Mechanical Thrombectomy in Distal Vessels: Revascularization Rates, Complications, and Functional Outcome

Sweid, Ahmad; Head, Jeffery; Tjoumakaris, Stavropoula; Xu, Vivian; Shivashankar, Kavya; Alexander, Tyler; Dougherty, Jaime; Gooch, M. Reid; Herial, Nabeel A.; Hasan, David; DePrince, Maureen; Rosenwasser, Robert H.; Jabbour, Pascal

doi:10.1016/j.wneu.2019.07.098

Cited by 36 publications

(37 citation statements)

References 16 publications

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“…5 While MT is deemed safe and effective in proximal M2 occlusions of the middle cerebral artery (MCA), its benefit in more distal locations remains unclear. 6 Considering the impact of rapid and full or near-complete recanalization on clinical outcome, 7 exploring the benefit of MT for primary or secondary DMVO is warranted. 3 Moreover, thromboembolic complications during embolization of brain aneurysms or arteriovenous malformation may also benefit from DMVO thrombectomy, 8 especially in patients receiving dual antiplatelet medication, where thrombolysis may result in or worsen hemorrhagic complications.…”

Section: Introductionmentioning

confidence: 99%

Effectiveness of very low profile thrombectomy device in primary distal medium vessel occlusion, as rescue therapy after incomplete proximal recanalization or following iatrogenic thromboembolic events

Rikhtegar

Mosimann

Weber

et al. 2021

J NeuroIntervent Surg

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BackgroundRecent progress with smaller retrievers has expanded the ability to reach distal brain arteries. We herein report recanalization, bleeding complications and short-term clinical outcomes with the smallest currently known low profile thrombectomy device in patients with primary or secondary distal medium vessel occlusion (DMVO).MethodsWe performed a retrospective analysis of 115 patients receiving mechanical thrombectomy (MT) in DMVO using the extended Thrombolysis in Cerebral Infarction (eTICI), European Cooperative Acute Stroke Study (ECASS) II classification, The National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) scores at admission and discharge to evaluate outcomes. Patients were stratified into three groups: (1) primary isolated distal occlusion (n=34), (2) secondary distal occlusion after MT of a proximal vessel occlusion (n=71), or (3) during endovascular treatment of aneurysms or arteriovenous malformations (AVMs) (n=10).ResultsSuccessful distal recanalization, defined as an eTICI score of 2b67, 2c and 3, was achieved in 74.7% (86/115) of patients. More specifically, it was 70.5% (24/34), 73.2% (52/71), and 100% (10/10) of primary DMVO, secondary DMVO after proximal MT, and rescue MT during aneurysm or AVM embolization, respectively. Symptomatic intraparenchymal bleeding occurred in 6.9% (eight patients). In-hospital mortality occurred in 18.1% (19/105) of patients with stroke. The most common cause of death was large infarct, old age, and therapy limitation.ConclusionDirect or rescue MT of DMVO using a very low profile thrombectomy device is associated with a high rate of successful recanalization and a reasonable rate of symptomatic hemorrhagic complication, despite a risk of 18.1% hospital mortality in elderly patients. Further trials are needed to confirm our results and assess long-term clinical outcomes.

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Section: Introductionmentioning

confidence: 99%

Effectiveness of very low profile thrombectomy device in primary distal medium vessel occlusion, as rescue therapy after incomplete proximal recanalization or following iatrogenic thromboembolic events

Rikhtegar

Mosimann

Weber

et al. 2021

J NeuroIntervent Surg

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“…28 Another comparative study of procedural outcomes according to thrombus location (proximal vs distal) found a similar rate of mRS score from 0 to 2 (71.1% vs 64.7%), TICI grade 2b or 3 (88% vs 89%), and mortality (12% vs 8%). 29 It should be noted that 89% of the distal locations comprised the M 2 segment of the MCA. Despite multiple studies that have reported the feasibility and safety of MT in treating AIS with distal occlusions, none of the studies to date have directly compared treatment outcomes between the MT devices and medical management.…”

Section: Discussionmentioning

confidence: 99%

Mechanical thrombectomy versus intravenous thrombolysis for distal large-vessel occlusion: a systematic review and meta-analysis of observational studies

Waqas

Kuo

Dossani

et al. 2021

Neurosurgical Focus

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OBJECTIVE While several studies have compared the feasibility and safety of mechanical thrombectomy (MT) for distal large-vessel occlusion (LVO) strokes in patients, few studies have compared MT with intravenous thrombolysis (IVT) alone. The purpose of this systematic review was to compare the effectiveness and safety between MT and standard medical management with IVT alone for patients with distal LVOs. METHODS PubMed, Google Scholar, Embase, Scopus, Web of Science, Ovid Medline, and Cochrane Library were searched in order to identify studies that directly compared MT with IVT for distal LVOs (anterior cerebral artery A2, middle cerebral artery M3–4, and posterior cerebral artery P2–4). Primary outcomes of interest included a modified Rankin Scale (mRS) score of 0 to 2 at 90 days posttreatment, occurrence of symptomatic intracerebral hemorrhage (sICH), and all-cause mortality at 90 days posttreatment. RESULTS Four studies representing a total of 381 patients were included in this meta-analysis. The pooled results indicated that the proportion of patients with an mRS score of 0 to 2 at 90 days (OR 1.16, 95% CI 0.23–5.93; p = 0.861), the occurrence of sICH (OR 2.45, 95% CI 0.75–8.03; p = 0.140), and the mortality rate at 90 days (OR 1.73, 95% CI 0.66–4.55; p = 0.263) did not differ between patients who underwent MT and those who received IVT alone. CONCLUSIONS The meta-analysis did not demonstrate a significant difference between MT and standard medical management with regard to favorable outcome, occurrence of sICH, or 90-day mortality. Prospective clinical trials are needed to further compare the efficacy of MT with IVT alone for distal vessel occlusion.

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“…[1][2][3][4][5] The Japanese Guidelines for the Management of Stroke 2015 and supplement version 2019 recommended this treatment as grade A, 14) and the number of treatment sessions has rapidly increased in Japan. 12) Several studies reported that mechanical thrombectomy was effective even in patients with occlusion at the M2 segment of the MCA, 15,16) those with posterior circulation occlusion, 17,18) mild-status patients, 19) and those with extensive ischemic changes. 20) In particular, two RCTs concerning patients with an interval beyond 6 hours of the time last known to be well were published in 2018.…”

Section: Discussionmentioning

confidence: 99%

Results of Mechanical Thrombectomy 6 Hours after Stroke Onset: Analysis of Multiple Stroke Centers in Fukushima Prefecture

Ito

Kojima

Sato

et al. 2021

JNET

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The purpose of this study was to examine the efficacy and safety of mechanical thrombectomy in patients with acute occlusion of a large cerebral artery in the anterior circulation beyond 6 hours of the time last known to be well using the real-world clinical data collected from non-urban areas of Japan. Methods: We analyzed a retrospective multicenter database collected at 10 thrombectomy capable primary stroke centers in Fukushima Prefecture. In all, 188 patients were presenting a large cerebral artery occlusion in the anterior circulation, that is, internal carotid and middle cerebral artery (M1 and M2 segment). In all, 158 patients received mechanical thrombectomy within 6 hours from symptom onset (early time window), and 30 patients exceeded 6 hours (late time window). We compared the patient background, outcomes, and safety variables between the two groups. The modified Rankin Scale (mRS) score of 0-2 at 90 days after treatment and the incidence of symptomatic intracranial hemorrhage were compared between groups to evaluate treatment efficacy and safety. Results: There was no significant difference in the proportion of mRS score 0-2 at 90 days after treatment (51.3 vs. 46.7%: P = 0.644). However, symptomatic intracranial hemorrhage was more frequent in the late time window group (7.0 vs. 16.7%: P = 0.081). Symptomatic intracranial hemorrhage was a significant factor of a poor functional outcome in the late time window group (P = 0.022). Conclusion: This study reflects the real-world results of mechanical thrombectomy in the non-urban areas of Japan. The treatment efficacy in the late time window patients was equivalent to that in the early time window patients. On the other hand, the incidence of symptomatic intracranial hemorrhage showed a trend to high in patients beyond 6 hours, which was a significant factor related to a poor functional outcome. Keywords▶ mechanical thrombectomy, late time window, acute ischemic stroke This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives International License.

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Mechanical Thrombectomy in Distal Vessels: Revascularization Rates, Complications, and Functional Outcome

Cited by 36 publications

References 16 publications

Effectiveness of very low profile thrombectomy device in primary distal medium vessel occlusion, as rescue therapy after incomplete proximal recanalization or following iatrogenic thromboembolic events

Effectiveness of very low profile thrombectomy device in primary distal medium vessel occlusion, as rescue therapy after incomplete proximal recanalization or following iatrogenic thromboembolic events

Mechanical thrombectomy versus intravenous thrombolysis for distal large-vessel occlusion: a systematic review and meta-analysis of observational studies

Results of Mechanical Thrombectomy 6 Hours after Stroke Onset: Analysis of Multiple Stroke Centers in Fukushima Prefecture

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