First-line Double Stentriever Thrombectomy for M1/TICA Occlusions

Abstract

Background Mechanical thrombectomy is the standard of care for acute ischemic stroke due to large-vessel occlusion; however, mechanical thrombectomy fails to achieve adequate recanalization in nearly one third of these cases. Rescue therapy using two stentrievers simultaneously yields good results in clots refractory to single stentriever treatment. We aimed to determine the safety and efficacy of first-line double stentriever thrombectomy for acute occlusion of the M1 segment of the middle cerebral artery and/or terminal internal carotid artery (TICA). Methods This single-center study prospectively enrolled consecutive patients with a single M1/TICA occlusion to undergo double stentriever thrombectomy between May and October 2020. Outcomes included successful recanalization (modified thrombolysis in cerebral infarction, TICI 2b/3), first-pass effect, procedure times, number of device passes, symptomatic intracerebral hemorrhage, National Institutes of Health Stroke Scale Score (NIHSS) at discharge, 90-day functional independence (modified Rankin scale 0–2), and 90-day mortality. Results We analyzed 39 patients median age 79 years (range 42–96 years); 23 (58.9%) female; 19 (48.7%) with TICA occlusions; 5 (12.8%) with mRS 3–5 at admission; mean NIHSS at admission, 17 ± 4.39). Mean time from symptom onset to final angiogram was 238.0 ± 94.6 min; mean intervention duration was 36.0 ± 24.2 min. The mean number of device passes was 1.5 ± 1.07. All patients had final TICI 2b/3, and 27 (69%) had TICI 2c/3 after the first pass. We observed 3 (7.9%) cases of intracerebral symptomatic hemorrhages. At 90 days, 16 (41%) patients were functionally independent and 9 (23%) had died. The percentage of patients with good clinical outcome at 90 days was 55.5% in the first-pass subgroup. Conclusion Our findings suggest that first-line double stentriever thrombectomy is safe and effective for M1/TICA occlusions.

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

“…The DSR was also recently reported as a front-line technique in anterior circulation occlusions in a single-center cohort of 39 patients, with a first-pass effect of 69% and a final recanalization rate of 100%. [12] The high rates of full recanalization by DSR in these clinical cohorts are close to the results we observed in vitro. However, the fact that all clots are retrieved by DSR at first pass in vitro is superior to what is observed in patients, where several passes may be required.…”

“…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.…”

First Experience with the Nimbus Stentretriever

“…Recanalization success of up to 80% has been described with this technique by Klisch et al in a small cohort of 10 patients who could not be reperfused with a single stentretriever. Recently, Vega et al even suggested the double stentretriever thrombectomy as a first-line technique in patients with M1 or distal carotid occlusions: in a cohort of 39 patients, they achieved mTICI 2b/3 in 100% of cases [17]. Also, there have been reports that a fast stent retrieval can improve recanalization rates for fibrin-rich clots in vitro [18] and may improve recanalization rates of TICI 2b or better in 90% of the cases with large vessel occlusion due to fibrin-rich clots [19].…”

Combined Technique for Internal Carotid Artery Terminus or Middle Cerebral Artery Occlusions in the ASTER2 Trial

“…The available data from the literature about CoT are heterogeneous, and most of the published studies are represented by retrospective and monocentric studies reporting the results of mixed cohorts of patients treated with different techniques and occlusion sites. 2,4,8,9 Furthermore, whereas a few meta-analyses have been published, 2). Furthermore, in the same subgroup of patients treated by CoT, we observed a lower rate of rescue treatments (20% versus 42.4%) without any difference in terms of procedure time when compared with isolated M1-MCA occlusions (Table 2).…”