Cerebral vessel anatomy as a predictor of first-pass effect in mechanical thrombectomy for emergent large-vessel occlusion

Srivatsa, Shaarada; Duan, Yifei; Sheppard, John P.; Pahwa, Shivani; Pace, Jonathan; Zhou, Xiaofei; Bambakidis, Nicholas C.

doi:10.3171/2019.11.jns192673

Cited by 25 publications

(22 citation statements)

References 18 publications

(21 reference statements)

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“…It was all the more important that we measured the achievement of complete/successful revascularization after 1 pass, which is associated with significantly higher rates of good clinical outcome. [20][21][22] In this experimental study, we reached 73% and 80% of complete and successful recanalization with 1 pass, while in clinical routine, current thrombectomy techniques yield around 30% and 50% complete and successful recanalization, respectively. [20][21][22] Although not instinctive, a fast removal can mobilize the clot suddenly, allow application of higher pulling force, enhance clot wedging, and minimize loss of apposition during the path of retrieval.…”

Section: Discussionmentioning

confidence: 58%

“…[20][21][22] In this experimental study, we reached 73% and 80% of complete and successful recanalization with 1 pass, while in clinical routine, current thrombectomy techniques yield around 30% and 50% complete and successful recanalization, respectively. [20][21][22] Although not instinctive, a fast removal can mobilize the clot suddenly, allow application of higher pulling force, enhance clot wedging, and minimize loss of apposition during the path of retrieval. Also, it may leave less time for variations of the pulling force, hence avoiding undesired loss of contact between SR and DC.…”

Section: Discussionmentioning

confidence: 58%

“…Also, tortuous anatomy probably has an impact that cannot be measured with our model. 22 Second, because we aimed to analyze only factors attributable to the SR, we did not apply aspiration. In all the in vitro attempts, the DC was always in the M1 proximal part, covering the anterior cerebral artery and in the same axis as the clot.…”

Section: Discussionmentioning

confidence: 99%

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Fast Stent Retrieval Improves Recanalization Rates of Thrombectomy: Experimental Study on Different Thrombi

Soize

Mirza²,

Gunning³

et al. 2020

AJNR Am J Neuroradiol

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BACKGROUND AND PURPOSE: About 20% of patients with acute ischemic stroke due to large-artery occlusion do not achieve recanalization with mechanical thrombectomy. We aimed to determine whether the speed of retrieval of the stent retriever influences the efficacy in removing different clot types.MATERIALS AND METHODS: Sixty mechanical thrombectomies were performed using an in vitro pulsatile cerebrovascular circulation model with controlled pressure and flow rate. Experiments were dichotomized into fast and slow retrieval using a wedging technique, in which the stent retriever and distal catheter are retrieved together. We used 3 different clot types: erythrocyte-rich, fibrin-rich, and friable clots. Primary end points were complete (TICI 3) and successful (TICI 2b-3) recanalizations. Secondary measures were distal and new territory embolizations.RESULTS: Fast retrieval was more frequently associated with complete (RR ¼ 1.83; 95% CI, 1.12-2.99) and successful recanalization (RR ¼ 1.50; 95% CI, 1.03-2.19) than slow retrieval, without a difference in distal embolization (RR ¼ 0.75; 95% CI, 0.29-1.90). There were no emboli in a new territory. The advantage of fast retrieval over slow retrieval differed according to the clot composition, with a stronger effect with fibrin-rich clots with regard to complete (RR ¼ 4.00; 95% CI, 1.11-14.35; Pint ¼ .04) and successful (Pint ¼ .10) recanalization. CONCLUSIONS:In our experimental model, a fast removal improved recanalization rates of mechanical thrombectomy, especially in the case of fibrin-rich clots. An in vivo confirmation is warranted to see whether our findings can have an impact in clinical practice. ABBREVIATIONS: DC ¼ distal catheter; MT ¼ mechanical thrombectomy; RR ¼ relative risk; Pint ¼ P interaction; RBC ¼ red blood cell; SR ¼ stent retriever M echanical thrombectomy (MT) is considered the first-line therapy for selected patients with acute ischemic stroke with a proximal cerebral artery occlusion. [1][2][3] The dramatic technological improvements, such as the combined use of stent retrievers (SRs) and distal catheters (DCs), have led to recanalization rates unreached before. 4,5 With the goal of increasing clot entrapment, techniques in which the thrombus is wedged between the SR and DC have become more popular. [6][7][8] Nevertheless, a successful

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Section: Discussionmentioning

confidence: 58%

Section: Discussionmentioning

confidence: 58%

See 1 more Smart Citation

Fast Stent Retrieval Improves Recanalization Rates of Thrombectomy: Experimental Study on Different Thrombi

Soize

Mirza²,

Gunning³

et al. 2020

AJNR Am J Neuroradiol

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“…Independent predictors of FP in the literature were use of BGC, better collateral grade ( 30 , 32 ), site of occlusion with ICA-terminus occlusion as worse predictor and M1 occlusion as better predictor of FP ( 6 , 30 , 31 ), older age, lower systolic blood pressure, a higher DWI-ASPECTS at admission, local anesthesia, and combined first-line device strategy ( 31 ). We also found pial collaterals in the angiography, as an independent predictor of FP.…”

Section: Discussionmentioning

confidence: 99%

First-Pass Reperfusion by Mechanical Thrombectomy in Acute M1 Occlusion: The Size of Retriever Matters

et al. 2021

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Introduction: Single-pass complete reperfusion using stent retrievers has been shown to improve functional outcome in patients with large vessel occlusion strokes. The aim of this study was to investigate the optimal size of stent retrievers to achieve one-pass complete reperfusion by mechanical thrombectomy.Methods: The study evaluated the results of aspiration-assisted mechanical thrombectomy of acute isolated occlusion of the middle cerebral artery in the M1 segment with a novel 5 × 40-mm stent retriever compared to the usual 4 × 20-mm device. Reperfusion status was quantified using the Thrombolysis In Cerebral Infarction (TICI) scale. We hypothesized that thrombectomy of M1 occlusions with 5 × 40-mm stent retriever yields higher rates of complete first-pass reperfusion (FP) (TICI ≥2c after one pass) and successful or modified FP (mFP) (TICI ≥2b after one pass) than thrombectomy with 4 × 20. We included isolated M1 occlusions treated with pRESET 5 × 40 (phenox) as first-choice device for thrombectomy and compared with M1 occlusions treated with pRESET 4 × 20. We excluded patients with additional occlusions or tandem stenosis or who received an intracranial stent or angioplasty as a part of the endovascular treatment.Results: One hundred thirteen patients were included in the 4 × 20 group and 57 patients in the 5 × 40 group. The 5 × 40 group achieved higher FP compared to 4 × 20 group [61.4% (35 of 57 patients) vs. 40.7% (46 of 113), respectively; adjusted odds ratio (OR) and 95% confidence interval (95% CI) = 2.20 (1.08–4.48), p = 0.030] and a higher mFP [68.4%, 39 of 57 patients vs. 48.7%, 55 of 113; adjusted OR (95% CI) = 2.11 (1.04–4.28), p = 0.037]. Frequency of successful reperfusion (TICI ≥2b) was similar in both groups (100 vs. 97.3%), but frequency of complete reperfusion (TICI ≥2c) was higher in the 5 × 40 group [82.5 vs. 61.9%, adjusted OR (95% CI) = 2.47 (1.01–6.04), p = 0.047]. Number of passes to achieve reperfusion was lower in the 5 × 40 group than in the 4 × 20 group [1.6 ± 1.1 vs. 2 ± 1.4, p = 0.033; adjusted incidence rate ratio (95% CI) = 0.84 (0.69–1.03), p = 0.096]. Modified Rankin scale at 90 days was similar in 5 × 40 and 4 × 20 groups.Conclusions: The size of stent retriever matters in acute M1 occlusions treated with aspiration-assisted mechanical thrombectomy. A longer stent retriever with a larger nominal diameter achieves a higher complete and successful FP and higher successful reperfusion compared to a shorter stent retriever.

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“…Thus, identifying factors influencing FPE could help clinicians and interventionalists maximize the benefit of MT through suitable patient selection and pre-interventional risk modification. There are many studies seeking to explore this phenomenon, but with inconsistent results (7,8,11,(13)(14)(15)(16)(17)(18)(19)(20). For example, balloon guide catheters (BGC) and non-internal carotid artery (ICA) terminus occlusion were correlated with FPE in the study of Zaidat et al (7), but factors such as older age, a lower systolic blood pressure, and conscious sedation were not (17).…”

Section: Introductionmentioning

confidence: 99%

Factors Influencing Recanalization After Mechanical Thrombectomy With First-Pass Effect for Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

et al. 2021

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Background: First-pass effect (FPE) is increasingly recognized as a predictor of good outcome in large vessel occlusion (LVO). This systematic review and meta-analysis aimed to elucidate the factors influencing recanalization after mechanical thrombectomy (MT) with FPE in treating acute ischemic stroke (AIS).Methods: Main databases were searched for relevant randomized controlled trials (RCTs) and observational studies reporting influencing factors of MT with FPE in AIS. Recanalization was assessed by the modified thrombolysis in cerebral ischemia (mTICI) score. Both successful (mTICI 2b-3) and complete recanalization (mTICI 2c-3) were observed. Risk of bias was assessed through different scales according to study design. The I2 statistic was used to evaluate the heterogeneity, while subgroup analysis, meta-regression, and sensitivity analysis were performed to investigate the source of heterogeneity. Visual measurement of funnel plots was used to evaluate publication bias.Results: A total of 17 studies and 6,186 patients were included. Among them, 2,068 patients achieved recanalization with FPE. The results of meta-analyses showed that age [mean deviation (MD):1.21,95% confidence interval (CI): 0.26–2.16; p = 0.012], female gender [odds ratio (OR):1.12,95% CI: 1.00–1.26; p = 0.046], diabetes mellitus (DM) (OR:1.17,95% CI: 1.01–1.35; p = 0.032), occlusion of internal carotid artery (ICA) (OR:0.71,95% CI: 0.52–0.97; p = 0.033), occlusion of M2 segment of middle cerebral artery (OR:1.36,95% CI: 1.05–1.77; p = 0.019), duration of intervention (MD: −27.85, 95% CI: −42.11–13.58; p < 0.001), time of onset to recanalization (MD: −34.63, 95% CI: −58.45–10.81; p = 0.004), general anesthesia (OR: 0.63,95% CI: 0.52–0.77; p < 0.001), and use of balloon guide catheter (BGC) (OR:1.60,95% CI: 1.17–2.18; p = 0.003) were significantly associated with successful recanalization with FPE. At the same time, age, female gender, duration of intervention, general anesthesia, use of BGC, and occlusion of ICA were associated with complete reperfusion with FPE, but M2 occlusion and DM were not.Conclusion: Age, gender, occlusion site, anesthesia type, and use of BGC were influencing factors for both successful and complete recanalization after first-pass thrombectomy. Further studies with more comprehensive observations indexes are need in the future.

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Cerebral vessel anatomy as a predictor of first-pass effect in mechanical thrombectomy for emergent large-vessel occlusion

Cited by 25 publications

References 18 publications

Fast Stent Retrieval Improves Recanalization Rates of Thrombectomy: Experimental Study on Different Thrombi

Fast Stent Retrieval Improves Recanalization Rates of Thrombectomy: Experimental Study on Different Thrombi

First-Pass Reperfusion by Mechanical Thrombectomy in Acute M1 Occlusion: The Size of Retriever Matters

Factors Influencing Recanalization After Mechanical Thrombectomy With First-Pass Effect for Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

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