Risk of distal embolization with stent retriever thrombectomy and ADAPT

Abstract

BackgroundThere is a discrepancy in clinical outcomes and the achieved recanalization rates with stent retrievers in the endovascular treatment of ischemic stroke. It is our hypothesis that procedural release of embolic particulate may be one contributor to poor outcomes and is a modifiable risk. The goal of this study is to assess various treatment strategies that reduce the risk of distal emboli.MethodsMechanical thrombectomy was simulated in a vascular phantom with collateral circulation. Hard fragment-prone clots (HFC) and soft elastic clots (SECs) were used to generate middle cerebral artery (MCA) occlusions that were retrieved by the Solitaire FR devices through (1) an 8 Fr balloon guide catheter (BGC), (2) a 5 Fr distal access catheter at the proximal aspect of the clot in the MCA (Solumbra), or (3) a 6 Fr guide catheter with the tip at the cervical internal carotid artery (guide catheter, GC). Results from mechanical thrombectomy were compared with those from direct aspiration using the Penumbra 5MAX catheter. The primary endpoint was the size distribution of emboli to the distribution of the middle and anterior cerebral arteries.ResultsSolumbra was the most efficient method for reducing HFC fragments (p<0.05) while BGC was the best method for preventing SEC fragmentation (p<0.05). The risk of forming HFC distal emboli (>1000 µm) was significantly increased using GC. A non-statistically significant benefit of direct aspiration was observed in several subgroups of emboli with size 50–1000 µm. However, compared with the stent-retriever mechanical thrombectomy techniques, direct aspiration significantly increased the risk of SEC fragmentation (<50 µm) by at least twofold.ConclusionsThe risk of distal embolization is affected by the catheterization technique and clot mechanics.

Predictors of the Aspiration Component Success of a Direct Aspiration First Pass Technique (ADAPT) for the Endovascular Treatment of Stroke Reperfusion Strategy in Anterior Circulation Acute Stroke

“…25 Nonetheless, controversies about the relevance of the technique have arisen as in case of aspiration component failure, it might induce a potential delay in reperfusion which could have been avoided using the SR technique and also because this technique does not use a proximal flow arrest with Balloon guide catheter known to prevent embolus in new territory. 26,27 Although no comparative studies have been conducted with ADAPT versus the validated SR technique, some evidences suggest noninferiority 9 or superiority of the ADAPT technique to achieve better reperfusion rates. 7 In this perspective, more insights are needed to identify which patients may benefit from this technique.…”

“…These rates of embolic complications are within the range of previous reports either in vitro or on patients' cohorts. 26 Improvements of the technique especially with development of larger less traumatic, with better trackability catheters, to decrease the needs for SR are required. Improvements in logistics, with patients more rapidly in the odds ratio, could have an impact on the efficacy of the aspiration component technique.…”

A Direct Aspiration, First Pass Technique (ADAPT) versus Stent Retrievers for Acute Stroke Therapy: An Observational Comparative Study

“…However, our sample size was limited; experimental work suggests that a combined strategy with aspiration with adjunct stent retrievers may decrease the rate of embolization in a new territory. 23 Symptomatic hemorrhagic complications, defined in this study as an ECASS-evident intracranial hemorrhage with an increase of Ն4 on the NIHSS scale at 24 hours from baseline, were lower after the ADAPT approach. Study results yielded symptomatic intracranial hemorrhage rates (2.4% for ADAPT versus 5.9% for Solitaire) similar to those of recent randomized controlled trials studying stroke.…”

Microbubble-Mediated Sonothrombolysis Improves Outcome After Thrombotic Microembolism-Induced Acute Ischemic Stroke

“…Despite the use of the latest thrombectomy devices, microemboli may still be found in cerebral arterioles downstream from the treated vessel. 12,13 Intravenous antiplatelet agents may suppress local microthrombus and microembolus formation, but clinical trial results have not demonstrated improved outcomes. Rather, they have highlighted an increased risk of intracranial hemorrhage after the combined use of antiplatelet agents and pharmacological fibrinolysis.…”