What to do about fibrin rich ‘tough clots’? Comparing the Solitaire stent retriever with a novel geometric clot extractor in an in vitro stroke model

Fennell, Vernard S.; Nagesh, Swetadri Vasan Setlur; Meess, Karen M; Gutierrez, Liza; James, Rhys H; Springer, Michael; Siddiqui, Adnan H.

doi:10.1136/neurintsurg-2017-013507

Cited by 60 publications

(58 citation statements)

References 17 publications

(7 reference statements)

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“…This finding is compatible with a clinical observation showing lower success in mechanical thrombectomy in the anterior circulation with large vessel angles 9. Fennell et al recently reported that hard clots were often dislodged in the tortuous carotid siphon by in vitro thrombectomy with the Solitaire stent 24. Machi et al also showed that elongation of the stent around a sharp curve reduced the interaction between the stent retriever and clot around the curve, resulting in dislodgement of the clot 23.…”

Section: Discussionsupporting

confidence: 82%

Stent retrievers with segmented design improve the efficacy of thrombectomy in tortuous vessels

Kaneko

Komuro

Yokota

et al. 2018

J NeuroIntervent Surg

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Section: Discussionsupporting

confidence: 82%

Stent retrievers with segmented design improve the efficacy of thrombectomy in tortuous vessels

Kaneko

Komuro

Yokota

et al. 2018

J NeuroIntervent Surg

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“…In particular, some studies have highlighted the relationship between hypodense thrombus in NECT and a high proportion of fibrin within the thrombi, which has been discussed as an important cause for poor outcome [15,16,29]. This finding is also consistent with recent findings on methodological difficulties of MT in fibrincontaining thrombi [23,24].…”

Section: Discussionsupporting

confidence: 80%

“…Current studies have shown that the performance of different MT methods is largely determined by the histological composition of the thrombus [23,24]. While current treatment strategies do not include the factor of thrombus composition, potential new individualized therapy methods for specific thrombi, for example, exactly those containing fibrin, are conceivable.…”

Section: Discussionmentioning

confidence: 99%

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Thrombus Enhancement Is a Predictor of Clinical Outcome in Acute Ischemic Stroke after Mechanical Thrombectomy

et al. 2018

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Background: Ex vivo computed tomography (CT) studies of artificial blood thrombi showed that contrast enhancement (CE) is determined by fibrin-content, while unenhanced density is associated with red blood cells. Thus, the present study investigates patient outcome in association with combined thrombus density measures in native and contrast-enhanced CT (CECT) of acute ischemic stroke patients. Methods: This retrospective study includes 137 patients with M1 occlusions treated by mechanical thrombectomy (MT) between 2010 and 2016. Clinical outcome was determined with modified Rankin Scale (mRS) at 90 days. Differentiation of complete and incomplete large vessel occlusion (CLVO/ILVO) was based on CT and angiography. Two blinded readers classified blood thrombi based on native non-enhanced CT (NECT) as (a) hypo-, (b) iso-, and (c) hyperdense and in CECT angio measurements as (d) not-enhancing, (e) intermediate and (f) enhancing. To make sure that the mean is not represented in any of the maximum/minimum groups, thresholds in both cases were selected in a way that all values within one SD around the mean value form the isodense/intermediate group. In addition, the CE per se was correlated with the outcome. Correlations between imaging and clinical scales were performed with Spearman’s Rho. For the group testing Pearson chi-square test, Mann-Whitney U, as well parametric and nonparametric one-factor ANOVA “Kruskal-Wallis” test including Bonferroni correction for multiple tests ware used. Results: Twenty-three patients with ILVO (16.8%) differed significantly from patients with CLVO in mRS at admission (median 4 vs. 5) and after 90 days (median 1 vs. 4; p < 0.05) and thus were excluded. In the ILVO cohort, the classification according to NECT did not show statistical difference between hypo-, iso- and hyperdense CLVOs in regard to outcome. Classification of CLVOs according to CECT allowed an outcome prediction between the intermediate (median 3) and enhancing group (median 5) and between the enhancing and non-enhancing group (median 3; both p < 0.05) with a correlation of 291 between CE and higher mRS after 90 days (p < 0.005). Conclusions: CE of thrombi – especially in a range from over 18.4 to 40.35 Hounsfield Units – is an independent predictor of poor clinical outcome in patients undergoing MT due to acute middle cerebral artery occlusion.

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“…The latter has been shown to be responsible for nearly half of unsuccessful procedures 16. Multiple variables are likely to govern device–thrombus interaction17 but patient factors associated with thrombectomy failure include fibrin rich18 or calcific emboli,19 intracranial atherosclerotic disease (ICAD),20 and vessel morphology 21…”

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confidence: 99%

A systematic review and meta-analysis of observational evidence for the use of bailout self-expandable stents following failed anterior circulation stroke thrombectomy

Wareham

Flood

Phan³

et al. 2018

J NeuroIntervent Surg

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BackgroundThe crucial role of thrombectomy in the management of emergent large vessel occlusive stroke is not disputed but there is a technical failure rate in a significant minority of patients whose outcomes are often poor. Our objective was to perform a systematic review and meta-analysis to assess the safety and efficacy of permanent self-expandable stent deployment as a bailout procedure in cases of failed anterior circulation thrombectomy.MethodsTwo independent reviewers searched the Pubmed (Medline) database for studies reporting outcomes following failed endovascular thrombectomy with subsequent rescue therapy employing self-expandable stents.ResultsEight studies (one prospective, seven retrospective) originating from Europe, Asia, and America comprising 160 patients met the inclusion criteria. Estimated baseline National Institutes of Health Stroke Scale score was 17.1 (95% CI 15.7 to 18.4). Following failed thrombetcomy and stent deployment, the rate of favorable outcome (modified Rankin Scale score 0–2) was 43% (95% CI 34% to 53%). Pooled mortality was 21% (95% CI 13% to 33%). Successful recanalization (Thrombolysis in Cerebral Infarction (TICI) 2b–3 or Thrombolysis in Myocardial Infarction (TIMI) 2–3) was 71% (95% CI 63% to 77%). Symptomatic intracerebral hemorrhage was seen in 12% (95% CI 7% to 18%). The Solitaire stent (Medtronic) was the most commonly deployed stent following failed thrombectomy attempts (66%; 95% CI 31% to 89%). Pre- or post-stent angioplasty was performed in 39%of patients (95% CI 29% to 48%). Glycoprotein IIb/IIIa inhibitors were used in 89% (95% CI 71% to 97%). 95% of patients received postprocedural antiplatelet therapy.ConclusionA rescue stent procedure seems reasonable as a last resort following failed thrombectomy but currently the level of evidence is limited. Prospective registries may aid in guiding future recommendations.

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What to do about fibrin rich ‘tough clots’? Comparing the Solitaire stent retriever with a novel geometric clot extractor in an in vitro stroke model

Abstract: Application of the GCE in this experimental stroke model to retrieve typically recalcitrant fibrin rich clots resulted in higher successful recanalization rates than the SR.

Cited by 60 publications

References 17 publications

Stent retrievers with segmented design improve the efficacy of thrombectomy in tortuous vessels

Stent retrievers with segmented design improve the efficacy of thrombectomy in tortuous vessels

Thrombus Enhancement Is a Predictor of Clinical Outcome in Acute Ischemic Stroke after Mechanical Thrombectomy

A systematic review and meta-analysis of observational evidence for the use of bailout self-expandable stents following failed anterior circulation stroke thrombectomy

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