Microcatheter navigation through the clot: does size matter?

Caroff, Jildaz; King, R; Arslanian, Rose; Marosfői, M; Langan, Erin; Gounis, Matthew J.; Chueh, Juyu

doi:10.1136/neurintsurg-2018-014105

Cited by 23 publications

(14 citation statements)

References 21 publications

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“…Better primary and ancillary devices together with improved selection protocols led to the first five positive trials that definitively launched EVT as an effective treatment for acute stroke patients with LVO around the world 1. However, lack of complete recanalization and clot fragmentation with distal embolization21–23 are still common problems despite the availability of effective thrombectomy tools such as stent retrievers, distal aspirating catheters, and BGCs. During a thrombectomy process the occluding clot must fit in an extracting catheter that represents the exit door from the arterial system.…”

Section: Discussionmentioning

confidence: 99%

ANCD thrombectomy device: in vitro evaluation

Sánchez¹,

Cortiñas²,

Villanova³

et al. 2019

J NeuroIntervent Surg

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IntroductionEndovascular treatment of stroke, although highly effective, may fail to reach complete recanalization in around 20% of cases. The Advanced Thrombectomy System (ANCD) is a novel stroke thrombectomy device designed to reduce clot fragmentation and facilitate retrieval by inducing local flow arrest and allowing distal aspiration in combination with a stent retriever. We aimed to assess the preclinical efficacy of ANCD.MethodsSoft red blood cell (RBC)-rich (n=20/group) and sticky fibrin-rich (n=30/group) clots were used to create middle cerebral artery (MCA) occlusions in two vascular phantoms. Three different treatment strategies were tested: (1) balloon guide catheter + Solitaire (BGC+SR); (2) distal access catheter + SR (DAC+SR); and (3) ANCD+SR, until complete recanalization was achieved or to a maximum of three passes. The recanalization rate was determined after each pass.ResultsAfter one pass, ANCD+SR resulted in an increased recanalization rate (94%) for all clots together compared with BGC+SR (66%; p<0.01) or DAC+SR (80%; p=0.04). After the final pass the recanalization rate increased in all three groups but remained higher with ANCD+SR (100%) than with BGC+SR (74%; p<0.01) or DAC+SR (90%; p=0.02). The mean number of passes was lower with ANCD+SR (1.06) than with BGC+SR (1.46) or DAC+SR (1.25) (p=0.01). A logistic regression model adjusted for treatment arm, clot type, and model used showed that both RBC-rich clots (OR 8.1, 95% CI 1.6 to 13.5) and ANCD+SR (OR 3.9, 95% CI 1.01 to 15.8) were independent predictors of first-pass recanalization.ConclusionIn in vitro three-dimensional models replicating MCA-M1 occlusion, ANCD+SR showed significantly better recanalization rates in fewer passes than other commonly used combinations of devices.

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Section: Discussionmentioning

confidence: 99%

ANCD thrombectomy device: in vitro evaluation

Sánchez¹,

Cortiñas²,

Villanova³

et al. 2019

J NeuroIntervent Surg

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“…Use of direct aspiration in these territories may have the advantage of not crossing the occlusion and could be safer than stent retrievers. 30 It has also been suggested that aspiration has the potential for less endothelial damage. However, results from bench-top and animal studies have been mixed, with some finding significantly less endothelial trauma with aspiration and others finding non-significant levels of vessel damage between aspiration and stent retriever.…”

Section: Discussionmentioning

confidence: 99%

ADAPT technique in ischemic stroke treatment of M2 middle cerebral artery occlusions in comparison to M1 occlusions: Post hoc analysis of the PROMISE study

2019

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Background/purpose The benefit of endovascular thrombectomy in acute ischemic stroke (AIS) therapy of proximal large vessel occlusions (LVO) is established. However, there are few prospective studies evaluating the use of a direct aspiration first pass technique in distal vessel occlusions. This post hoc analysis of the PROMISE study examines the safety and effectiveness of the Penumbra System with the ACE68 and ACE64 Reperfusion Catheters for aspiration thrombectomy in the M1 and M2 segments of the middle cerebral artery. Methods PROMISE is a prospective, multicenter study that enrolled 204 patients with anterior circulation LVO AIS-treated frontline with ACE68/ACE64 catheters. We compared clinical and angiographic outcomes, complications, and mortality in patients with M1 and M2 occlusions. The association of M1 and M2 location and functional independence or mTICI 2b-3 reperfusion was described in univariable and multivariable analyses. Results One hundred sixty-one patients (124 M1 and 37 M2 locations) met the study criteria. Post procedure mTICI 2b-3 reperfusion (93% vs. 92%, p = 1.00), functional independence (57% vs. 70%, p = 0.18), symptomatic intracranial hemorrhage (1.6% vs. 2.7%, p = 0.55), device- or procedure-related serious adverse events at 30 days (4.0% vs. 8.1%, p = 0.39), and mortality at 90 days (6.6% vs. 2.7%, p = 0.69) were comparable between M1 and M2 occlusions. In multivariable analysis, lower age, lower baseline NIHSS, and shorter time from onset to admission were independent predictors of functional independence. Conclusions For frontline aspiration thrombectomy of stroke, use of large-bore ACE68/ACE64 catheters for treatment of M2 occlusions appeared as safe and effective as for M1 occlusions.

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“…Gaining access to the clot, which for most current thrombectomy technologies requires crossing the embolus with wires and microcatheters. 58 2. Initial activation of the retraction, which is even more common for aspiration thrombectomy when the clot is corked in the tip of the catheter and all force is applied to the proximal aspect of the embolus relying solely on adhesion of the embolus to resist fracture (Supplementary Movie 2).…”

Section: Distal Emboli and Vascular Traumamentioning

confidence: 99%

“…10 During these experiments, we learned that clot fragments are lost during discrete processes throughout the procedures: Gaining access to the clot, which for most current thrombectomy technologies requires crossing the embolus with wires and microcatheters. 58 Initial activation of the retraction, which is even more common for aspiration thrombectomy when the clot is corked in the tip of the catheter and all force is applied to the proximal aspect of the embolus relying solely on adhesion of the embolus to resist fracture (Supplementary Movie 2). 59 As the embolus is extracted from the MCA, as the device-clot ensemble turns around the tip of the internal carotid artery, clot can be snowplowed into the anterior cerebral artery causing distal emboli to a new territory.…”

Section: Distal Emboli and Vascular Traumamentioning

confidence: 99%

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Biomechanics and hemodynamics of stent-retrievers

Kühn

Vardar

Kraitem

et al. 2020

J Cereb Blood Flow Metab

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In 2015, multiple randomized clinical trials showed an unparalleled treatment benefit of stent-retriever thrombectomy as compared to standard medical therapy for the treatment of a large artery occlusion causing acute ischemic stroke. A short time later, the HERMES collaborators presented the patient-level pooled analysis of five randomized clinical trials, establishing class 1, level of evidence A for stent-retriever thrombectomy, in combination with intravenous thrombolysis when indicated to treat ischemic stroke. In the years following, evidence continues to mount for expanded use of this therapy for a broader category of patients. The enabling technology that changed the tide to support endovascular treatment of acute ischemic stroke is the stent-retriever. This review summarizes the history of intra-arterial treatment of stroke, introduces the biomechanics of embolus extraction with stent-retrievers, describes technical aspects of the intervention, provides a description of hemodynamic implications of stent-retriever embolectomy, and proposes future directions for a more comprehensive, multi-modal endovascular approach for the treatment of acute ischemic stroke.

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Microcatheter navigation through the clot: does size matter?

Abstract: The clot crossing maneuver has a significant effect on the total number of small particles induced during mechanical thrombectomy. Smaller microcatheter sizes should be favored when possible.

Cited by 23 publications

References 21 publications

ANCD thrombectomy device: in vitro evaluation

ANCD thrombectomy device: in vitro evaluation

ADAPT technique in ischemic stroke treatment of M2 middle cerebral artery occlusions in comparison to M1 occlusions: Post hoc analysis of the PROMISE study

Biomechanics and hemodynamics of stent-retrievers

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