted with NIHSS 2 (nasolabial sulcus erasure and hypoesthesia in LUL), in thrombolysis window, has seen in cerebral and neck angiotomography critical stenosis of the internal carotid artery and in CT scan with perfusion Mismatch volume 72 ml and infinite ratio. Since the patient did not have sufficient criteria for thrombolysis and since the clinical prognosis was unfavorable, a diagnostic arteriography was indicated, which showed ICAR stenosis 90%. The patient proceeded with angioplasty and stenting using the ADPAT technique and mechanical thrombectomy due to occlusion in segment M1 with total recanalization (TICI 3) and NIHSS after and at discharge of 0. Conclusion: The advent of thrombectomy impacts the improvement of functional dependence and the reduction of mortality, especially in stroke with large vessel occlusion, whose treatment with thrombolytic therapy only has a low chance of recanalization.

scholarly journals Reasons for Failed Mechanical Thrombectomy in Posterior Circulation Ischemic Stroke Patients

2020 ◽  
Author(s):  
Charlotte S. Weyland ◽  
Ulf Neuberger ◽  
Arne Potreck ◽  
Johannes A. R. Pfaff ◽  
Simon Nagel ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Mortality Rate ◽  
Vascular Access ◽  
High Mortality ◽  
Mechanical Thrombectomy ◽  
Posterior Circulation ◽  
Target Vessel ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Stroke Etiology

Abstract Background and Purpose To determine reasons for failed recanalization in mechanical thrombectomy (MT) of the posterior circulation. Methods Retrospective single center analysis of reasons for MT failure in the posterior circulation. Failed MTs were categorized according to the reason for procedure failure in failed vascular access, failed passage of the target vessel occlusion and MT failure after passing the occluded target vessel. Patient characteristics were compared between failed and successful MT. Results Patients with failed MT (30/218 patients, 13.8%) were categorized into futile vascular access (13/30, 43.3%), abortive passage of the target vessel occlusion (6/30, 20.0%) and MT failure after passing the vessel occlusion (11/30, 36.7%). In 188/218 (86.2%) successful MTs alternative vascular access, local intra-arterial (i.a.) thrombolysis and emergency stent-assisted PTA prevented 65 MT failures. Patients with failed MT showed a higher NIHSS at discharge, a higher pc-ASPECTS in follow-up imaging, a higher mRS 90 days after stroke onset and a high mortality rate of 77.0% (mRS at 90 days, median (IQR): 6 (6–6) vs. 4 (2–6) for successful MT, p-value < 0.001). Co-morbidities and stroke etiology were not different compared to sufficient recanalization with atherosclerotic disease as the leading stroke etiology in both groups. Conclusion Failure of MT in posterior circulation ischemic stroke patients is associated with a high mortality rate. Reasons for MT failure are diverse with futile vascular access and MT failure after passing the vessel occlusion as the leading causes. Alternative vascular access, local i.a. thrombolysis and stent-assisted PTA can prevent MT failure.

scholarly journals Endovascular Treatment of Stroke Caused by Carotid Artery Dissection

2020 ◽  
Vol 10 (11) ◽  
pp. 800
Author(s):  
Grzegorz Meder ◽  
Milena Świtońska ◽  
Piotr Płeszka ◽  
Violetta Palacz-Duda ◽  
Dorota Dzianott-Pabijan ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Carotid Artery ◽  
Endovascular Treatment ◽  
Small Proportion ◽  
Mechanical Thrombectomy ◽  
Carotid Artery Dissection ◽  
Large Vessel ◽  
Artery Dissection ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion

Ischemic stroke due to large vessel occlusion (LVO) is a devastating condition. Most LVOs are embolic in nature. Arterial dissection is responsible for only a small proportion of LVOs, is specific in nature and poses some challenges in treatment. We describe 3 cases where patients with stroke caused by carotid artery dissection were treated with mechanical thrombectomy and extensive stenting with good outcome. We believe that mechanical thrombectomy and stenting is a treatment of choice in these cases.

scholarly journals Carotid Artery Perivascular Adipose Tissue Density Relates to Recanalization and Clinical Outcome After Mechanical Thrombectomy

2021 ◽  
Vol 13 ◽  
Author(s):  
Jiaolei Jin ◽  
Rui Huang ◽  
Qiuyue Chen ◽  
Boxi Ke ◽  
Taotao Tao ◽  
...  
Keyword(s):  
Adipose Tissue ◽  
Carotid Artery ◽  
Functional Outcome ◽  
Mechanical Thrombectomy ◽  
Surrogate Marker ◽  
Independent Effect ◽  
Large Artery ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Perivascular Adipose Tissue

Background: Perivascular adipose tissue (PVAT) imaging can be used in clinical practice as a surrogate marker of vascular disease. We aimed to analyze the association between the density of carotid artery PVAT and clinical features and outcomes in stroke patients treated with mechanical thrombectomy.Methods: A total of 183 consecutive patients treated with mechanical thrombectomy due to anterior circulation large vessel occlusion were retrospectively included from January 2016 to May 2021. The density of carotid artery PVAT was evaluated by preoperative computed tomography angiography. Successful arterial recanalization was defined as a modified Thrombolysis in Cerebral Infarction score of 2b-3 on the final angiographic examination. Poor functional outcome was defined as a modified Rankin Scale (mRS) score &gt; 2 at 3 months after stroke. We assessed the independent effect of carotid artery PVAT density on revascularization, functional outcome, and mortality using logistic regression models adjusted for relevant confounders.Results: Patients with large artery atherosclerotic stroke have higher carotid artery PVAT density than patients with other stroke etiologies (–65.82 ± 12.96 vs. –75.77 ± 13.44, P &lt; 0.001). Higher carotid artery PVAT density was associated with unsuccessful recanalization [adjusted odds ratio (AOR) (95% CI), 2.968 (1.292, 6.819), P = 0.010], and poor outcome [AOR (95% CI), 2.704 (1.610, 4.541), P &lt; 0.001] and mortality [AOR (95% CI), 1.894 (1.040, 3.449), P = 0.037] at 3 months in stroke patients treated with thrombectomy.Conclusion: Higher carotid artery PVAT density before mechanical thrombectomy is an indicator of worse postprocedural arterial revascularization and a worse functional outcome in acute stroke patients.

Abstract 1122‐000085: Endovascular Treatment of Acute Extracranial ICA Strokes – A Systematic Review and Pooled Analysis

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Ammad A Baig ◽  
Ammad A Baig ◽  
Andre Monteiro ◽  
Muhammad Waqas ◽  
Rimal H Dossani ◽  
...  
Keyword(s):  
Systematic Review ◽  
Carotid Artery ◽  
Endovascular Treatment ◽  
Pooled Analysis ◽  
High Rate ◽  
Endovascular Management ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Meta Analyses ◽  
Tandem Lesions

Introduction : Ischemic stroke secondary to acute extracranial internal carotid artery (EC‐ICA) occlusion with a concurrent intracranial anterior circulation large vessel occlusion (tandem lesions) account for approximately 20% of all stroke cases. Endovascular management includes acute carotid artery stenting (CAS) with or without balloon angioplasty for pure EC‐ICA occlusions and concurrent mechanical thrombectomy (MT) for tandem lesions. In lieu of the scarcity of randomized data and abundance of observational studies, we intend to perform a systematic review and pooled analysis of the data over the past decade to evaluate clinical outcomes, safety and feasibility of endovascular management of acute EC‐ICA strokes. Methods : Systematic search of the Pubmed, MEDLINE, and EMBASE databases was conducted based on Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines. We performed a systematic review of all acute EC‐ICA stroke papers (including tandem lesions) published between January 2010 and December 2020. A pooled analysis of the extracted data was performed. Results : Data from 1153 patients from 22 studies were pooled and analyzed. Mean age after pooling was 66.9 years, mean NIHSS at admission was 15.9, % IV tPA use before endovascular intervention was seen 56.1% of studies. 82.8% of subjects had a tandem lesion involving both Extracranial and intracranial part of ICA and only 17.2% had a pure and isolated EC‐ICA lesion. Angioplasty + stenting (both) was done in 77.6% of cases. Pooling was also done for any and all approaches taken in case of a tandem lesion i.e. anterograde or retrograde. Anterograde approach was taken in 61.7% of cases whereby CAS was performed first followed by MT. Outcome measures were reported as successful recanalization (TICI ≥ 2B) in 80.0% of cases, with good outcome (90‐day mRS <2) in 49.6% and a mortality rate of 12.9%. Conclusions : Our systematic review for endovascular treatment of EC‐ICA strokes found a high rate of good outcomes and an impressive rate for recanalization, with low mortality rates. Since these results are from observational, retrospective studies, more rigorous randomized trials are required to establish the best approach.

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