Efficacy of ADAPT with large-bore reperfusion catheter in anterior circulation acute ischemic stroke: a multicentric Italian experience.

INTRODUCTION: A direct aspiration first pass technique (ADAPT) is an alternative technique as first-line thrombectomy for large vessel occlusion in acute ischemic stroke, still debated when compared to first-line stent retriever. To retrospectively evaluate technical and clinical outcomes of the ADAPT as first-line treatment for anterior circulation acute ischemic stroke with large-bore reperfusion catheters. METHODS: A multicentric data collection from 14 medical centers was retrospectively analyzed. Large-bore catheters had a distal diameter between 0.64 and 0.71 in; stent retriever was added when aspiration alone failed. Baseline characteristics, technical and clinical variables were collected, including NIHSS, thrombolysis in cerebral infarction (TICI), peri-procedural complications, 90-day mRS and 90-day mortality. RESULTS: Overall, 501 patients were treated. No statistically significant difference in terms of baseline features or tPA administration was recorded between patients treated with ADAPT and with additional stent retriever. ADAPT alone was successful in achieving TICI ≥ 2b in 71.8% with a median of 1.55 aspiration attempts. In terms of TICI ≥ 2b, ADAPT alone was better than additional stent retriever (p < 0.001), while no statistical difference was achieved from catheter diameter. Embolization to a new territory was less frequent in ADAPT group (5.2 vs 18%; p = 0.0026). Patients treated with ADAPT alone had better clinical outcomes in terms of mRS ≤ 2 (p < 0.001). CONCLUSIONS: ADAPT is a valid technique with respect to the rates of TICI 2b/3 recanalization and 90-day mRS scores. In this series, an attempt at recanalization with ADAPT with larger-bore reperfusion catheter may be warranted prior to stentriever thrombectomy.

Single-center experience using the 3MAX or 4MAX reperfusion catheter for the treatment of acute ischemic stroke with distal arterial occlusions in patients not eligible for intravenous fibrinolysis.

BACKGROUND: In acute stroke, distal cerebrovascular occlusions can be linked to severe clinical symptoms, and treatment by mechanical thrombectomy may have an important clinical impact. When intravenous fibrinolytic therapy is firmly contraindicated, it remains the only treatment option. METHODS: A total of 42 patients with isolated distal arterial occlusions and absolute contraindication for intravenous fibrinolytic therapy were retrospectively included. Mechanical thrombectomy was performed using Penumbra 4MAX or 3MAX aspiration catheters. When aspiration alone did not result in successful revascularization, a stent retriever was added. RESULTS: Direct thromboaspiration was the first treatment option in all patients. 16.7% of cases required the additional use of a stent retriever. A TICI score ≥ 2b reperfusion at the end of the procedure was obtained in 76.2% and a Rankin Score of 2 or less at 90 days in 45.7%. Two hemorrhagic complications were observed. CONCLUSIONS: Direct thromboaspiration appears a safe technique in acute isolated distal arterial occlusions. In a cohort of patients with absolute contraindication for intravenous fibrinolytic therapy, a significant percentage achieved good revascularization.

Aspiration Catheter Reach to Thrombus (ART) Sign in Combined Technique for Mechanical Thrombectomy: Impact for First-Pass Complete Reperfusion.

OBJECTIVE: The important factor for successful first-pass complete reperfusion (FPR) after combined techniques for mechanical thrombectomy (MT) is unclear. We consider that for successful FPR, the aspiration catheter (AC) should reach to and hold the thrombus before the device is pulled out. Therefore, we defined an ART (AC reached thrombus) sign characterized by the cessation of reverse blood flow in aspiration pump and deformation of stent retriever (SR) at the tip of AC. The purpose of this study was to identify the impact of the ART sign on the outcomes of the combined techniques. METHODS: A retrospective analysis was conducted between January 2015 and September 2018 on the data of consecutive patients who underwent MT for anterior circulation stroke using both SR and AC at the first-pass procedure. We divided the patients into 2 groups based on whether the first-pass procedure achieved the ART sign (ARTs group) or not (Non-ARTs group). The primary endpoint was FPR defined as modified thrombolysis in cerebral infarction (mTICI) score of 3. RESULTS: Sixty-six patients were included in our study (n = 38, ARTs group; n = 28, Non-ARTs group). There were no differences at mTICI 2b/3 (97.3% versus 89.2%, P = .30), but the FPR and mTICI3 were more common in the ARTs group (81.5% versus 14.2%, P < .001; and 89.4% versus 32.1%, P < .001, respectively). CONCLUSIONS: ART sign in combined technique was found to be an important factor for successful FPR.

Endovascular thrombectomy in acute ischemic stroke: new treatment guide.

PURPOSE OF REVIEW: Recent randomized clinical trials (RCTs) have demonstrated strong efficacy of endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) from large vessel occlusions (LVO). SIESTA, AnSTROKE, GOLIATH showed no deleterious effects of general anesthesia on patient outcome after EVT compared with conscious sedation. DAWN and DEFUSE 3 are extending the time window for EVT up to 24 h in carefully selected patients. This review discusses the current literature on the rapidly expanding subject of endovascular stroke therapy and optimal anesthetic management. RECENT FINDINGS: Recent retrospective studies of RCT data sets show that general anesthesia is associated with negative clinical outcome in AIS patients undergoing EVT when compared with sedation. Two of the possible mechanisms of this finding are systolic hypotension and hypocapnia. SIESTA, AnSTROKE, GOLIATH showed no difference in short-term clinical outcome between EVT patients treated with general anesthesia versus conscious sedation. DAWN and DEFUSE 3 demonstrated improved functional outcomes after EVT in those treated up to 24 h after selection with perfusion imaging, increasing the number of patients eligible for EVT. SUMMARY: Effective reperfusion with stent retriever technology, careful patient selection using perfusion imaging, and careful use of anesthetic technique affect outcome.

[Application of PeriCam PSI blood flow imaging perfusion system in rat brain ischemia reperfusion injury models].

OBJECTIVE: : To study the feasibility and effect of PeriCam PSI system guiding the establishment of ischemia/reperfusion injury model in rats. METHODS: : A total of 70 adult male Sprague-Dawley rats were divided into the control group(n=6), PSI monitoring group(n=34) and traditional operation group(n=30). Ischemia reperfusion model was established with reference to improve Zea-Longa line plug method. After the model established, the blood flow to the brain of control group, PSI monitoring group (ischemic 2 h, 24 h reperfusion) were observed and recorded respectively with PSI. The rats were then executed after 24 h, and the 2,3,5-triphenyltetrazolium chloride (TTC) staining and HE staining were used to observe the brain tissue. RESULTS: : The survival rate and modeling success rate of PSI monitoring group were higher than those of the traditional operation group(all P<0.05). The blood perfusion in the brain and the distribution of blood vessels were clearly observed in the control group, and the data were normal. In 2 h ischemic group, the arterial flow was interrupted in the right cerebral artery, and the blood flow in the middle arterial blood supply was significantly decreased than that in the control group(P<0.05). After the recovery of 24 h, the artery in the right side of the brain was restored to blood flow, but the blood flow in the partial supply area decreased, unable to recover to normal level. The TTC staining results indicated that there were obvious infarcts in the right brain tissue of PSI monitoring group,and the infarct area was more stable than that of the traditional operation group. The results of HE staining showed that the structure of brain tissue in the control group was normal, and the morphological rules of nerve cells were not change. While in brain tissue from PSI monitoring group, cortex and ischemia half dark stripe, nerve cell degeneration, necrosis and glial fiber disintegration, liquefaction, and light color, screen mesh in ischemic central area were observed. CONCLUSIONS: : PSI system can guide ischemia reperfusion model building and improve the success rate of the model.

End-ischemic reconditioning of liver allografts: Controlling the rewarming.

Different nonhypothermic preservation modalities have shown beneficial effects in liver transplantation models. This study compares controlled oxygenated rewarming (COR) to normothermic machine perfusion (NMP) to resuscitate liver grafts following cold storage (CS). Porcine livers were preserved for 18 hours by CS. Before reperfusion, the grafts were put on a machine perfusion device (Liver Assist) for 3 hours and were randomly assigned to COR (n = 6) or NMP (n = 5) and compared to standard CS. COR was carried out with the new Custodiol-N solution, slowly increasing temperature from 8 °C to 20 °C during the first 90 minutes. NMP was carried out with diluted autologous blood at 37 °C for 3 hours. In both cases, the perfusate was oxygenated to partial pressure of oxygen > 500 mm Hg. Then liver viability was tested for 180 minutes during in vitro isolated sanguineous reperfusion. Activity of the mitochondrial caspase 9 was lower after COR. Measurement of tissue adenosine triphosphate and total adenine nucleotides at the end of the reconditioning period showed better energetic recovery after COR. COR also resulted in significantly lower enzyme leakage and higher bile production (P < 0.05) during reperfusion. This first comparison of COR and NMP as end-ischemic reconditioning modalities demonstrates superior results in terms of mitochondrial integrity resulting in better energetic recovery, less hepatocellular injury, and ultimately superior function in favor of COR. Liver Transplantation 22 1223-1230 2016 AASLD.

Carotid artery stenting: an update.

In patients with carotid disease, the purpose of carotid artery revascularization is stroke prevention. For >50 years, carotid endarterectomy has been considered the standard treatment for severe asymptomatic and symptomatic carotid stenoses. Carotid artery stenting (CAS) has emerged in the last 15 years as minimally invasive alternative to surgery. However, the value of the endovascular approach in the management of carotid disease patients remains highly controversial. The aims of this review are to elucidate the current role of CAS, to describe the major technology advancements in the field, and to speculate about the future of this therapy.

Selective Heart, Brain and Body Perfusion in Open Aortic Arch Replacement.

Open aortic arch replacement is a complex and challenging procedure, especially in post dissection aneurysms and in redo procedures after previous surgery of the ascending aorta or aortic root. We report our experience with the simultaneous selective perfusion of heart, brain, and remaining body to ensure optimal perfusion and to minimize perfusion-related risks during these procedures. We used a specially configured heart-lung machine with a centrifugal pump as arterial pump and an additional roller pump for the selective cerebral perfusion. Initial arterial cannulation is achieved via femoral artery or right axillary artery. After lower body circulatory arrest and selective antegrade cerebral perfusion for the distal arch anastomosis, we started selective lower body perfusion simultaneously to the selective antegrade cerebral perfusion and heart perfusion. Eighteen patients were successfully treated with this perfusion strategy from October 2012 to November 2015. No complications related to the heart-lung machine and the cannulation occurred during the procedures. Mean cardiopulmonary bypass time was 239 ± 33 minutes, the simultaneous selective perfusion of brain, heart, and remaining body lasted 55 ± 23 minutes. One patient suffered temporary neurological deficit that resolved completely during intensive care unit stay. No patient experienced a permanent neurological deficit or end-organ dysfunction. These high-risk procedures require a concept with a special setup of the heart-lung machine. Our perfusion strategy for aortic arch replacement ensures a selective perfusion of heart, brain, and lower body during this complex procedure and we observed excellent outcomes in this small series. This perfusion strategy is also applicable for redo procedures.

Postmortem pump-driven reperfusion of the vascular system of porcine lungs: towards a new model for surgical training.

PURPOSE: The objective of this experiment is to establish a continuous postmortem circulation in the vascular system of porcine lungs and to evaluate the pulmonary distribution of the perfusate. This research is performed in the bigger scope of a revascularization project of Thiel embalmed specimens. This technique enables teaching anatomy, practicing surgical procedures and doing research under lifelike circumstances. METHODS: After cannulation of the pulmonary trunk and the left atrium, the vascular system was flushed with paraffinum perliquidum (PP) through a heart-lung machine. A continuous circulation was then established using red PP, during which perfusion parameters were measured. The distribution of contrast-containing PP in the pulmonary circulation was visualized on computed tomography. Finally, the amount of leak from the vascular system was calculated. RESULTS: A reperfusion of the vascular system was initiated for 37 min. The flow rate ranged between 80 and 130 ml/min throughout the experiment with acceptable perfusion pressures (range: 37-78 mm Hg). Computed tomography imaging and 3D reconstruction revealed a diffuse vascular distribution of PP and a decreasing vascularization ratio in cranial direction. A self-limiting leak (i.e. 66.8% of the circulating volume) towards the tracheobronchial tree due to vessel rupture was also measured. CONCLUSIONS: PP enables circulation in an isolated porcine lung model with an acceptable pressure-flow relationship resulting in an excellent recruitment of the vascular system. Despite these promising results, rupture of vessel walls may cause leaks. Further exploration of the perfusion capacities of PP in other organs is necessary. Eventually, this could lead to the development of reperfused Thiel embalmed human bodies, which have several applications.

Use of del Nido Cardioplegia for Adult Cardiac Surgery at the Cleveland Clinic: Perfusion Implications.

Cardiac arrest by cardioplegia provides a reproducible and safe method to induce and maintain electromechanical cardiac quiescence. Techniques of intraoperative myocardial protection are constantly evolving. For the past three decades, modified Buckberg cardioplegia solution has been used for adult cardiac surgery at the Cleveland Clinic. This formulation serves as the crystalloid component, which is delivered 4:1 with oxygenated patient's blood to crystalloid. Meanwhile, our use of the del Nido cardioplegia solution in adult patients, heretofore primarily used in pediatric cardiac surgical centers, has been increasing over the past several years. Single-dose, cold blood del Nido cardioplegia can be delivered antegrade if the duration of the operation will be limited and if there is no significant coronary artery disease or aortic insufficiency that would limit the distribution of cardioplegia. The addition of del Nido cardioplegia to our cardioplegia armamentarium allows us to customize our myocardial protection strategies for different surgical needs. This article aims to provide information on technical aspects of del Nido cardioplegia in adult cardiac surgery and its use at the Cleveland Clinic in the adult surgical population.

Low frequency mechanical actuation accelerates reperfusion in-vitro.

BACKGROUND: Rapid restoration of vessel patency after acute myocardial infarction is key to reducing myocardial muscle death and increases survival rates. Standard therapies include thrombolysis and direct PTCA. Alternative or adjunctive emergency therapies that could be initiated by minimally trained personnel in the field are of potential clinical benefit. This paper evaluates a method of accelerating reperfusion through application of low frequency mechanical stimulus to the blood carrying vessels. MATERIALS AND METHOD: We consider a stenosed, heparinized flow system with aortic-like pressure variations subject to direct vessel vibration at the occlusion site or vessel deformation proximal and distal to the occlusion site, versus a reference system lacking any form of mechanical stimulus on the vessels. RESULTS: The experimental results show limited effectiveness of the direct mechanical vibration method and a drastic increase in the patency rate when vessel deformation is induced. For vessel deformation at occlusion site 95% of clots perfused within 11 minutes of application of mechanical stimulus, for vessel deformation 60 centimeters from the occlusion site 95% percent of clots perfused within 16 minutes of stimulus application, while only 2.3% of clots perfused within 20 minutes in the reference system. CONCLUSION: The presented in-vitro results suggest that low frequency mechanical actuation applied during the pre-hospitalization phase in patients with acute myocardial infarction have potential of being a simple and efficient adjunct therapy.

Characterizing photothrombotic distal middle cerebral artery occlusion and YAG laser-induced reperfusion model in the Izumo strain of spontaneously hypertensive rats.

No study has systematically studied the relevance of original Izumo strain of spontaneously hypertensive rats (SHR/Izm) as a stroke model. Furthermore, both SHR/Izm and stroke-prone SHR/Izm (SHRSP/Izm) are commercially available, and recent progress in genetic studies allowed us to use several congenic strains of rats constructed with SHR/Izm and SHRSP/Izm as the genetic background strains. A total of 166 male SHR/Izm and 17 male SHRSP/Izm were subjected to photothrombotic middle cerebral artery (MCA) occlusion with or without YAG laser-induced reperfusion. The pattern of distal MCA was recorded. Infarct volumes were determined with 2,3,5-triphenyltetrazolium chloride. At 24 or 48 h after MCA occlusion, infarct volumes in the permanent occlusion and 2-h occlusion groups (88 ± 22 [SD] and 87 ± 25 mm³, respectively) were significantly larger than that in the 1-h occlusion group (45 ± 14 mm³), indicating the presence of sizeable zone of penumbra. Infarct size in SHRSP/Izm determined at 24 h after MCA occlusion was fairly large (124.0 ± 34.8 mm³, n = 10). Infarct volume in SHR/Izm with simple distal MCA was 76 ± 19 mm³, which was significantly smaller than 95 ± 22 mm³ in the other SHR/Izm with more branching MCA. These data suggest that this stroke model in SHR/Izm is useful in the preclinical testing of stroke therapies and elucidating the pathophysiology of cerebral ischemia/reperfusion.

Bigger is Still Better: A Step Forward in Reperfusion With React 71.

BACKGROUND: While multiple new larger-bore aspiration catheters have been introduced for stroke thrombectomy, sizeable cohort outcome studies are lacking along with meaningful comparative studies to evaluate whether they represent a clinically relevant improvement compared to predecessors. OBJECTIVE: To evaluate comparative angiographic and clinical outcomes between an 071 and 068 aspiration catheter. METHODS: The authors reviewed an institutional thrombectomy database extracting the first 150 consecutive cases utilizing React 71 (Medtronic, Dublin, Ireland) with a comparison of background/demographic, procedural, angiographic, and clinical outcome variables to a cohort of patients treated with our previously most frequently utilized 0.068-inch aspiration catheter. RESULTS: In our React 71 cohort, successful reperfusion (thrombolysis in cerebral infarction [TICI] 2b-3) was achieved in 95% of cases. In comparison to a prior cohort of 96 patients treated with a 0.068-inch catheter, there was no statistically significant difference in rates of successful reperfusion (TICI 2b-3), initial disposition, and 90-d outcome. However, the frequency of single pass cases was significantly higher in the React 71 cohort (47% vs 35%, P = .019 on multivariate analysis) along with the rate of TICI 2c-3 reperfusion after the first pass (26% vs 14%, P = .019 on multivariate analysis), and final TICI 2c-3 reperfusion (39% vs 28%, P = .04 on multivariate analysis). CONCLUSION: While rates of TICI 2b-3 reperfusion and clinical outcome results were similar, our study suggests that a newer, larger bore aspiration catheter may be associated with a greater frequency of single pass cases and higher quality reperfusion, judged as TICI 2c-3 frequency after the first and final pass.

JET 7 XTRA Flex reperfusion catheter related complications during endovascular thrombectomy.

Endovascular thrombectomy has revolutionized the management of acute ischemic stroke from emergent large vessel occlusion. Continued technological advancement in the field, as evidenced by successive introduction of large bore aspiration catheters with enhanced trackability and large inner diameter, has played a major role in achieving fast and robust recanalization and improved clinical outcome. Here, we present three patients with intraprocedural device malfunction related to the JET 7 XTRA Flex reperfusion catheter.

Use of a rosch-uchida needle for recanalization of refractory dialysis-related central vein occlusion.

OBJECTIVE: The purpose of this study was to evaluate our experience with the use of a Rösch-Uchida needle technique to recanalize central vein occlusion that cannot be traversed with a guidewire. MATERIALS AND METHODS: We retrospectively evaluated 33 recanalization procedures performed with a Rösch-Uchida needle on 20 men and 13 women with central vein occlusion during the period January 1999-December 2008. The occlusions were in the subclavian vein (n = 29) and the brachiocephalic vein (n = 4). A 9- or 10-French Rösch-Uchida introducer sheath was advanced centrally to abut the occlusion. The Rösch-Uchida needle was directed and advanced toward a transfemoral angiographic catheter placed on the central side of the occlusion. After passage of a guidewire through the occlusion, balloon angioplasty and stent insertion were performed. The outcome measures evaluated were technical success rate, primary and secondary patency, and complication rate. RESULTS: The mean occlusion length was 1.73 +/- 0.8 cm. The rate of technical success of recanalization was 93.9% (31 of 33 procedures). The 3-, 6-, and 12-month primary patency rates were 43.6%, 24%, and 8%, and the 3-, 6-, and 12-month secondary patency rates were 77.4%, 68.8% and 55.9%. One patient reported shoulder pain lasting 2 weeks, which resolved with conservative treatment. CONCLUSION: Use of a Rösch-Uchida needle to recanalize central vein occlusion refractory to a traditional procedure is feasible and safe and can preserve the involved extremity for long-term hemodialysis.

Can a Stent Retriever Damage the JET 7 Reperfusion Catheter?

We encountered 2 separate instances of damage to JET 7 reperfusion catheters when they were used in conjunction with a stent retriever during mechanical thrombectomy. On both occasions, after 1 or 2 passes with a stent retriever, we found that the distal end of the catheter was frayed and it ballooned up on flushing with saline. This mechanical failure could potentially lead to serious complications; hence, it should be shared with fellow neurointerventionalists.

Trends in Endovascular Reperfusion Therapy for Acute Stroke after Introduction of Mechanical Thrombectomy Devices: Japanese Registry of NeuroEndovascular Therapy (JR-NET)3.

In Japan, the era of thrombectomy for acute stroke started when the Merci retriever was approved in 2010 and the Penumbra system in 2011. New-generation Penumbra catheters (MAX series) and stent retrievers were introduced in 2013 and 2014, respectively. The aim of this study was to clarify the general status and trends in endovascular reperfusion therapy for stroke in Japan from 2010 to 2014. We extracted a total of 3705 patients (72.1 ± 12.2 years, 1482 women) from a nationwide study of patients receiving any neuroendovascular treatment, the Japanese Registry of NeuroEndovascular Therapy 3. Reperfusion therapy resulted in a successful reperfusion rate of 59%, and 31% of patients achieved a favorable outcome at 30 days of onset. The frequency of Merci-including procedures increased to 52% in the first half of 2011, but conversely decreased to 1% in the second half of 2014. The frequency of Penumbra-including procedures increased from 18% in the second half of 2011 to 67% in the first half of 2014, decreasing to 38% in the second half of 2014. The reperfusion rate and 30-day clinical outcomes remained almost unchanged until June 2013, and started to improve thereafter, coincident with the introduction and spread of newer-generation devices. The rate of successful reperfusion reached 71-76%, and 36-38% of patients achieved a favorable outcome in 2014. After multivariate adjustment for preprocedure variables, the calendar period from 2013 to 2014 was significantly associated with improvement in reperfusion rates and clinical outcomes.

Preclinical evaluation of the ANCD thrombectomy device: safety and efficacy in a swine clot model.

BACKGROUND: The Advanced Thrombectomy System (ANCD) provides a new funnel component designed to reduce clot fragmentation and facilitate retrieval in patients with stroke by locally restricting flow, allowing distal aspiration in combination with a stent retriever (SR). OBJECTIVE: To evaluate the preclinical efficacy and safety of the ANCD in a swine clot model. METHODS: Soft and firm clots were implanted in the lingual and cervical arteries of 11 swine to obtain Thrombolysis in Cerebral Infarction (TICI) 0 blood flow. Mechanical thrombectomy was performed with either a balloon guide catheter+Solitaire 2 stent retriever (BGC+SR, n=13) or ANCD+SR (n=13). TICI flow was evaluated and successful revascularization was defined as TICI 3 (normal perfusion). To characterize safety, a total of 3 passes were performed in each vessel independent of recanalization. Tissues were explanted for histopathological analysis after 3 and 30 days, respectively. RESULTS: First pass reperfusion rates were ANCD+SR: 69% and BGC+SR: 46%. Reperfusion increased after the third pass in both groups (ANCD+SR: 100%, vs BGC+SR: 77%). Recanalization was achieved after an average of 1.4 and 1.9 passes in ANCD+SR and BGC+SR (p=0.095), respectively. Vessel injury was comparable in both groups; endothelial loss at 3 days was the most common injury seen (ANCD+SR: 1.78±1.22; BGC+SR: 2.03±1.20; p=0.73), while other histopathological markers were absent or minimal. Tissues downstream from targeted vessels also showed absence or minimal lesions across both groups. CONCLUSIONS: Results in a swine clot model support the high efficacy of the ANCD+SR without causing clinically significant vessel injury potentially related to the new funnel component.

ADAPT with New Catalyst 5 Reperfusion Catheter for Distal M2 Ischemic Stroke: Preliminary Experience.

OBJECTIVE: We sought to assess preliminary technical and clinical outcomes of Catalyst 5 (CAT 5) as front-line aspiration treatment for M2-M3 occlusion in acute ischemic stroke. METHODS: Patients with symptomatic stroke and distal M2 or M3 occlusions were enrolled retrospectively. A direct aspiration first-pass technique was used as the first treatment option for absolute contraindication to intravenous fibrinolytic therapy. Time to recanalization, first attempt recanalization, and number of attempts were recorded. Successful recanalization was defined as a modified thrombolysis in cerebral infarction score ≥2b; incidence of procedure-related complications was recorded. National Institutes of Health Stroke Scale at discharge and modified Rankin Scale score at 90 days were evaluated by a dedicated neurologist. RESULTS: A total of 11 acute occlusions of distal M2-M3 segment were treated with a direct aspiration first-pass technique using CAT 5 (mean age 69.3 years). Tandem occlusion was present in 2 cases. Intracranial preocclusive mean vessel diameter was 1.9 mm. Overall modified thrombolysis in cerebral infarction score ≥2b was obtained in 72.7% of patients with mean time to recanalization of 36.4 minutes and a mean of 1.9 attempts. First-attempt recanalization with CAT 5 was obtained in 54% of patients with a mean time to recanalization of 29.2 minutes. A stent retriever with proximal aspiration was incorporated as a rescue device in 2 cases. Embolization of new territories was reported after CAT 5 aspiration in 1 patient. No intracranial hemorrhage was detected on follow-up computed tomography. The median National Institutes of Health Stroke Scale score at discharge was 3. At 90 days, a modified Rankin Scale score of 0-2 was achieved in 90.9% of patients. CONCLUSIONS: Preliminary experience using CAT 5 in distal occlusions demonstrates that it may be safe and effective in acute stroke treatment.

Effectiveness of Revive SE in the RAPID registry : Revive Acute Ischemic Stroke Patients ImmeDiately (RAPID) Prospective Multicenter Trial.

PURPOSE: The prospective, multicenter Revive Acute ischemic stroke Patients ImmeDiately (RAPID) trial was carried out to evaluate the real-world safety and efficacy of the Revive SE stent retriever. METHODS: From January 2017 the study planned to enroll 100 patients with acute ischemic stroke who were treated with the Revive SE as a first pass. The study primary outcomes were rates of favorable reperfusion using the modified thrombolysis in cerebral infarction score [mTICI] 2b/3 and rates of favorable outcome with the modified Rankin Scale (mRS) ≤2 at 3 months. The secondary outcomes were time interval from puncture to vascular reperfusion, number of passes by Revive SE stent-retriever, incidence of distal embolization and into new territories and rate of symptomatic intracranial hemorrhage (SICH) within 24 h post intervention. RESULTS: A total of 100 treated patients (mean age: 65.6 ± 11.3 years) were enrolled. The median National Institutes of Health Stroke Scale before the procedure was 16. Target vessel occlusions were as follows: middle cerebral artery (MCA) M1 in 48, M2 in 6, anterior cerebral artery (ACA) in 3, internal carotid artery (ICA) in 22, basilar artery (BA) in 17, and vertebral artery (VA) in 4. Reperfusion rate with Revive SE without rescue devices was 69%. Reperfusion rate with Revive SE only was 83.3% in MCA M2, followed by 82.4% in BA. Thromboembolic complications and SICH developed in 10% and 2% of patients, respectively. Overall, a satisfactory reperfusion was achieved in 92% and a favorable outcome at 90 days in 48%. CONCLUSION: Use of the Revive SE for thrombectomy appeared to be effective and safe but these findings need be confirmed in larger clinical trials (RAPID ClinicalTrials.gov number, NCT03007082).