Clinical studyHybrid mechanical thrombectomy for acute ischemic stroke using an intermediate aspiration catheter and Trevo stent simultaneously
Introduction
Mechanical thrombectomy (MT) has been accepted as a standard treatment option for acute large artery occlusion [1], [2], [3], [4], [5]. Traditional MTs, including catheter aspiration and stent retrievers, have been widely used. However, these techniques have limitations, such as thrombus fragmentation and migration during withdrawal of the aspiration catheter or stent retrievers, resulting in incomplete or failed recanalization [6], [7], [8], [9], [10], [11]. To overcome these limitations, new techniques using stent retrievers and aspiration catheters simultaneously, such as continuous aspiration prior to intracranial vascular embolectomy (CAPTIVE) [10] or stent retriever-assisted vacuum-locked extraction (SAVE) [7], have been introduced. However, the risk of fragmentation and migration has remained. By using a balloon guide catheter (BGC) in these techniques, completely suppressing antegrade blood flow is possible. These new techniques have been introduced as aspiration-retriever technique for stroke (ARTS) [8], a stent-retrieving into an aspiration catheter with proximal balloon (ASAP) [12] and proximal balloon occlusion together with direct thrombus during stent retriever thrombectomy (PROTECT) [9].
At our hospital, we used a hybrid MT using an intermediate catheter as suction aspiration and a stent retriever simultaneously as follows: 1) a stent (Trevo, Stryker Neurovascular, Fremont, CA, USA) is deployed to cover the entire thrombus burden; 2) subsequently, the intermediate catheter (Catalyst 6F; Stryker Neurovascular) is navigated to the proximal portion of thrombus burden according to the deployed stent system; 3) proximal flow is arrested by BGC (9F Optimo; Tokai Medical Products, Aichi, Japan); and 4) the intermediate catheter and stent are removed simultaneously under continuous negative pressure with a 50 cc syringe, without removing the stent delivery microcatheter completely.
In this study, we retrospectively compared our hybrid MT with traditional MT regarding clinical outcome, radiological outcome and procedure-related factors. We also evaluated factors affecting the first pass successful recanalization, which could be considered to be an important factor for good clinical outcomes in MT for acute large artery occlusions.
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Patient selection criteria and patient characteristics
From January 2017 to January 2019, 129 consecutive patients who met the inclusion criteria were selected for this study. The inclusion criteria were as follows: 1) acute ischemic stroke with symptoms, 2) large artery occlusions confirmed by either CT or MR angiography, 3) period of less than 24 h from the last normal time (LNT) to treatment, and 4) treated using hybrid MT or traditional MT, with a BGC for both techniques.
Among the patients, 38 patients were excluded for the following reasons:
Results
In our study of 91 patients with large artery occlusions treated by MT, 53 patients (58.2%) achieved good clinical outcomes, and successful recanalization was achieved in 82 patients (90.1%). The mortality rate was 7.7% (n = 7 out of 91 patients); among these mortalities, four patients died of medical problems such as pneumonia (n = 3) or cancer (n = 1). Postprocedure hemorrhage occurred in 23 patients (25.3%); among these patients, 6 had intracerebral hemorrhage that did not need surgical
Discussion
MT has become the standard treatment for managing acute ischemic stroke caused by large vessel occlusion [1], [2], [3], [4], [5]. However, traditional MT, including suction aspiration and a stent retriever, has a high incidence of thrombus fragmentation and migration by embolization in new territories (7–9% of cases in the SWIFT and TREVO trials, and up to 14% in subsequent registries; 10% of cases in the ADAPT series) [8]. Recently, new techniques using a combination of stent retriever and
Conclusion
In our study, hybrid MT achieved better clinical and radiological outcomes than traditional MT, although the statistical significance was insufficient. Additionally, hybrid MT significantly reduced procedure time and attempt number in comparison with traditional MT. Because first pass successful recanalization was achieved more frequently with hybrid MT than with traditional MT, particularly in M1 occlusion, hybrid MT can be used as a first-line MT modality, particularly in M1 occlusion.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Ethical approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study formal consent is not required.
Informed consent
Informed consent was obtained from all individual participants included in the study.
Animal experiments
This article does not contain any studies with animals performed by any of the authors.
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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