Carotid Artery Stenting Using the Walrus Balloon Guide Catheter With Flow Reversal for Proximal Embolic Protection: Technical Description and Single-Center Case Series

Cappuzzo, Justin M; Monteiro, André; Waqas, Muhammad; Baig, Ammad A; Popoola, Daniel; Almayman, Faisal; Khawar, Wasiq; Farkash, Zoe G.; Davies, Jason M.; Siddiqui, Adnan H.; Levy, Elad I.; Snyder, Kenneth V.

doi:10.1227/ons.0000000000000442

Cited by 4 publications

(5 citation statements)

References 21 publications

(47 reference statements)

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“…Hence, in the future, findings from this study may also inform potential differences between the similarly sized new generation large bore BGCs compared to the conventional (non-balloon) guide catheters. The results of this study could also potentially be applicable to other neurointerventional procedures where proximal flow arrest may be considered, such as in carotid artery stenting for symptomatic carotid stenosis (30).…”

Section: Discussionmentioning

confidence: 92%

Section: Discussionmentioning

confidence: 99%

“…The results of this study could also potentially be applicable to other neurointerventional procedures where proximal flow arrest may be considered, such as in carotid artery stenting for symptomatic carotid stenosis. 30 Although there is an increasing trend of EVT treatment using the radial artery approach, there remains some reluctance amongst interventionists to use large bore BGCs for anterior circulation EVT, particularly in patients with a small radial arterial diameter due to the theoretical risk of arterial injury or occlusion. 31 However, recent studies have reported on the successful completion of EVT procedures performed using a sheathless BGC via the transradial approach.…”

Section: Discussionmentioning

confidence: 99%

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Effect of proximal blood flow arrest during endovascular thrombectomy (ProFATE): Study protocol for a multicentre randomised controlled trial

Dhillon

Butt

Podlasek

et al. 2023

European Stroke Journal

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Background: Observational studies have demonstrated improved outcomes with the adjunctive use of balloon guide catheters (BGC) during endovascular thrombectomy (EVT) for anterior circulation acute ischaemic stroke (AIS). However, the lack of high-level evidence and global practice heterogeneity justifies a randomised controlled trial (RCT) to investigate the effect of transient proximal blood flow arrest on the procedural and clinical outcomes of patients with AIS following EVT. Hypothesis: Proximal blood flow arrest in the cervical internal carotid artery during EVT for proximal large vessel occlusion is superior to no flow arrest in achieving complete vessel recanalisation. Methods: ProFATE is an investigator-initiated, pragmatic, multicentre RCT with blinding of participants and outcome assessment. An estimated 124 participants with an anterior circulation AIS due to large vessel occlusion, an NIHSS of ⩾2, ASPECTS ⩾ 5 and eligible for EVT using a first-line combined technique (contact aspiration and stent retriever) or contact aspiration only will be randomised (1:1) to receive BGC balloon inflation or no inflation during EVT. Outcomes: The primary outcome is the proportion of patients achieving near-complete/complete vessel recanalisation (eTICI 2c-3) at the end of the EVT procedure. Secondary outcomes include the functional outcome (modified Rankin Scale at 90 days), new or distal vascular territory clot embolisation rate, near-complete/complete recanalisation after the first pass, symptomatic intracranial haemorrhage, procedure-related complications and death at 90 days. Discussion: This is the first RCT to investigate the effect of proximal blood flow arrest during EVT using a BGC on the procedural and clinical outcomes of patients with AIS due to large vessel occlusion.

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Section: Discussionmentioning

confidence: 92%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Effect of proximal blood flow arrest during endovascular thrombectomy (ProFATE): Study protocol for a multicentre randomised controlled trial

Dhillon

Butt

Podlasek

et al. 2023

European Stroke Journal

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“…13,14) Larger GCs are also frequently employed in carotid artery stenting procedures. 15,16) While using large GCs raises safety concerns due to the small size of the radial artery, 3) Hanaoka et al 7) reported a RAO rate of 1.5% in their study of TRA-NET using a 6-F guide sheath (which has an outer diameter equivalent to that of a sheathless 8-F GC). This rate aligns with findings from previous studies and our study.…”

Section: Journal Of Neuroendovascular Therapymentioning

confidence: 99%

Feasibility and Challenges of Transradial Approach in Neuroendovascular Therapy: A Retrospective Observational Study

Tanoue,

Ono,

Toyooka

et al. 2024

NOUSHINKEI KEKKANNAI TIRYOU

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Objective Transradial approach (TRA) is increasingly used as a viable alternative to the traditional transfemoral approach (TFA) in neuroendovascular therapy (NET) owing to its potential anatomical benefits and lower puncture-site complication rates. However, the real-world challenges of implementing TRA-NET have not been thoroughly studied, particularly those related to guide catheter (GC) placement. In this study, we aimed to explore the feasibility and challenges of TRA-NET, with a specific focus on GC placement. Methods This retrospective observational study included patients who underwent NET at our institution between December 2019 and May 2022. Procedural success was defined as the successful placement of a GC in the target vessel. Cases in which a Simmons-shaped GC was used or the approach was changed to TFA were classified as difficult. Safety was assessed based on the rate of severe puncture-site complications requiring either blood transfusion or surgical intervention. Results Among the 310 patients who underwent NET during the study period, 222 (71.6%) with a median age of 74 years were selected for TRA-NET. The target vessel was in the left anterior circulation (LtAC) in 101 (45.5%) patients, and 8-F GCs were the most frequently used (40.1%). TRA-NET achieved a 95.0% success rate, with a switch to TFA required in 5.0% of the cases. Procedural challenges occurred in 42 (18.9%) patients, primarily in those with LtAC lesions. Specifically, a type III aortic arch ( p <0.0001) and age ≥80 years ( p = 0.01) were significantly associated with procedural difficulties. Radial artery evaluation was confirmed in 66 cases (29.7%), revealing one instance (1.5%) of radial artery occlusion. No severe puncture-site complications were observed. Conclusion TRA-NET may provide substantial therapeutic benefits without significant limitations in device use. However, it may be challenging, particularly in older patients and those with a type III aortic arch with LtAC lesions. Consequently, careful selection of the approach route is imperative.

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“…In their study, they found no difference in outcome between CEA and CAS. This may reflect the advancement of the endovascular device including stroke protection filter and flowreversal technique (20,21). We need to keep in mind that compared to the past now that various endovascular devices are developed, we need to update the result from past studies ( 22).…”

mentioning

confidence: 99%

Is it time to update the treatment result of extracranial internal carotid artery stenosis?

Hong¹

2023

Ann Palliat Med

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Extracranial internal carotid artery stenosis is one of the major causes of ischemic strokes accounting for 8-20% (1,2). Its management includes the best medical treatment (BMT), carotid artery stenting (CAS), and carotid endarterectomy (CEA). The comparisons between these three methods have been studied extensively. To decide the treatment, we need to consider whether it is symptomatic. Symptomatic disease is characterized by one or more transient ischemic attacks of neurologic dysfunction, amaurosis fugax, or one or more ischemic strokes within the previous six months (3,4). If symptomatic with 50-99% stenosis of the internal carotid artery, CAS and CEA can be considered (5-8). On the other hand, if asymptomatic, CAS and CEA can be considered for 60-99% stenosis (6,(8)(9)(10). We need to factor in patients' specific factors including age, sex, comorbidities, and anatomical factors among others, to decide CAS or CEA. Patients 75 years old or younger had a better outcome after CAS compared to older patients (11,12). However, even for elderly patients, if there is no vascular tortuosity, calcification, or decreased cerebral reserve, CAS was shown to be safely performed (13).Non-exhaustive past studies on the outcomes of CAS and CEA were summarized in Table 1 (5-10,14-19). In earlier studies, periprocedural strokes were more common in patients treated with CAS (5-7). However, in the later studies including the one performed by Cho et al., periprocedural strokes after CAS and CEA were comparable (8-10,16). One study even showed periprocedural stroke rate was higher in patients treated with CEA (18). In the study performed by Cho et al. (16), they performed a single-center retrospective study on the patients treated with CEA (107 patients) and CAS (128 patients) between 2012 and 2020. No statistically significant differences were observed in myocardial infarction (CAS group, 0.8%; CEA group, 0.9%), cerebral infarction (CAS group, 3.1%; CEA group 0.9%), or death (CAS group, 0.8%; CEA group 0%), within 30 days after surgery. In their study, they found no difference in outcome between CEA and CAS. This may reflect the advancement of the endovascular device including stroke protection filter and flowreversal technique (20,21). We need to keep in mind that compared to the past now that various endovascular devices are developed, we need to update the result from past studies ( 22). The way of embolic protection during CAS is not necessarily the same as in past studies, which showed higher periprocedural stroke rates in patients treated with CAS (5-7). A nationwide study on patients treated either with CEA or CAS during 2010-2015 showed CEA patients had a higher periprocedural stroke rate than CAS patients after matching for characteristics and morbidity (18).

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Carotid Artery Stenting Using the Walrus Balloon Guide Catheter With Flow Reversal for Proximal Embolic Protection: Technical Description and Single-Center Case Series

Cited by 4 publications

References 21 publications

Effect of proximal blood flow arrest during endovascular thrombectomy (ProFATE): Study protocol for a multicentre randomised controlled trial

Effect of proximal blood flow arrest during endovascular thrombectomy (ProFATE): Study protocol for a multicentre randomised controlled trial

Feasibility and Challenges of Transradial Approach in Neuroendovascular Therapy: A Retrospective Observational Study

Is it time to update the treatment result of extracranial internal carotid artery stenosis?

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