Walrus Balloon Guide Catheter for Stroke Intervention: Technical Considerations and Clinical Outcomes.

BACKGROUND: The use of balloon guide catheters (BGCs) for proximal flow arrest during neurointerventional procedures has been limited owing to the incompatibility of BGCs with large-bore aspiration catheters and difficulty in device navigation. The objective of our study was to describe the use of the Walrus catheter (Q'Apel Medical, Fremont, California, USA), a new 8F BGC, with a variety of aspiration catheters and procedures requiring flow arrest. METHODS: Consecutive cases using Walrus BGCs for proximal flow arrest during mechanical thrombectomy for acute stroke cases were recorded. The procedure indication, vessel occlusion site, technique, first-pass effect (modified thrombolysis in cerebral infarction score of 2C or 3 after the first recanalization attempt), and complications were recorded and evaluated statistically. RESULTS: Our study included 57 patients who had undergone mechanical thrombectomy. In addition to mechanical thrombectomy, the Walrus BGC was used in conjunction with the following techniques: stent retrieval in 2 patients (3.5%), stent retrieval followed by aspiration (Solumbra technique) in 41 (71.9%), and aspiration followed by stent retrieval in 14 patients (24.6%). Eight different aspiration catheters were used in 56 of these 57 procedures. The first-pass effect (modified thrombolysis in cerebral infarction score of 2C and 3) was achieved in 36 (63.2%) of 57 procedures. Two patients (3.5%) had experienced intraoperative complications (symptomatic intracerebral hemorrhage) and one patient (1.8%) had died in-hospital. CONCLUSIONS: Our results have demonstrated that the Walrus BGC is a highly navigable 8F guide catheter compatible with most available aspiration catheters. Owing to its compatibility with most available aspiration catheters and ease of use, the Walrus BGC is a valuable addition to the tools available for mechanical thrombectomy.

Influence of Thrombus Composition on Thrombectomy: ADAPT vs. Balloon Guide Catheter and Stent Retriever in a Flow Model.

PURPOSE: A first-pass, direct aspiration technique and stent retrieval with a balloon guide catheter represent advanced thrombectomy techniques that are increasingly being used in the clinical routine. The purpose of this experimental study was to evaluate whether the techniques' effectiveness depended on the clot composition and to visualize the interaction between the devices and the clot. MATERIALS AND METHODS: Erythrocyte-rich (red) and fibrin-rich (white) clots were placed into the M1-segment of the middle cerebral artery in a transparent vascular phantom with physiological architecture. Physiological hemodynamic conditions were maintained with a programmable pump. On the one hand direct aspiration with a 5F aspiration catheter (ADAPT) and on the other hand stent retrieval with a balloon guide catheter (flow arrest/reversal) was performed. The experiments were made under direct visual control to observe the interaction between the devices and the clot. The primary end points were the number of passes/maneuvers and the occurrence of distal emboli and emboli in a new territory (anterior cerebral artery), until full recanalization was achieved. The experiment was filmed with a full high-definition camera identifying emboli. RESULTS: Six experiments were conducted for each technique and clot model. Red clots were retrieved by ADAPT with fewer passes and distal emboli, and could usually be aspirated directly at the occlusion site. White clots clogged the tip of the 5F aspiration catheter in every experiment. The catheter had to be pulled back into the long sheath in the cervical internal carotid artery, producing distal emboli. White clots were retrieved by the stent retriever and balloon guide catheter with fewer distal emboli. There was no difference in the number of passes. The stent-thrombus interaction was superficial in both clot models. Successful retrieval was granted by the flow arrest and proximal aspiration/flow reversal. One embolus in a new territory developed when using each technique in white clots. CONCLUSION: This experimental study showed that the efficacy of advanced thrombectomy techniques might depend on clot composition. Identifying the right technique for the right clot might improve the results of thrombectomy. In a clinical setting the thrombus morphology in non-enhanced CT could be used as a marker for patient selection. KEY POINTS: · The efficacy of thrombectomy seems to depend on thrombus composition.. · ADAPT might be more effective for rbc-rich clots.. · Thrombectomy with BGC might be more effective for fibrin-rich clots.. CITATION FORMAT: · Madjidyar J, Pineda Vidal L, Larsen N et al. Influence of Thrombus Composition on Thrombectomy: ADAPT vs. Balloon Guide Catheter and Stent Retriever in a Flow Model. Fortschr Röntgenstr 2020; 192: 257 - 263.

Surgery for the Venous Disaster - Phlegmasia Cerulea Dolens.

Phlegmasia cerulea dolens is an acute fulminating form of extensive venous thrombosis. Limb loss, post-thrombotic syndrome and life-threatening conditions can occur without appropriate management. Treatment methods vary; there presently is no consensus on the best form of treatment. Endovascular procedures have been a good option for treating deep vein thrombosis, yet they may be insufficient for patients suffering from phlegmasia cerulea dolens. Venous thrombectomy with the guidance of venography quickly relieves symptoms, hardly causes complications, yields optimal mid-term results, and can be a justifiable treatment for phlegmasia cerulea dolens.

Balloon-assisted tracking technique to overcome intracranial stenosis during thrombectomy for stroke.

Anatomical vessel obstacles such as an intracranial stenosis in stroke are challenging and may lead to delayed clot access for thrombectomy. We describe a simple and effective technique to overcome the step-off between the intermediate catheter and an intracranial vessel stenosis during thrombectomy. The patient presented with acute embolic left middle cerebral artery occlusion and a favorable penumbral pattern. Clot access was made challenging by focal stenosis in the ipsilateral cavernous segment. The balloon-assisted tracking technique was effective in traversing the step-off to enable TICI 3 aspiration thrombectomy. This simple and effective technique should be kept in mind during stroke procedures where a proximal stenotic obstacle complicates access to the site of occlusion.

Double Fogarty balloon catheter technique for difficult to retrieve esophageal foreign bodies.

BACKGROUND: Foreign body ingestion is common, especially in the pediatric population. Plans for retrieval should be tailored to the specific esophageal foreign bodies. CASE PRESENTATION: We present a difficult to retrieve esophageal foreign body in a 3-year-old girl who ingested a 2 cm glass pebble. Intraoperatively, attempts using conventional optical forceps and retrieval baskets were unsuccessful due to the size and smooth texture of the object. A novel strategy using double Fogarty embolectomy balloon catheters for retrieval of blunt esophageal foreign bodies was devised and described. CONCLUSION: The double fogarty retrieval technique described appeared to be safe and efficacious, allowing for extraction of large esophageal foreign bodies under direct visualization.

A novel balloon technique to induce intra-abdominal hypertension and its effects on cardiovascular parameters in a conscious dog model.

OBJECTIVE: To evaluate a new balloon technique to induce intra-abdominal hypertension (IAH) and abdominal compartment syndrome in a conscious dog model, and to evaluate the effect of intra-abdominal pressure (IAP) on cardiovascular, respiratory, and arterial blood gas values in conscious dogs with IAH. DESIGN: Prospective, experimental study. SETTING: University-based small animal research facility. ANIMALS: Six healthy Beagle dogs, 4 males, and 2 females. INTERVENTIONS: A new balloon device designed for this study using a Foley urethral catheter and latex balloon was placed in the abdominal cavity. Consecutive measurements of IAP were made by measuring the intravesicular pressure. The abdomen was inflated with air to IAPs of 10, 15, 20, and 25 mm Hg. Heart rate, respiratory rate, systolic arterial blood pressure, and arterial blood gases were evaluated at baseline and at 15, 30, 45, 60, 120, 240, and 300 minutes after IAP increase. MEASUREMENTS AND MAIN RESULTS: The air insufflated into the intra-abdominal balloon device significantly increased the IAP and led to sustained IAH. The respiratory rate increased significantly (P < 0.05) when IAP was increased to 15, 20, and 25 mm Hg. Although heart rate, systolic arterial blood pressure, PaO2 , and PaCO2 did not show statistically significant differences between baseline and posttreatment values over time, the dogs with increased IAP showed a distended abdomen and apparent discomfort, and 4/6 (67%) vomited. After measurement of IAP, air was removed. There were no adverse effects noted after removal of the balloon device. CONCLUSION: The balloon device was successfully insufflated and led to sustained IAH in conscious dogs. This balloon technique does not require general anesthesia for instillation or removal of gas after installment. An acute IAP increase in normal conscious dogs induced discomfort, vomiting, and increased respiratory effort.

Efficacy of Mechanical Thrombectomy Using Stent Retriever and Balloon-Guiding Catheter.

PURPOSE: Intra-arterial therapy of acute ischemic stroke has developed rapidly in recent years. Due to proven efficacy in randomized trials, stent retrievers were replacing first-generation thrombectomy devices and have been defined as method of choice. However, aspiration catheters or a combination of several techniques have shown promising rates of successful recanalizations. To create a basis for comparison of the new approaches according to real-world data, we determined the first pass recanalization rate of an evidence-based standard technique with the use of a stent retriever in combination with a balloon-guiding catheter. The assessment was based on the number of required passages and reperfusion rate, but not on clinical results. METHODS: Patients from our institution with anterior circulation occlusions and mechanical thrombectomy by using stent retrievers in combination with balloon-guiding catheters were analyzed retrospectively. Reperfusion was graded with the "thrombolysis in cerebral infarction" (TICI) classification on post-interventional angiograms. Additionally, the number of passes and the duration of the recanalization procedure were recorded. RESULTS: Between 2014 and July 2017, 201 patients met the inclusion criteria. Successful recanalization, defined as a TICI scale 2b/3, was 91% (TICI 2b was achieved in 44% and TICI 3 in 47%) after the procedure. After the first passage, successful recanalization was achieved in 65% of the patients. Mean number of passes was 1.4 (1-5 passes) for all patients. Median duration of the procedure was 49 min (0:11-2:35 h). CONCLUSIONS: Even a standard thrombectomy technique with the use of a stent retriever together with a balloon-guiding catheter provides reasonable recanalization rates with only one passage. The results can be taken as benchmark for alternative and more complex techniques.

Initial clinical experience using the two-stage aspiration technique (TSAT) with proximal flow arrest by a balloon guiding catheter for acute ischemic stroke of the anterior circulation.

BACKGROUND: Our initial experience using the two-stage aspiration technique (TSAT) with proximal flow arrest by a balloon guiding catheter is presented. In TSAT, aspiration is applied with the 5MAX ACE and also with the 3MAX catheter with a Penumbra aspiration pump, while arresting proximal flow by balloon inflation. METHODS: In patients treated with TSAT, clinical data including National Institutes of Health Stroke Scale (NIHSS) score at admission and the modified Rankin Scale (mRS) score at discharge, as well as procedural data including the Thrombolysis in Cerebral Infarction (TICI) score, procedural time, and complications were analyzed. RESULTS: Thirty-four consecutive patients (19 men (56%); mean age 73 years) were treated with TSAT using a balloon guiding catheter. The patients presented with a mean NIHSS score of 17.4 and 23 (68%) patients received IV tissue plasminogen activator. Median time from groin puncture to successful recanalization was 41 min (range 15-160 min). All patients were successfully revascularized; TICI 2b or better recanalization was achieved in 30 (88%) patients. No patient required an additional procedure such as use of a stent retriever. Procedure-related complications occurred in two (5.9%) patients (vessel injury and guidewire perforation). Symptomatic intracranial hemorrhage occurred in one patient and asymptomatic hemorrhagic infarction occurred in two patients. There were no cases of embolization to new territory (ENT). The mean NIHSS score at discharge improved to 6.1. Sixteen patients (47%) achieved a good outcome with an mRS score of 0-2 at discharge (mean hospitalization period 20 days). CONCLUSIONS: TSAT with proximal flow arrest by a balloon guiding catheter is an effective and safe method to achieve good clinical and angiographic outcomes. This method may reduce ENT in the direct aspiration first-pass thrombectomy (ADAPT) technique.

The relationship between the duration of acute cauda equina compression and functional outcomes in a rat model.

STUDY DESIGN: Immunohistochemical and behavioral study using a rat model of acute cauda equina syndrome (CES). OBJECTIVE: To determine the effect of duration of extradural cauda equina compression (CEC) on bladder, sensory, and motor functions. SUMMARY OF BACKGROUND DATA: Cauda equina syndrome is a devastating injury treated with surgical decompression. Controversy exists regarding the optimal timing of surgery. Animal models of CES have focused on motor recovery but have not evaluated pain behavior or bladder function. METHODS: A 4-mm balloon-tipped Fogarty catheter was inserted between the fifth and sixth lumbar lamina into the dorsal epidural space and inflated to compress the nerve roots at the L5 level. Maximal inflation was maintained at a constant balloon pressure of 304 Kpa for 1 or 4 hours. The catheter was inserted but not inflated in sham animals. During a 4-week period, pain behavior, bladder function, and locomotor function were assessed. Postmortem bladders and the lesion site were collected for analysis. RESULTS: Mechanical allodynia was 2-fold greater in 1-hour CEC rats than 4-hour CEC (P=0.002) and sham-operated (P=0.001) rats at 4 weeks after injury. Hind limb locomotor function was not different between groups at 4 weeks after injury. Both the 1-hour and 4-hour CEC group rats retained greater volumes of urine than the sham-operated rats throughout the 4-week period (P<0.05). At 4 weeks, bladder weight and volume were 2-fold greater in the 4-hour CEC group than in the 1-hour CEC group (P=0.006 and P=0.01, respectively). Histology of the bladder wall revealed an overall thinning after 4-hour CEC. Histology of the lesion site revealed a greater overall severity of injury after 4-hour CEC than after 1-hour CEC (P=0.04) and sham operation (P=0.002). CONCLUSION: Our data suggest that recovery of motor function is less affected by the timing of decompression compared with bladder function and pain behavior. Early decompression preserved bladder function but was associated with allodynia. LEVEL OF EVIDENCE: N/A.

Treatment of elastase-induced intracranial aneurysms in New Zealand white rabbits by use of a novel neurovascular embolization stent device.

INTRODUCTION: This study aims to test a novel balloon expandable stent covered with a polytetrafluoroethylene membrane (neurovascular embolization cover (NEC), NFocus Neuromedical, Palo Alto, California) regarding angiographic and histologic aneurysm occlusion. Radiopacity, stent placement, navigation, flexibility, and intimal proliferation were also evaluated. METHODS: Eight aneurysms were induced in New Zealand white rabbits. Digital subtraction angiography (DSA) was performed directly after stent placement and after 5 and 10 min. Four and 8 weeks after stent placement, an intra-arterial DSA control was performed. The animals were then sacrificed and the aneurysms histologically evaluated. RESULTS: The radiopaque markers were clearly visible. Although all the stents were easily navigated into the subclavian artery, the limited flexibility of the stent resulted in straightening of the vessel in four cases. As a result, exact stent placement was achieved and acutely confirmed in only two cases. However, at sacrifice, angiographic and histologic occlusion was noted at follow-up in five aneurysms. CONCLUSION: In tortuous anatomy, the relative stiffness of the stent makes exact stent placement challenging. This may have been exacerbated by the movement of the vessels due to proximity to the heart in this model. Future studies should evaluate whether existing residual flow into an aneurysm lumen might lead to embolization without any additional treatment. Anticoagulation remains a very important part of aneurysm treatment with stents. The trend toward aneurysm occlusion by excluding it from the blood circulation seems a promising method in future endovascular therapy. The NEC device shows good potential.

Identification of the narrow lumen of the ureter using a Fogarty catheter during laparoscopic pyeloplasty.

It is difficult to identify the narrow sites of the ureter from the outside while carrying out laparoscopic pyeloplasty in patients with ureteropelvic junction obstruction. We developed and named a new method, the Fogarty test, to identify the narrow sites of the ureter using a Fogarty catheter. A 4- to 5-Fr Fogarty catheter was inserted through an incision in the pelvis to the proximal ureter, inflated with air and withdrawn gently to determine resistance. The narrow lumen of the ureter was identified under direct vision and spatulated by laparoscopic scissors. This procedure was carried out repeatedly until the ureter was fully spatulated. By using the Fogarty test, we can visualize the narrow position and length of the ureter under direct vision, and confirm whether it is fully spatulated or not. This technique is very simple and easy to carry out. We believe it is useful for sufficient spatulation of intrinsic ureteral stricture, especially in patients where multiple narrow sites exist.

Percutaneous retrogasserian balloon compression for trigeminal neuralgia: review of critical technical details and outcomes.

OBJECTIVE: To describe percutaneous balloon compression (PBC) of the trigeminal rootlets as treatment for trigeminal neuralgia (TN), including history, operative techniques, outcomes, side effects, and some recent findings increasing the likelihood of a positive outcome. METHODS: PBC is indicated in patients with TN in whom microvascular decompression is considered less suitable. The procedure is simplified by the use of biplanar fluoroscopy, although it is usually carried out with C-arm fluoroscopy to facilitate the introduction of the needle and the visualization of the inflated catheter. In the right position, a clearly defined pear shape usually appears after injection of 0.5-0.7 mL of contrast material. The balloon is kept inflated for 1.5-3 minutes. It is crucial to obtain a pear shape because this probably is the most significant factor for obtaining good, long-lasting pain relief. RESULTS: An analysis of 100 consecutive PBC procedures showed an initial success rate of 90% and a median pain-free time without medication of 28 months. Subdividing these patients into primary TN (n = 77) and TN secondary to multiple sclerosis (n = 23), the median pain-free times were 33 months and 24 months (P = 0.2), indicating that the outcome may depend on the preoperative conditions. CONCLUSIONS: Complications and side effects include cardiovascular stress during the procedure, local hemorrhages in the cheek, postoperative sensory disturbance, masseter weakness, infections, and transitory diplopia after surgery. Measures to minimize side effects are proposed. With meticulous technique, PBC is a straightforward, effective, and fast procedure that compares well with other percutaneous therapies for TN.

Use of a Fogarty catheter after tracheobronchial inhalation of a bead.

We describe a case of tracheobronchial inhalation of a bead by a five-year-old girl in Djibouti. The bead was extracted using a Fogarty balloon catheter passed through the rigid bronchoscope without complication. This kind of accident is not exceptional and we discuss the management of such cases with limited diagnostic tools and therapeutic environments.