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Why Does Mechanical Thrombectomy in Large Vessel Occlusion Sometimes Fail?

A Review of the Literature

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Abstract

Thrombectomy is a technique that has completely changed the management of acute stroke and current devices have shown that they can achieve upwards of 90% successful recanalization in selected cohorts. However, despite the effectiveness of these devices, there are a proportion of patients who still fail to achieve reperfusion of the affected vascular territory and an even larger portion of patients who have poor functional outcomes in spite of successful recanalization. There are no guidelines on how to treat these patients when such failures occur. In an effort to understand the underpinnings of how failed thrombectomy occurs, we extensively reviewed the current literature in clot properties, vascular access problems, stroke pathogenic mechanisms, embolic complications, failed procedures and pre-procedural imaging. A short summary of each of these contentious areas are provided and the current state of the art. Together these elements give a cohesive overview of the mechanisms of failed thrombectomy as well as the controversies facing the field. New techniques and devices can then be developed to minimize such factors during stroke thrombectomy.

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Acknowledgements

The authors gratefully acknowledge David Vale and Michael Gilvarry of Neuravi/Cerenovus Inc. for the use of figures and videos from their in vitro modeling.

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Authors and Affiliations

  1. Division of Neurology, Department of Medicine, National University Health System, 1E Kent Ridge Rd, 119228, Singapore, Singapore

    Leonard L. L. Yeo & Benjamin Tan

  2. Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore

    Leonard L. L. Yeo, Anil Gopinathan, Yang Cunli & Benjamin Tan

  3. Department of Neuroradiology, St. Bartholomew’s and the Royal London Hospital, London, UK

    Pervinder Bhogal

  4. Department of Diagnostic Imaging, National University Health System, Singapore, Singapore

    Anil Gopinathan & Yang Cunli

  5. Department of Clinical Neuroscience, Karolinska Institutet and Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden

    Tommy Andersson

  6. Department of Medical Imaging, AZ Groeninge, 8500, Kortrijk, Belgium

    Tommy Andersson

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  1. Leonard L. L. Yeo
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Correspondence to Leonard L. L. Yeo.

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Conflict of interest

L.L.L. Yeo has received substantial grant funding from the National Medical Research Council (NMRC), Singapore, substantial grant funding from the Ministry of Health (MOH), Singapore and a moderate grant funding from I2R, A‑STAR, Singapore. P. Bhogal is consultant for Neurvana Medical and Phenox. T. Andersson is a consultant for Ablynx, Amnis Therapeutics, Medtronic, Neuravi/J&J, Rapid Medical and Stryker. A. Gopinathan, Y. Cunli and B. Tan declare no conflict of interest.

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Yeo, L.L.L., Bhogal, P., Gopinathan, A. et al. Why Does Mechanical Thrombectomy in Large Vessel Occlusion Sometimes Fail?. Clin Neuroradiol 29, 401–414 (2019). https://doi.org/10.1007/s00062-019-00777-1

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