Stent Retriever Angioplasty for Acute Restenosis of the Middle Cerebral Artery: A Case Report.

We present a case of ischemic stroke treated by stent retriever angioplasty for restenosis during mechanical thrombectomy. An 85-year-old man was admitted to our hospital because of left hemiplegia and left-sided hemispatial neglect caused by an occlusion at the origin of the right middle cerebral artery. Although mechanical thrombectomy transiently resulted in recanalization of the occluded lesion, restenosis immediately occurred and recurred repeatedly. On an angiogram, the stent retriever appeared poorly dilated at the stenosis and showed a contrast deficit. We concluded that restenosis was due to a secondary thrombus resulting from a ruptured atherosclerotic plaque. The stent retriever was kept deployed for 15 minutes. After the stent was retrieved, restenosis did not occur. Stent retriever angioplasty may be effective for determining the cause of restenosis after mechanical thrombectomy as well as for the treatment of restenosis.

Efficacy and safety of combined stent retriever and contact aspiration vs. stent retriever alone on revascularization in patients with acute ischemic stroke: a systematic review and meta-analysis.

Objective: Whether the efficacy of combined stent retriever and contact aspiration (S + A) is superior to stent retriever (S) alone for revascularisation in patients with large vessel occlusive stroke remains uncertain. The aim of this meta-analysis was to assess the safety and efficacy of combined stent retriever and contact aspiration for the treatment of acute ischaemic stroke with large vessel occlusion by comparing it with stent retriever alone. Methods: We systematically searched the PubMed, Embase, Web of Science, and The Cochrane Library databases for randomised controlled trials and observational studies (case-control and cohort studies) published before 1 October 2023 comparing the efficacy of combined stent retriever and contact aspiration versus tent retriever alone in patients with large vessel occlusive stroke. The end point of the primary efficacy observed in this meta-analysis study was the rate of first pass nearly complete or complete recanalisation (mTICI 2c-3). Secondary effectiveness nodes were: rate of first pass successful recanalisation (mTICI 2b-3), rate of near-complete or complete recanalisation of the postoperative vessel, rate of successful recanalisation of the postoperative vessel, and MRS 0-2 within 90 days. Safety endpoints were interoperative embolism, symptomatic intracranial haemorrhage, and mortality within 90 days. Results: A total of 16 studies were included in the literature for this meta-analysis, with a total of 7,320 patients (S + C group: 3,406, S group: 3,914). A comprehensive analysis of the included literature showed that combined stent retriever and contact aspiration had a higher rate of near-complete or complete recanalisation of the postoperative vessel [OR = 1.53, 95% CI (1.24, 1.88), p < 0.0001] and rate of successful recanalisation of the postoperative vessel compared to stent retriever alone [OR = 1.83, 95% CI (1.55, 2.17), p < 0.00001]; there were no statistically significant differences between the two groups in terms of the rate of first pass nearly complete or complete recanalisation [OR = 1.00, 95% CI (0.83, 1.19), p = 0.96], rate of first pass successful recanalisation [OR = 1.02, 95% CI (0.85, 1.24), p = 0.81], interoperative embolism [OR = 0.93, 95% CI (0.72, 1.20), p = 0.56], symptomatic intracranial haemorrhage [OR = 1.14, 95% CI (0.87, 1.48), p = 0.33], MRS 0-2 within 90 days [OR = 0.89, 95% CI (0.76, 1.04), p = 0.14] and mortality within 90 days [OR = 1.11, 95% CI (0.94, 1.31), p = 0.22]. Conclusion: Combined stent retriever and contact aspiration has a higher rate of postprocedural revascularisation (mTICI 2c-3/mTICI 2b-3) compared with stent retriever alone in patients with large vessel occlusion stroke. In addition, it was not superior to stenting alone in terms of the rate of first pass recanalisation (mTICI 2c-3/mTICI 2b-3), interoperative embolisation, symptomatic intracranial haemorrhage, good functional prognosis within 90 days and mortality within 90 days.

Endovascular treatment of embolism-related acute basilar artery occlusion stroke: ADAPT versus stent retriever thrombectomy.

PURPOSE: This study aimed to compare the efficacy and safety of a direct aspiration first-pass technique (ADAPT) and stent retriever thrombectomy (SRT) technique in embolism-related acute basilar artery occlusion (EMB-ABAO). METHODS: We collected data from patients with EMB-ABAO in multiple stroke centers from January 2017 to February 2024. We defined two groups of enrolled patients, the ADAPT group and the SRT group. The primary outcome was the first attempt recanalization (FAR) rate. Secondary outcomes were the puncture to recanalization (PTR) time and the 90-day favorable functional outcome. The safety outcome was 90-day all-cause mortality rate. RESULTS: A total of 406 patients were screened for endovascular treatment (EVT) of ABAO ischemic stroke, and 108 patients were identified with EMB-ABAO stroke. Among these, 96 patients were included in the final analysis. Among them, 58 (60.42%) were in the ADAPT group, and 38 (39.58%) were in the SRT group. Compared with the SRT group, the ADAPT group achieved FAR more frequently (60.34% versus 39.47%; p = 0.045) and a higher 90-day favorable functional outcome rate (44.83% versus 36.84%; p = 0.438). The median PTR time of the ADAPT group was significantly shorter than that of the SRT group (42 versus 105 min; p < 0.001). CONCLUSION: In cases where EMB-ABAO is suspected, ADAPT was superior to SRT in terms of FAR rate and PTR time, but the 90-day mRS scores had no statistical significance. Given the reduced time to recanalization with ADAPT, an initial attempt at recanalization with ADAPT may be necessary before stent retriever. However, due to the study limitations, these findings should be interpreted as preliminary and require further study.

Mechanical thrombectomy with Embolus Retriever with Interlinked Cages device for medium vessel occlusions: First pass results and safety profile.

BACKGROUND: Reperfusion of medium vessel occlusions is correlated with good outcomes. However, optimal techniques and medical devices are still unclear. In this study, we sought to evaluate the safety and efficacy of mechanical thrombectomy with Embolus Retriever with Interlinked Cages (ERIC™) retrieval device in patients with acute ischemic stroke due to distal medium vessel occlusions. METHODS: A retrospective review of the prospectively collected mechanical thrombectomy database revealed 50 patients who had fulfilled the inclusion criteria. The data collected includes clinical patient characteristics, procedural measures, timestamps at each stage, and patient outcomes. Intravenous thrombolytics application, pre- and post-intervention imaging findings, device-related adverse events and any type of intracranial hemorrhage were recorded. RESULTS: There were 25 men (50%) and 25 women (50%) with a median of 67 years (interquartile range (IQR) 41-84). Median presenting NIHSS was 14 (IQR, 3-23). First pass rates were: eTICI3 in 16 cases (32%), eTICI-2c in eight cases (16%), eTICI-2B67 in nine cases (10%), eTICI2B50 in three cases (6%) and mTICI 0-2A in 18 cases (36%). Final recanalization rate of mTICI 2b-3 was 90% and 2c-3 was 70%. CONCLUSION: In conclusion, the ERIC thrombectomy device offers a high rate of first-pass success along with a favorable safety profile. Larger series and multi-center studies are needed for further investigation.

Stent-retriever characteristics and strategies associated with recanalization in thrombectomy for acute ischemic stroke.

INTRODUCTION: Predictive factors for successful reperfusion in mechanical thrombectomy for acute ischemic stroke, and especially technical factors, remain controversial. We investigated various techniques for better angiographic outcomes. METHODS: In this retrospective study, acute ischemic stroke patients with large vessel occlusion treated with mechanical thrombectomy with combined technique were included. Scoring of the reperfusion grade for each attempt was conducted, and each attempt was divided into two groups based on successful reperfusion, which was defined using the presence or absence of modified thrombolysis in cerebral infarction 2b-3. The following characteristics were evaluated: the choice of stent-retriever, its length, occlusion site, thrombus position relative to deployed stent-retriever, methods of thrombectomy, and successful advancement of the distal access catheter to the proximal end of the thrombus. RESULTS: Among 251 patients who underwent mechanical thrombectomy, 154 patients (255 attempts: mTICI 0-2a group, n = 119; mTICI 2b-3 group, n = 136) were included in the analysis. The thrombus position relative to the deployed stent-retriever was likely associated with successful reperfusion, although it was not statistically significant (proximal two-thirds 56.8 %; distal one-third 44.3 %, p = 0.09). Successful advancement of the distal access catheter was related to successful reperfusion both in univariate analysis (success 57.9 %; fail 35.8 %, p < 0.01) and in multivariate regression analysis (odds ratio 2.45; 95 % confidence interval: 1.30-4.61, p < 0.01). CONCLUSIONS: Successful advancement of the distal access catheter to the proximal end of thrombus might be a key component for successful reperfusion in mechanical thrombectomy.

Coaxial Method of PTA Balloon and Aspiration catheter using the delivery wire of a stent retriever for tandem occlusion: CoMBAt tandem occlusion.

PURPOSE: Tandem occlusion, in which the intracranial artery is obstructed along with proximal carotid occlusive or stenotic lesions, occurs in 10-15% of patients with large vessel occlusion. Our study introduces a novel technique for tandem occlusion treatment that involves the simultaneous coaxial deployment of a percutaneous transluminal angioplasty balloon and aspiration catheters with the delivery wire of a stent retriever. After percutaneous transluminal angioplasty of the carotid lesion with a thin balloon catheter, the aspiration catheter was advanced over the balloon to eliminate the ledge between the catheter tip and delivery wire. After balloon removal, intracranial thrombectomy was performed using an aspiration catheter and stent retriever. This study aimed to evaluate the safety and efficacy of this approach. MATERIALS AND METHODS: Medical records of patients with acute stroke due to tandem occlusion treated using our technique were analyzed for its effectiveness and safety. The puncture-to-recanalization time, modified thrombolysis in cerebral infarction (mTICI) grade, functional prognosis and incidence of hyperperfusion were assessed. RESULTS: Seven patients were included in this study. In all patients, mTICI 2b-3 recanalization was achieved after smooth delivery of the aspiration catheter from the carotid lesion to the intracranial thrombus. The median puncture-to-recanalization time was 52 min. Ninety days post-stroke onset, six of seven patients had a modified Rankin Scale score of 0-2, and none of the patients had perioperative hyperperfusion syndrome. CONCLUSION: Our technique allows simultaneous treatment of carotid and intracranial lesions, leading to faster recanalization. Furthermore, percutaneous transluminal angioplasty with a thin balloon may reduce the risk of hyperperfusion.

The effect of stent retriever mechanical thrombectomy combined with tirofiban in treating acute ischemic stroke.

OBJECTIVE: To analyze the effectiveness of stent retriever mechanical thrombectomy combined with tirofiban in treating acute ischemic stroke. METHODS: Markedly effective is defined as an SIS score of over 90, effective is indicated by an SIS score of between 50-90, and a score of below 50 suggests ineffective treatment results. RESULTS: ①The treatment's overall effectiveness in the observation group (91.30%) was significantly higher than that in the control group (75.56%) (p < 0.05). ②The vascular recanalization rate in the observation group (89.13%) was significantly higher than that in the control group (71.11%) (p < 0.05). ③The stent retrieval operation count (2.41 ± 0.23) was significantly lower in the observation group than in the control group (1.29 ± 0.16) (p < 0.05). ④ After treatment, the platelet aggregation rate (10.74 ± 3.95) and NIHSS scores (6.58 ± 1.04) were significantly lower, and the Barthel index (77.86 ± 7.21) was significantly higher in the observation group compared to the control group (26.47 ± 5.12, 7.75 ± 2.36, 68.12 ± 6.15) (p < 0.05). All platelet aggregation rate, NIHSS scores and Barthel Index showed significant improvement after treatment when compared to those before treatment (p < 0.05). CONCLUSION: The combined application of stent retriever mechanical thrombectomy and tirofiban in acute ischemic stroke treatment shows promising effectiveness. Compared to stent retriever alone, tirofiban adjunctive therapy enhances vascular recanalization, reduces retrieval procedures, shortens treatment duration, inhibits platelet aggregation, and improves neurological function recovery, daily living activities, and prognosis. Moreover, it doesn't significantly increase symptom-related risks.

The effect of actuation frequency on clot integration with the Tigertriever device: A preliminary in vitro study.

BACKGROUND: The Tigertriever stent retriever (Rapid Medical) can be actively expanded and contracted by the operator, which allows for several actuation-related parameters to be optimized to potentially improve device efficacy. These parameters have not yet been evaluated. We conducted a benchtop study to evaluate the effect of actuation frequency on clot integration within the stent. METHODS: A Tigertriever 17 device was deployed within a biological clot analog placed in a straight tube. The device was actuated between the maximally contracted and maximally expanded states with three different frequencies: passive (one-time opening, n = 6), slow (20 s/cycle, n = 6), and fast (5 s/cycle, n = 7). A flat-detector CT scan was acquired, the clot and stent wires were segmented, and the boundaries of the clot and stent wires were calculated on each axial slice. The intersection between the stent and clot boundaries throughout the volume was defined as the volume of clot integrated within the stent. The clot integration factor (ratio of integrated clot volume to total clot volume) was then statistically compared between the three frequencies as an estimate of clot capture efficiency. RESULTS: The clot integration factor was significantly higher (23% increase, p = 0.01) with the fast actuation as compared to the passive and slow actuations, with a post hoc test showing no difference (p > 0.05) between the passive and slow groups. CONCLUSIONS: Faster actuation frequencies may result in improved clot integration with the Tigertriever device. This effect needs to be validated by clinical data.

Mechanical Thrombectomy in Stroke-Retrospective Comparison of Methods: Aspiration vs. Stent Retrievers vs. Combined Method-Is Aspiration the Best Starting Point?

Background: There are three main methods of mechanical thrombectomy (MT): using a stent retriever (SR) only (SO), aspiration catheter (AC) only (AO) and the combined method (CM) using both the SR and AC. This paper describes a real-life, single-center experience using SO, AO and CM during 276 consecutive MTs. Methods: The primary endpoint was the frequency of first-pass complete (FPE TICI3). The secondary endpoints were final mTICI 2b-3, procedure duration, clinical outcome and the total number of device passes. The third aim of this study was to test the association between the clinical outcomes in patients treated with each method and various factors. Results: There was a significant difference (p = 0.016) between the groups' FPE TICI3 rates with 46% mTICI 3 in the AO group, 41% in the CM group and 21% in the SO group. AO resulted in procedure time shortening to a mean duration of 43 min, and the scores were 56 min for CM and 63 min for SO (p < 0.0001). There were no significant differences in clinical outcomes or in-hospital mortality. The analysis showed a correlation between good clinical outcomes and the administration of IVT: OR 1.71 (1.03-2.84) p = 0.039. Patients ≥66 years old had higher odds of a bad outcome compared to younger patients in general (OR, 1.99 95% CI, 1.17-3.38; p = 0.011). FPE TICI3 was associated with good functional outcomes in the whole treated cohort (OR, 1.98; 95% CI, 1.21-3.25; p = 0.006). Conclusions: In our series, AO proved to be the best starting point in most cases. It demonstrates good technical efficacy regarding FPE, it is fast and clinical outcomes seem to be the least age- and FPE TICI3-dependent. It can be easily converted into the combined method, which had the second-best outcomes in our cohort.

Novel use of a closed-tip stent retriever to prevent distal embolism in the posterior circulation: illustrative case.

BACKGROUND: In mechanical thrombectomy for tandem occlusions in vertebrobasilar stroke, distal emboli from the vertebral artery lesion should be prevented. However, no suitable embolic protection devices are currently available in the posterior circulation. Here, the authors describe the case of a vertebral artery lesion effectively treated with a closed-tip stent retriever as an embolic protection device in the posterior circulation. OBSERVATIONS: A 65-year-old male underwent mechanical thrombectomy for basilar artery occlusion, with tandem occlusion of the proximal vertebral artery. After basilar artery recanalization via the nonoccluded vertebral artery, a subsequent mechanical thrombectomy was performed for the occluded proximal vertebral artery. To prevent distal embolization of the basilar artery, an EmboTrap III stent retriever was deployed as an embolic protection device within the basilar artery to successfully capture the thrombus. LESSONS: A stent retriever with a closed-tip structure can effectively capture thrombi, making it a suitable distal embolic protection device in the posterior circulation.

Initial experience with a novel stent-based mechanical thrombectomy device for management of acute myocardial infarction cases with large thrombus burden.

BACKGROUND: Patients with acute myocardial infarction (AMI) and large thrombus burden (LTB) still represent a challenge. Afflicted patients have a high morbidity and mortality. Aspiration thrombectomy is often ineffective in those cases. Mechanical thrombectomy devices (MTDs), which are effective for management of ischemic strokes, were recently CE-approved for treatment of thrombotic coronary lesions. Real-world data about their performance in AMI cases with LTB are scarce. This study sought to summarize our early experience with a novel MTD device in this context. METHODS: We analyzed consecutive patients from the prospective OPTIMISER registry (NCT04988672), who have been managed with the NeVa™ MTD (Vesalio, USA) for AMI with LTB at a tertiary cardiology facility. Outcomes of interest included, among others, periprocedural complications, target lesion failure (TLF), target lesion revascularization (TLR) and target vessel myocardial infarction (TV-MI). RESULTS: Overall, 15 patients underwent thrombectomy with the NeVa™ device. Thrombectomy was successfully performed in 14 (93%) patients. Final TIMI 3 flow was achieved in 13 (87%) patients, while 2 (13%) patients had TIMI 2 flow. We encountered no relevant periprocedural complications, especially no stroke, stent thrombosis or vessel closure. After a mean follow-up time of 26 ± 2.9 months, 1 (7%) patient presented with TLR due to stent thrombosis (10 months after treatment with the MTD and stenting). CONCLUSIONS: In AMI patients with LTB, the deployment of the novel NeVa™ MTD seems efficient and safe. Further randomized trials are warranted to assess whether the use of the NeVa™ device in cases with LTB improves procedural and clinical outcomes.

Mechanical Thrombectomy Using Double Stent Retriever Technique for Acute Ischemic Stroke Following Embolism From the Pulmonary Vein Stump After Left Upper Lobectomy: A Case Report.

Acute ischemic stroke (AIS) following pulmonary lobectomy, which is traditionally attributed to air embolism and atrial fibrillation (AF), may occur after thrombus formation in the pulmonary vein stump (PVS). Herein, we document the mechanical thrombectomy (MT) of a carotid bifurcation occlusion post-left upper lobectomy (LUL) to manage AIS. A 76-year-old male with a history of diabetes, dyslipidemia, and a treated dural arteriovenous fistula at the transverse sigmoid junction, with no history of AF, successfully underwent LUL for a pulmonary tumor. The patient independently walked on postoperative day 1. He developed right hemiparesis and total aphasia on the morning of the second day after surgery, which was discovered by the nursing staff. A magnetic resonance imaging (MRI) confirmed an occlusion of the left common carotid artery (CCA). Tissue plasminogen activator (t-PA) was not administered owing to recent surgery. An urgent MT using multiple MT techniques carried out 90 minutes after the discovery of symptoms only achieved partial recanalization. Subsequently, a double stent retriever technique (DSRT) addressed the occlusion in the common and cervical internal carotid artery (ICA). Following this, a T occlusion was encountered, which was addressed with a combined approach using a single stent retriever (SR), achieving a thrombolysis in cerebral infarction (TICI) grade 2b result. However, postoperative aphasia and severe right hemiparesis remained. Postoperative imaging showed a significant left cerebral hemisphere infarction and a thrombus in the PVS. Oral edoxaban was administered, and PVS thrombosis did not recur. The patient was transferred to a rehabilitation facility 190 days post-embolization with a modified Rankin Scale score of 4. In this report, we demonstrate the challenging case of the DSRT in addressing AIS after LUL, which led to the formation of a massive thrombus and occlusion of the carotid artery, as revealed by the PVS. This case emphasizes the importance of collaborative efforts between thoracic surgeons and all staff involved in stroke care in managing such complex scenarios.

Steerable microcatheter for distal access of a giant cavernous carotid artery aneurysm during treatment with Pipeline Embolization Device: A case report and review of the literature.

Background: In the treatment of giant cerebral aneurysms with flow-diverting stents, access to the distal parent artery is critical but occasionally challenging. This article provides our experience with a novel steerable microcatheter in such a situation, as well as a review of the literature. Case Description: A 73-year-old woman presented with right ptosis and external ophthalmoplegia. Magnetic resonance angiography revealed a giant right cavernous internal carotid artery aneurysm. Endovascular treatment was planned with flow diversion, but distal access was not possible using the standard technique. A 2.4-Fr steerable microcatheter, Leonis Mova Selective, was implemented, and by bending the catheter tip toward the distal parent artery, a guidewire could be guided distally. After the catheter exchange, two flow-diverting stents were deployed successfully. Conclusion: Steerable microcatheters may provide an option in treatment with flow-diverting stents for giant cerebral aneurysms where access to the distal parent artery is compromised.

Use of the pRESET LITE thrombectomy device in combined approach for medium vessel occlusions: A multicenter evaluation.

PURPOSE: Our purpose was to assess the efficacy and safety of the pRESET LITE stent retriever (Phenox, Bochum, Germany), designed for medium vessel occlusion (MeVO) in acute ischemic stroke (AIS) patients with a primary MeVO. METHODS: We performed a retrospective analysis of the MAD MT Consortium, an integration of prospectively maintained databases at 37 academic institutions in Europe, North America, and Asia, of AIS patients who underwent mechanical thrombectomy with the pRESET LITE stent retriever for a primary MeVO. We subcategorized occlusions into proximal MeVOs (segments A1, M2, and P1) vs. distal MeVOs/DMVO (segments A2, M3-M4, and P2). We reviewed patient and procedural characteristics, as well as angiographic and clinical outcomes. RESULTS: Between September 2016 and December 2021, 227 patients were included (50% female, median age 78 [65-84] years), of whom 161 (71%) suffered proximal MeVO and 66 (29%) distal MeVO. Using a combined approach in 96% of cases, successful reperfusion of the target vessel (mTICI 2b/2c/3) was attained in 85% of proximal MeVO and 97% of DMVO, with a median of 2 passes (IQR: 1-3) overall. Periprocedural complications rate was 7%. Control CT at day 1 post-MT revealed a hemorrhagic transformation in 63 (39%) patients with proximal MeVO and 24 (36%) patients with DMVO, with ECASS-PH type hemorrhagic transformations occurring in 3 (1%) patients. After 3 months, 58% of all MeVO and 63% of DMVO patients demonstrated a favorable outcome (mRS 0-2). CONCLUSION: Mechanical thrombectomy using the pRESET LITE in a combined approach with an aspiration catheter appears effective for primary medium vessel occlusions across several centers and physicians.

Microfabricated Nitinol Stent Retrievers with a Micro-Patterned Surface.

Stent retrievers are medical devices that are designed to physically remove blood clots from within the blood vessels of the brain. This paper focuses on microfabricated nitinol (nickel-titanium alloy) stent retrievers, which feature micro-patterns on their surface to enhance the effectiveness of mechanical thrombectomy. A thick film of nitinol, which was 20 µm in thickness, was sputtered onto a substrate with a micro-patterned surface, using electroplated copper as the sacrificial layer. The nitinol film was released from the substrate and then thermally treated while folded into a cylindrical shape. In vitro experiments with pig blood clots demonstrated that the micro-patterns on the surface improved the efficacy of blood clot retrieval.

Analysis of frictional forces in experimental models of stent retriever mechanical thrombectomy.

Acute ischemic stroke (AIS) and mechanical thrombectomy (MT) are commonly studied in vitro using cerebral artery models made of nonbiological materials. However, these models often report higher recanalization rates than those observed clinically, suggesting a discrepancy between experimental models and clinical settings. We believe this may be partly due to the frictional interactions between blood clots, stent retrievers (SRs), and the vessel walls. Experiments were performed to measure the coefficients of static and kinetic friction between blood clots, common nonbiological model materials, and bovine carotid arteries (CAs). Additional friction testing was performed with nitinol SRs. Coefficients of static friction between blood clots and nonbiological materials were found to range from 0.1 to 0.2, increasing with decreasing clot hematocrit, but were significantly higher between blood clots and CAs (1.49, 0.57, and 0.46 for 0, 20, and 40% hematocrit clots, respectively). For 0% and 40% hematocrit clots, the coefficients of kinetic friction with nonbiological materials were less than 0.1, while significantly higher with CAs (0.26 and 0.23 for 0% and 40% hematocrit clots, respectively). However, no significant differences in the coefficients of kinetic friction were found between the different hematocrit clots. Testing with the nitinol SR showed no significant differences in the coefficients of kinetic friction for CAs (0.73) and silicone (0.78), suggesting that silicone could be a suitable model material for evaluating SR-vessel interactions in vitro. Overall, it is evident that discrepancies exist in the frictional forces between materials commonly used in experimental models of AIS and MT and those seen in vivo. The individual contributions of clot-artery, SR-artery, and clot-SR interactions during blood clot removal merit further investigation.

Use of a stent-retriever for treatment of iatrogenic vasospasm secondary to mechanical thrombectomy.

The treatment strategy for iatrogenic intracranial vasospasm has not been established. We reported a rare case of stent-retriever use for the treatment of iatrogenic vasospasm after mechanical thrombectomy. The patient presented acute ischemic stroke due to the occlusion of the left middle cerebral artery (MCA). The patient underwent a successfully mechanical thrombectomy, however, severe stenosis was visualized in MCA, which was considered to be an iatrogenic mechanical vasospasm. This vasospasm was successfully treated with the Solitaire stent device, and the patient recovered from ischemic symptoms. A stent-retriever is a safe and effective treatment for iatrogenic vasospasm after mechanical thrombectomy.

Evaluating the efficacy of stent retriever and catheter aspiration combination in refractory cerebral venous sinus Thrombosis: A comprehensive Meta-Analysis.

BACKGROUND: Cerebral Venous Sinus Thrombosis (CVST) is a rare but potentially life-threatening condition, often associated with specific risk factors. The primary treatment for CVST is anticoagulation, but some cases progress to Refractory CVST (rCVST), requiring endovascular treatment. A combination of stent retriever and catheter aspiration is emerging as a promising technique to enhance treatment effectiveness. We conducted a systematic review and meta-analysis to assess the safety and efficacy of this approach, aiming to improve recanalization success and neurological outcomes while reducing complications in rCVST patients. METHODS: A search following PRISMA guidelines was conducted across Pubmed, Embase, Web of Science, and Cochrane databases to identify studies on the use of stent retrievers and catheter aspiration for rCVST. Pooled analysis with 95 % confidence intervals was used to assess the effects. Heterogeneity was evaluated using I2 statistics and a random-effects model was used. Complete recanalization. good clinical outcomes (mRS ≤ 2), hemorrhagic, neurological, ischemic, and total complications, poor clinical outcomes (mRS > 2), and mortality were assessed. RESULTS: A meta-analysis of five retrospective studies involving 55 patients examined outcomes in CVST. The median mean age was 40 years. Complete recanalization rate: 36 % (95 % CI: 9 % to 62 %, I2 = 90 %). Good clinical outcomes: 72 % (95 % CI: 50 % to 94 %, I2 = 76 %). Hemorrhagic complications: 2 % (95 % CI: 0 % to 8 %, I2 = 15 %). Ischemic complications: 0 % (95 % CI: 0 % to 6 %, I2 = 0 %). Neurological complications: 7 % (95 % CI: 0 % to 14 %, I2 = 0 %). Poor clinical outcomes: 26 % (95 % CI: 6 % to 46 %, I2 = 70 %). Total complications: 6 % (95 % CI: 0 % to 15 %, I2 = 10 %). Mortality rate: 5 % (95 % CI: 0 % to 13 %, I2 = 19 %). CONCLUSION: This systematic review and meta-analysis scrutinized the efficacy of combining Stent Retriever and Catheter Aspiration for rCVST. Findings highlighted varied outcomes, including recanalization rates, complications, and mortality. The dichotomy between good and poor outcomes underscores the necessity for personalized therapeutic decisions. While offering a comprehensive overview, the study emphasizes literature heterogeneity, suggesting a need for more rigorous and standardized research to optimize therapeutic strategies in clinical practice.

Cost-Effectiveness of a Direct-Aspiration First-Pass Technique versus Stent Retriever in Mechanical Thrombectomy.

OBJECTIVE: A direct-aspiration first-pass technique (ADAPT) in mechanical thrombectomy has been described in recent studies as an efficacious strategy compared with using a stent retriever (SR). We sought to evaluate for cost differences of ADAPT technique versus SR as an initial approach. METHODS: We conducted a retrospective analysis of consecutive patients with mechanical thrombectomy at our institution between 2022 and 2023. Patients were grouped into ADAPT with/without SR as a rescue strategy and SR as an initial approach with allowance of concomitant aspiration. Direct cost data (consumables) were obtained. Baseline demographics, stroke metrics, procedure outcomes and cost, and last follow-up outcomes in modified Rankin Scale were compared between 2 groups. RESULTS: Fifty-six patients were included. Thirty-seven (66.1%) underwent ADAPT, with 11 (29.7%) eventually requiring an SR. Mean age was 64.8 years. The average National Institutes of Health Stroke Scale score was 13.2 in the ADAPT group and 14.0 in the SR group (P = 0.68), with a similar proportion of tissue plasminogen activator (P = 0.53), site of occlusion (P = 0.66), and tandem occlusion (P = 0.69) between the groups. Recanalization was achieved in 94.6% of all patients, with an average of 1.9 passes, 89.3% being TICI 2B or above, with no differences between the 2 groups. Significantly lower cost (P < 0.01) was observed in ADAPT ($14,243.4) compared with SR ($19,003.6). Average follow-up duration was 180.2 days, with mortality of 23.2%. At last follow-up, 55.4% remained functionally independent (modified Rankin Scale score <3) with no difference (P = 0.56) between the ADAPT (59.5%) and SR (47.4%) groups. CONCLUSIONS: Outcomes were comparable between the ADAPT and SR groups. ADAPT reduced procedural consumables cost by approximately $5000 (25%), even if stent retrievers were allowed to be used for rescue. Establishing ADPAT as initial approach may bring significant direct cost savings while obtaining similar outcomes.

Aspiration Thrombectomy Versus Stent-Retriever Thrombectomy for the First-Pass Therapy of Intracranial Atherosclerosis-Related Large Vessel Occlusion: A Post Hoc Analysis of The Endovascular Treatment With Versus Without Tirofiban for Patients with Large Vessel Occlusion Stroke Trial.

BACKGROUND: This study sought to scrutinize the clinical outcomes associated with first-pass mechanical thrombectomy strategies in the management of intracranial atherosclerosis (ICAS)-related large vessel occlusion (LVO). METHODS: Within this post-hoc analysis of the The Endovascular Treatment With vs Without Tirofiban for Patients with Large Vessel Occlusion Stroke (RESCUE BT) trial, we compared data pertaining to patients with ICAS-LVO situated in the anterior circulation who underwent initial therapeutic interventions utilizing either aspiration thrombectomy or stent-retriever thrombectomy. The analysis encompassed the assessment of intraprocedural recanalization, rescue procedures involving balloon angioplasty or stenting, 48-hour reocclusion rates, occurrences of cerebral hemorrhagic complications, and 90-day Modified Rankin Scale scores. RESULTS: Among the 948 patients encompassed in the RESCUE BT trial, a total of 230 patients with ICAS-LVO in the anterior circulation were enrolled in the study. Of these, 111 underwent aspiration thrombectomy as the first-pass therapy, while 119 patients underwent stent-retriever thrombectomy as the initial intervention. The difference in first pass recanalization rates between aspiration thrombectomy and stent-retriever thrombectomy was not statistically significant (17.1% vs. 14.3%, P = 0.555), and mechanical thrombectomy success rates (90.1% vs. 90.8%, P = 0.864), the use of balloon angioplasty or stenting for rescue therapy (54.6% vs. 45.9%, P = 0.189; 23.4% vs. 25.2%, P = 0.752), and favorable 90-day Modified Rankin Scale outcomes (53.2% vs. 40.3%, P = 0.051) showed no statistically significant differences. CONCLUSIONS: Both aspiration thrombectomy and stent-retriever thrombectomy can be considered as primary therapeutic options for patients presenting with ICAS-LVO in the anterior circulation.