Retrograde Angiography to Detect Dropped Thrombus in Mechanical Thrombectomy

2021 ◽  
pp. 159101992110527
Author(s):  
Kazuaki Aoki ◽  
Yoichi Miura ◽  
Naoki Toma ◽  
Yume Suzuki ◽  
Masashi Fujimoto ◽  
...  
Keyword(s):  
Mechanical Thrombectomy ◽  
Stent Retriever ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Inflated Balloon ◽  
Novel Technique ◽  
Catheter Tip ◽  
Contrast Medium Injection ◽  
Guiding Catheter

Objective The risk of embolization to distal territory or to new territory in mechanical thrombectomy remains a major issue despite advancements in technological device. This condition can be caused by a large and firm dropped thrombus without passing through a guiding catheter during stent retriever or aspiration catheter withdrawal. This report introduced a novel technique referred to as retrograde angiography to detect dropped thrombus. Methods The retrograde angiography to detect dropped thrombus technique is a kind of retrograde angiography that consists of a contrast medium injection via a distal microcatheter and aspiration through an inflated balloon-guiding catheter. This method was used to detect dropped thrombus at the balloon-guiding catheter tip when back flow was blocked from the balloon-guiding catheter after stent retriever or aspiration catheter withdrawal. We retrospectively reviewed four consecutive patients who underwent the retrograde angiography to detect dropped thrombus technique during mechanical thrombectomy for acute ischemic stroke due to large vessel occlusion in the anterior circulation between January 2018 and January 2021. Results Three of four patients had dropped thrombus, which was diagnosed with the technique and retrieved completely with subsequent procedures while maintaining the balloon-guiding catheter inflated. None of the patients experienced embolization to distal territory/embolization to new territory, and a successful reperfusion was achieved in all four cases. Conclusions The retrograde angiography to detect dropped thrombus is a technique to detect a dropped thrombus at the balloon-guiding catheter tip and allows us to retrieve it with subsequent mechanical thrombectomy procedures while maintaining the balloon-guiding catheter inflated and it may be useful for reducing the risk of embolization to distal territory/embolization to new territory.

First-line use of contact aspiration for thrombectomy versus a stent retriever for recanalization in acute cerebral infarction: The randomized ASTER study protocol

2017 ◽  
Vol 13 (1) ◽  
pp. 87-95 ◽  
Author(s):  
Bertrand Lapergue ◽  
Julien Labreuche ◽  
Raphael Blanc ◽  
Xavier Barreau ◽  
Jérome Berge ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Cerebral Infarction ◽  
Primary Outcome ◽  
Mechanical Thrombectomy ◽  
Stent Retriever ◽  
Treatment Technique ◽  
Large Vessel Occlusion ◽  
First Line ◽  
Anterior Circulation ◽  
Vessel Occlusion

Rationale Mechanical thrombectomy with a stent retriever is now the standard of care in anterior circulation ischemic stroke caused by large vessel occlusion. New techniques for mechanical thrombectomy, such as contact aspiration, appear promising to increase reperfusion status and improve clinical outcome. Aim We aim at ascertaining whether contact aspiration is more efficient than the stent retriever as a first-line endovascular procedure. Sample size estimates With a two-sided test (alpha = 5%, power = 90%) and an anticipated rate of spontaneous recanalization and catheterization failures of 15%, we estimate that a sample size of 380 patients will be necessary to detect an absolute difference of 15% in primary outcome (superiority design). Methods and design The ASTER trial is a prospective, randomized, multicenter, controlled, open-label, blinded end-point clinical trial. Patients admitted with suspected ischemic anterior circulation stroke secondary to large vessel occlusion, with onset of symptoms <6 h, will be randomly assigned to contact aspiration or stent retriever in a 1:1 ratio; stratified by center and prior IV thrombolysis. If the assigned treatment technique is not successful after three attempts, another technique will be applied, at the operator’s discretion. Study outcomes The primary outcome will be successful recanalization (modified Thrombolysis in Cerebral Infarction score 2b–3) at the end of the endovascular procedures. Secondary outcome will include successful recanalization after the assigned first-line treatment technique alone, procedural times, the need for a rescue technique, complications and modified Rankin Scale at three months. Discussion No previous head to head randomized trials have directly compared contact aspiration versus stent retriever reperfusion techniques. This prospective trial aims to provide further evidence of benefit of contact aspiration versus stent retriever techniques among patients with ischemic stroke.

scholarly journals Inadvertent Stent Retriever Detachment: A Multicenter Case Series and Review of Device Experience FDA Reports

2015 ◽  
Vol 4 (3-4) ◽  
pp. 75-82 ◽  
Author(s):  
Hesham Masoud ◽  
Thanh N. Nguyen ◽  
Coleman O. Martin ◽  
William E. Holloway ◽  
Sudheer Ambekar ◽  
...  
Keyword(s):  
First Generation ◽  
Mechanical Thrombectomy ◽  
Rare Complication ◽  
Case Series ◽  
Standard Of Care ◽  
Stent Retriever ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
The Us ◽  
Solitaire Fr

Mechanical thrombectomy using retrievable stents or stent retriever devices has become the mainstay of intra-arterial therapy for acute ischemic stroke. The recent publication of a series of positive trials supporting intra-arterial therapy as standard of care for the treatment of large vessel occlusion will likely further increase stent retriever use. Rarely, premature stent detachment during thrombectomy may be encountered. In our multicenter case series, we found a rate of detachment of less than 1% (n = 7/1,067), and all were first-generation Solitaire FR devices. A review of the US Food and Drug Administration database of device experience yielded 90 individual adverse reports of detachment. There were 82, 1 and 7 detachments of Solitaire FR (first generation), Solitaire FR2 (second generation) and Trevo devices, respectively. We conclude with a brief overview of the technical and procedural considerations which may be helpful in avoiding this rare complication.

Abstract WP290: Endovascular Treatment Of In-hospital Strokes: An Open Book

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Dolora Wisco ◽  
KEN UCHINO ◽  
ESTEBAN CHENG CHING ◽  
Shazia Alam ◽  
SHUMEI MAN ◽  
...  
Keyword(s):  
Mechanical Thrombectomy ◽  
Patient Characteristics ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Valve Repair ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Ct Brain ◽  
Contrast Ct ◽  
Iv Tpa

INTRODUCTION: In-hospital stroke (IHS) presents a different treatment challenge than out of hospital stroke. IHS often has contraindication to IV tPA, such as such as recent surgery, MI, and use of anticoagulation. Intra-arterial therapy (IAT) with tPA and/or mechanical thrombectomy is an option for large vessel acute IHS with contraindications to or fail to recanalize with IV tPA, to restore cerebral perfusion. Objective: To assess the characteristics and outcomes of patients with in-hospital strokes large vessel occlusion who receive IAT. Methods: From our database of patients from 1/1/2008 to 12/31/2011 who had IAT for an acute stroke due to large vessel occlusion, in hospital strokes and out of hospital strokes were identified. Patient characteristics, imaging, and outcomes were retrospectively collected. Statistical analysis was performed on JMP 9.0. Result: 151 patients were included, 23 (15%) were in-hospital strokes (IHS) and 128 (85%) were out of hospital strokes (OHS). Initial median NIHSS of 17 and 16 respectively (p=0.3). IHS were frequently in the cardiology/CTS service (14, 60%) for CHF and cardiac valve repair (12, 52%). Other comorbidities present were atrial fibrillation (68%), hypertension (68%), and hyperlipidemia (56%). Seven (30%) were on warfarin prior to admission, but all had subtherapeutic INR. Three (13%) IHS received IV tPA. The time from last known well (LKW) to non-contrast CT brain was 80 min, and to CTA was 113 min in IHS, and 147 min and 229 min respectively in OHS (p = 0.0003). 20 (87%) had lesion in the anterior circulation. LKW to IAT recanalization was 248 min in IHS, compared to 375 min in OHS. Recanalization rate was 68% for IHS and 81% for OHS (p=0.2). Nine (39%) IHS had favorable mRS of 1 to 3 at 90 days, compared to 44 (34%) OHS, (p = 0.6). Despite faster recanalization time, there was no difference in the 90 day mortality of IHS v OHS (48% vs 30%, p = 0.1), and IHS had greater 1 year mortality (65% vs 30%, p = 0.005). Discussion: In-hospital strokes have higher mortality than out of hospital strokes. There is a role for IAT In carefully selected IHS with large vessel occlusion. A multicenter study is needed to reveal the characteristics of IHS patients who may benefit from IAT.

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.

Abstract WP502: Predictors Of First Pass Reperfusion In Anterior Circulation Large Vessel Occlusion Stroke

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Mahmoud Mohammaden ◽  
Leonardo Pisani ◽  
Catarina Perry da Camara ◽  
Mehdi Bousalma ◽  
Alhamza Al bayati ◽  
...  
Keyword(s):  
Mechanical Thrombectomy ◽  
Univariate Analysis ◽  
Multivariate Regression Analysis ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Performance Metric ◽  
First Pass ◽  
Thrombectomy Device

Introduction: The speed and completeness of endovascular reperfusion strongly correlate with functional outcomes. First-Pass Reperfusion (FPR) has been recently established as a critical procedural performance metric for mechanical thrombectomy (MT). We aimed to study the predictors of FPR and its effect on the outcome Methods: Review of a prospectively collected database of MT patients with large vessel occlusion strokes (LVOS) from 05/2012-11/2018. Patients were included in the analysis if they had an anterior circulation LVOS that was successfully reperfused (mTICI 2b-3). FPR was defined as the achievement of mTICI 2c-3 after a single pass with any thrombectomy device. Uni- and multivariate analyses were performed to identify the independent predictors of FPR. Results: A total of 563 patients qualified for the analysis (mean age, 64.4±12.3 years, baseline NIHSS 16.2). FPR was achieved in 202 (35.9%) patients. On univariate analysis, FPR was significantly associated with higher ASPECTS (8.1 vs. 7.8, p=0.008), higher usage of balloon guide catheters (BGC) (88.1% vs. 75.3%, p<0.001), lower use of general anesthesia (9.5% vs. 18.2%, p= 0.006), and shorter procedure duration (mean, 45.5 vs. 79.9 min, p <0.001 and 90.5%). Both BGC (OR, 2.26; 95%CI [1.32-3.87], p=0.003) and ASPECTS (OR, 1.15; 95% CI [1.03-1.28], p= 0.01) were independent predictors of FPE on multivariate regression analysis. Conclusion: Higher baseline ASPECTS score and the use of BGC are strong predictors of First-Pass Reperfusion in mechanical thrombectomy.

Combined use of contact aspiration and the stent retriever technique versus stent retriever alone for recanalization in acute cerebral infarction: the randomized ASTER 2 study protocol

2020 ◽  
Vol 12 (5) ◽  
pp. 471-476 ◽  
Author(s):  
Bertrand Lapergue ◽  
Julien Labreuche ◽  
Raphaël Blanc ◽  
Gaultier Marnat ◽  
Arturo Consoli ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Cerebral Infarction ◽  
Endovascular Treatment ◽  
Scale Score ◽  
Stent Retriever ◽  
Large Vessel Occlusion ◽  
First Line ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Combined Use

RationaleMechanical thrombectomy (MT) using a stent retriever (SR) device is currently the recommended treatment in ischemic stroke due to anterior circulation large vessel occlusion. Combining contact aspiration (CA) with SR is a promising new treatment, although it was not found to be superior to SR alone as first-line treatment for achieving successful reperfusion.AimTo determine whether endovascular treatment combining first-line use of CA and SR is more efficient than SR alone.MethodsThe ASTER 2 clinical trial is a prospective, randomized, multicenter, open-label trial with a blinded endpoint. We included patients admitted with suspected anterior circulation ischemic stroke secondary to large vessel occlusion <8 hours from symptom onset. They were randomly allocated in a 1:1 ratio to one of two treatment groups (combined CA and SR or SR alone). In the case of failure of the assigned technique after three attempts, other adjunctive techniques were applied.Study outcomeThe primary outcome is the rate of successful/complete reperfusion (modified Thrombolysis In Cerebral Infarction (mTICI) score 2c/3) after the entire endovascular procedure. Secondary outcomes include reperfusion rates after the assigned first-line intervention alone and at the end of the procedure, procedural times, change in NIH Stroke Scale score at 24 hours, intracerebral hemorrhage at 24 hours, procedure-related serious adverse events, the modified Rankin Scale score, and all-cause mortality at 90 days and 1 year. The cost effectiveness of the two procedures will also be analyzed.DiscussionThis is the first head-to-head randomized trial to directly compare the efficacy of the combined use of CA and SR versus SR alone. This prospective trial aims to demonstrate the synergistic effects of CA and SR devices in first-line endovascular treatment.

scholarly journals Mechanical Thrombectomy in Ischemic Stroke Patients With Alberta Stroke Program Early Computed Tomography Score 0–5

Stroke ◽  
2019 ◽  
Vol 50 (4) ◽  
pp. 880-888 ◽  
Author(s):  
Johannes Kaesmacher ◽  
Panagiotis Chaloulos-Iakovidis ◽  
Leonidas Panos ◽  
Pasquale Mordasini ◽  
Patrik Michel ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Intracerebral Hemorrhage ◽  
Mechanical Thrombectomy ◽  
Functional Independence ◽  
Favorable Outcome ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Symptomatic Intracerebral Hemorrhage

Background and Purpose— If anterior circulation large vessel occlusion acute ischemic stroke patients presenting with ASPECTS 0–5 (Alberta Stroke Program Early CT Score) should be treated with mechanical thrombectomy remains unclear. Purpose of this study was to report on the outcome of patients with ASPECTS 0–5 treated with mechanical thrombectomy and to provide data regarding the effect of successful reperfusion on clinical outcomes and safety measures in these patients. Methods— Multicenter, pooled analysis of 7 institutional prospective registries: Bernese-European Registry for Ischemic Stroke Patients Treated Outside Current Guidelines With Neurothrombectomy Devices Using the SOLITAIRE FR With the Intention for Thrombectomy (Clinical Trial Registration—URL: https://www.clinicaltrials.gov . Unique identifier: NCT03496064). Primary outcome was defined as modified Rankin Scale 0–3 at day 90 (favorable outcome). Secondary outcomes included rates of day 90 modified Rankin Scale 0–2 (functional independence), day 90 mortality and occurrence of symptomatic intracerebral hemorrhage. Multivariable logistic regression analyses were performed to assess the association of successful reperfusion with clinical outcomes. Outputs are displayed as adjusted Odds Ratios (aOR) and 95% CI. Results— Two hundred thirty-seven of 2046 patients included in this registry presented with anterior circulation large vessel occlusion and ASPECTS 0–5. In this subgroup, the overall rates of favorable outcome and mortality at day 90 were 40.1% and 40.9%. Achieving successful reperfusion was independently associated with favorable outcome (aOR, 5.534; 95% CI, 2.363–12.961), functional independence (aOR, 5.583; 95% CI, 1.964–15.873), reduced mortality (aOR, 0.180; 95% CI, 0.083–0.390), and lower rates of symptomatic intracerebral hemorrhage (aOR, 0.235; 95% CI, 0.062–0.887). The mortality-reducing effect remained in patients with ASPECTS 0–4 (aOR, 0.167; 95% CI, 0.056–0.499). Sensitivity analyses did not change the primary results. Conclusions— In patients presenting with ASPECTS 0–5, who were treated with mechanical thrombectomy, successful reperfusion was beneficial without increasing the risk of symptomatic intracerebral hemorrhage. Although the results do not allow for general treatment recommendations, formal testing of mechanical thrombectomy versus best medical treatment in these patients in a randomized controlled trial is warranted.

scholarly journals Comparing different thrombectomy techniques in five large-volume centers: a ‘real world’ observational study

2017 ◽  
Vol 10 (6) ◽  
pp. 525-529 ◽  
Author(s):  
Amélie Carolina Hesse ◽  
Daniel Behme ◽  
André Kemmling ◽  
Antonia Zapf ◽  
Nils Große Hokamp ◽  
...  
Keyword(s):  
High Volume ◽  
Stent Retriever ◽  
Large Vessel ◽  
Combined Approach ◽  
Large Vessel Occlusion ◽  
Primary Analysis ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Significant Difference ◽  
First Pass

Background and purposeThrombectomy has become the standard of care for acute ischaemic stroke due to large vessel occlusion. Aim of this study was to compare the radiological outcomes and time metrics of the various thrombectomy techniques.MethodsIn this retrospective, multicenter study we analysed the data of 450 patients with occlusion of the anterior circulation, treated in five high-volume center from 2013 to 2016. The treatment techniques were divided in three categories: first-pass use of a large-bore aspiration-catheter; first-pass use of a stent-retriever; and primary combined approach (PCA) of an aspiration-catheter and stent-retriever. Primary endpoints were successful reperfusion and groin to reperfusion time. Secondary endpoints were the number of attempts and occurrence of emboli in new territory (ENT). The primary analysis was based on the intention to treat groups (ITT).ResultsThe ITT-analysis showed significantly higher reperfusion rates, with 86% of successful reperfusion in the PCA-group compared with 73% in the aspiration group and 65% in the stent-retriever group. There was no significant difference in groin to reperfusion time regarding the used technique. The secondary analysis showed an impact of the technique on the number of attempts and the occurrence of ENTs. Lowest ENT rates and attempts were reported with the combined approach.ConclusionsThe combined first-pass deployment of a stent-retriever and an aspiration-catheter was the most effective technique for reperfusion of anterior circulation large vessel occlusion. Our results correlate with the latest single-centrere studies, reporting very high reperfusion rates with PCA variations.

Transradial versus transfemoral access for anterior circulation mechanical thrombectomy: comparison of technical and clinical outcomes

2019 ◽  
Vol 11 (9) ◽  
pp. 874-878 ◽  
Author(s):  
Stephanie H Chen ◽  
Brian M Snelling ◽  
Samir Sur ◽  
Sumedh Subodh Shah ◽  
David J McCarthy ◽  
...  
Keyword(s):  
Aortic Arch ◽  
Mechanical Thrombectomy ◽  
Vascular Anatomy ◽  
Patient Characteristics ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Cohort Differences ◽  
Number Of Passes

BackgroundA transradial approach (TRA) is associated with fewer access site complications than a transfemoral technique (TFA).However, there is concern that performing mechanical thrombectomy (MT) via TRA may lead to longer revascularization times and thus worse outcomes. Nonetheless, TRA may confer added benefits in MT since navigation of challenging aortic arch and carotid anatomy is often facilitated by a right radial artery trajectory.ObjectiveTo compare outcomes in patients who underwent MT via TRA versus TFA.MethodsWe performed a retrospective review of our institutional database to identify 51 patients with challenging vascular anatomy who underwent MT for anterior circulation large vessel occlusion between February 2015 and February 2018. Patient characteristics, procedural techniques, and outcomes were recorded. TFA and TRA cohorts were compared.ResultsOf the 51 patients, 18 (35%) underwent MT via TRA. There were no significant cohort differences in patient characteristics, clot location, or aortic arch type and presence of carotid tortuosity. There were no significant differences in outcomes between the two cohorts, including single-pass recanalization rate (54.5% vs 55.6%, p=0.949) and average number of passes (1.9 vs 1.7, p=0.453). Mean access-to-reperfusion time (61.9 vs 61.1 min, p=0.920), successful revascularization rates (Thrombolysis in Cerebral Infarction score ≥2b 87.9% vs 88.9%, p=1.0) and functional outcomes (modified Rankin Scale score≤2, 39.4% vs 33.3%, p=0.669) were similar between TFA and TRA cohorts, respectively.ConclusionsOur results demonstrate equivalence in efficacy and efficiency between TRA and TFA for MT of anterior circulation large vessel occlusion in patients with challenging vascular anatomy. TRA may be better than TFA in well-selected patients undergoing MT.

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