Clinical study
Hybrid mechanical thrombectomy for acute ischemic stroke using an intermediate aspiration catheter and Trevo stent simultaneously

https://doi.org/10.1016/j.jocn.2020.04.079Get rights and content

Highlights

  • Catheter aspiration and stent retrievers have limitations (thrombus migration).

  • We designed hybrid MT using an intermediate aspiration catheter and a Trevo stent.

  • Hybrid MT had a shorter procedure time and fewer attempts.

  • Hybrid MT showed a higher first pass successful recanalization rate.

Abstract

Purpose

To overcome the limitations of traditional mechanical thrombectomy (MT), including catheter aspiration and stent retrievers, such as thrombus fragmentation or migration, we designed hybrid MT using an intermediate aspiration catheter and a Trevo stent simultaneously. We retrospectively compared hybrid MT with the traditional MT.

Methods

From January 2017 to January 2019, we performed MT on 91 occlusions, including internal carotid artery bifurcation (n = 17), M1 segment (n = 53) and M2 segment (n = 21), using hybrid MT (n = 42) and traditional MT (n = 49).

Results

Hybrid MT had a shorter procedure time (52.4 ± 22.0 vs. 73.0 ± 36.2 min, p = 0.002) and fewer attempts (1.50 ± 0.86 vs. 1.92 ± 1.10 times, p = 0.049) than traditional MT did. Hybrid MT achieved more good clinical outcome (3-month modified Rankin Scale score, 2 or less) and better successful recanalization (Thrombolysis In Cerebral Infarction grade, 2b or 3) than traditional MT did, but the difference was not significant (61.9% vs. 55.1%, p = 0.531, 92.9% vs. 87.8%, p = 0.498). Hybrid MT showed a higher first pass successful recanalization rate than traditional MT did (69.0% vs. 40.8%, p = 0.011). Multivariable logistic regression analysis demonstrated that first pass successful recanalization is related to the M1 segment rather than other segments (adjusted odds ratio (OR); 3.277, confidence interval (CI); 1.227–8.749, p = 0.018) and hybrid MT rather than traditional MT (adjusted OR; 4.995, CI; 1.725–14.460, p = 0.003).

Conclusions

Hybrid MT can be used as a first-line MT modality, particularly in M1 occlusion, based on our high first pass successful recanalization results.

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.

Section snippets

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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