Device size selection can enhance Y-stentrieving efficacy and safety as a rescue strategy in stroke thrombectomy

Abstract

BackgroundDespite advancements in stroke treatment, refractory clots are relatively common, prompting the exploration of alternative techniques. Bifurcation occlusions pose specific intraprocedural challenges, occasionally dealt with by two stentrievers deployed in Y-configuration. Previous studies have portrayed this strategy as feasible, yet little is known about its safety and efficacy, and how to best select retrievers.ObjectiveTo determine whether device selection influences the efficacy and safety of Y-stentrieving.MethodsWe performed a multicentric, retrospective analysis of patients undergoing Y-stentrieving rescue for bifurcation occlusions. Demographics, devices, procedural metrics, neurological severity, reperfusion, disability, and safety were assessed.ResultsY-configuration stents were used as a rescue maneuver after 2.16±1.5 failed attempts with other techniques in 20 patients. Successful reperfusion (modified Thrombolysis in Cerebral Infarction score 2b–3) was achieved in 70% of patients after the first Y-stentrieving attempt. The first stentriever more often had a larger diameter (5.15±0.92 vs 3.67±0.57 mm, p=0.017) and longer length (33.12±5.78 vs 20.67±1.15 mm, p=0.002) in successfully reperfused cases. Also, the diameter of the first device was associated with both any parenchymal (6.0 vs 4.71±0.99 mm, p=0.045) and symptomatic (6.0 vs 4.86±1.02 mm, p<0.001) hemorrhages. Exact logistic regression demonstrated that a longer length first stentriever independently predicted better angiographic outcomes (OR=1.26, p=0.036), and a 6 mm diameter first stentriever independently predicted more intracranial hemorrhages (OR=15.28, p=0.044). No periprocedural mortality was recorded.ConclusionY-stentrieving is an effective and safe bail-out strategy for refractory bifurcation clots. Longer stents may promote better angiographic outcomes, whereas avoidance of disproportionately large retrievers may mitigate intracranial hemorrhage. Future studies should account for these factors when evaluating alternative stentriever techniques.

First-line Double Stentriever Thrombectomy for M1/TICA Occlusions

“…Various authors have analyzed double stentriever thrombectomy as a rescue therapy in bifurcation occlusion [ 13 – 19 ]. With the exception of Li et al.…”

“…Rescue therapy using two simultaneous stentrievers yields good results in patients with clots refractory to mechanical thrombectomy with a single stentriever [ 13 – 19 ]; however, the feasibility of this technique as a first-line treatment remains to be determined.…”

Benchtop evaluation of a double stent retriever thrombectomy technique for acute ischemic stroke treatment

“…A multicenter analysis of DSR clinical cases has indeed shown that the choice of SR size influences the effectiveness of MTB, but that large diameter SRs lead to more hemorrhagic complications. [2] However, further studies are needed to evaluate the precise effect of the DSR on arterial walls during MTB, e.g., using histological analyses in animal models as discussed by Nogueira et al[15]…”

“…[10] DSR was first reported as a rescue technique in three consecutive, retrospective patient cohorts, two single center trials comprising 28 and 10 patients, respectively[6, 5] and one multicenter study of 20 patients. [2] These studies reported final recanalization rates between 80% and 85.7% (mTICI ≥ 2b/3), respectively, and a recanalization rate of 70% at the first DSR pass for the multicenter study. These recanalization rates are high when considering that these were clots that were not removed by MTB with SSR.…”

“…A mechanical thrombectomy (MTB) technique using a double stent retriever (DSR) has been recently reported as a successful approach to treat patients suffering from an acute ischemic stroke (AIS) due to the occlusion of a large vessel of the anterior circulation. [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12] Compared with a single stent retriever (SSR) technique, a DSR would ensure a larger metal surface interacting with the clot and an associated pincer effect, thus increasing the odds of successful capture. On the other hand, such an approach would lead to a greater force exerted by the two SRs over the vessel wall, potentially increasing the risks of vessel damage.…”