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Comparing Mechanical Thrombectomy Techniques in the Treatment of Large Vessel Occlusion for Acute Ischemic Stroke
Accepted Manuscript Comparing Mechanical Thrombectomy Techniques in the Treatment of Large Vessel Occlusion for Acute Ischemic Stroke Carlos M. Alvarez, M.D., David J. McCarthy, Samir Sur, M.D., Brian M. Snelling, M.D., Robert M. Starke, M.D., M.Sc. PII:
S1878-8750(17)30275-9
DOI:
10.1016/j.wneu.2017.02.102
Reference:
WNEU 5333
To appear in:
World Neurosurgery
Please cite this article as: Alvarez CM, McCarthy DJ, Sur S, Snelling BM, Starke RM, Comparing Mechanical Thrombectomy Techniques in the Treatment of Large Vessel Occlusion for Acute Ischemic Stroke, World Neurosurgery (2017), doi: 10.1016/j.wneu.2017.02.102. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Comparing Mechanical Thrombectomy Techniques in the Treatment of Large Vessel Occlusion for Acute Ischemic Stroke
RI PT
Carlos M. Alvarez, M.D., David J. McCarthy, Samir Sur, M.D., Brian M. Snelling, M.D., Robert M. Starke, M.D., M.Sc.
Department of Neurosurgery and Radiology, University of Miami Miller School of Medicine, Miami, FL
M AN U
SC
The role of mechanical thrombectomy for large vessel occlusion in acute ischemic stroke has come to the forefront after five randomized controlled trials published in 2015 demonstrated better outcomes compared to medical management alone.1–5 Although stent retriever (SR) devices were used in 88% to 100% of these trials, there is no consensus on the optimal method for thrombectomy. The use of balloon guide catheters (BCG) in conjunction with SR deployment has been widely described, but alternative strategies exist, including the direct aspiration firstpass technique (ADAPT), SR use with simultaneous aspiration at the clot face (Solumbra), and multi-modal thrombectomy, employing these techniques in combination.
TE D
There are several advantages to BGC use in the endovascular treatment of acute stroke. First, BGCs provide sturdy proximal support for accessing distal, intracranial thrombi and facilitate either direct microcatheter advancement for stent-retriever deployment, or use of an intermediate aspiration or distal access catheter. Second, inflation of the balloon creates flow arrest and subsequent aspiration through the BCG creates flow reversal, which can prevent the downstream embolization of thrombotic material during clot retrieval and has been demonstrated in an in-vitro model.6 BCG use can also enable proximal control in this fashion in cases complicated by vessel perforation.
AC C
EP
Flow arrest and aspiration via a balloon-guide catheter has also been described as a useful initial therapeutic option for proximal or long segment occlusions. Thus, the BCGs may be able to function as a stand-alone thrombectomy device via cervical aspiration as well as increase the effectiveness of stent-retriever thrombectomy.7,8 In conjunction with SR, BGCs have been shown to lead to improved rates of revascularization, time to revascularization, reduced infarct size and improved outcomes when compared to standard guide catheters.9-11 Disadvantages of balloon-guide catheter use include difficulty in navigating the relatively large guide system into the parent internal carotid artery which may increase procedural times and theoretical risk of damage to the ICA from balloon inflation. Additionally, newer support catheters that are able to track farther may improve first and subsequent pass thrombectomy rates. However, the development of a smaller, navigable 6F balloon guide system which can be utilized in conjunction with transradial access may alleviate some of these concerns. The direct aspiration first-pass thrombectomy (ADAPT) is a technique which involves aspiration of the thrombus from the clot face, often using intermediate sized, specially designed catheters.
ACCEPTED MANUSCRIPT
RI PT
This more distal aspiration may allow for increased suction effect, flow reversal, and reduced non-target emboli compared to BCG use, in which collateral blood flow via the ophthalmic, anterior cerebral, anterior choroidal, and posterior communicating arteries can mitigate the aspiration effect.9 Reported ADAPT recanalization rates range between 82-95%.12,13 Interestingly, in several studies, ADAPT was deemed to offer higher recanalization rates with decreased costs and similar clinical outcomes when compared to SR use.12,13 Two current trials randomizing patients to SR versus ADAPT will hopefully provide further data on the optimal initial thrombectomy devices.
M AN U
SC
Stent retrieval with simultaneous aspiration at the face of the clot is often called the “Solumbra” technique. Solumbra is the most recently developed mechanical thrombectomy technique and therefore comprehensive reporting on its efficacy and outcomes is currently unavailable. One recent series has compared ADAPT and Solumbra techniques, showing that the ADAPT technique is associated with better clinical outcomes and lower rates of symptomatic intracranial hemorrhage.18
TE D
Finally, a multi-modality approach can be used, including BGC, SR, and aspiration at the clot face. Studies show that SR following a failed ADAPT attempt results in improved revascularization suggesting that resistant clots may be optimally approached by multiple or differing techniques.13,14 Further, although ADAPT is rarely employed under conditions of proximal flow arrest via BCG, this adjunct flow arrest may offer improved efficacy. Though this approach is costly, the authors contend that having all of the tools within the thrombectomy armamentarium at one’s disposal maximizes the likelihood that successful recanalization will occur, and that this strategy also warrants further investigation.
AC C
EP
To date, studies attempting to elucidate the potential differences in outcome between patients treated with SR with standard guide catheters, versus BGC, ADAPT, and Solumbra in mechanical thrombectomy have been retrospective, nonrandomized, or comparisons between centers which used one or the other technique exclusively.10,13,18 In order to draw more definitive conclusions about the comparative benefits of these techniques, future well designed trials will be necessary to define the optimal therapeutic strategies. The outcomes recorded should include metrics for patient improvement such as modified Rankin functional outcome, technical parameters such as procedure duration, and complications such as emboli in a new vascular territory. With adequately randomized trials with sufficient size to provide adequate power and effect size, these data would shed light on the optimal strategies for mechanical thrombectomy in acute ischemic stroke.
ACCEPTED MANUSCRIPT
References Goyal M, Demchuk AM, Menon BK, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372(11):1019-1030.
2.
Campbell BCV, Mitchell PJ, Kleinig TJ, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372(11):1009-1018.
3.
A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke. N Engl J Med. 2015;372(4):394-394.
4.
Saver JL, Goyal M, Bonafe A, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015;372(24):2285-2295.
5.
Jovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372(24):2296-2306.
6.
Chueh J-Y, Kühn AL, Puri AS, Wilson SD, Wakhloo AK, Gounis MJ. Reduction in distal emboli with proximal flow control during mechanical thrombectomy: a quantitative in vitro study. Stroke. 2013;44(5):1396-1401.
7.
Haussen DC, Bouslama M, Grossberg JA, Nogueira RG. Remote aspiration thrombectomy in large vessel acute ischemic stroke. J Neurointerv Surg. 2017;9(3):250-252.
8.
Kim Y-W, Kang D-H, Hwang Y-H, Park J, Kim Y-S. Efficacy of Proximal Aspiration Thrombectomy for Using Balloon-Tipped Guide Catheter in Acute Intracranial Internal Carotid Artery Occlusion. J Korean Neurosurg Soc. 2016;59(4):379-384.
9.
Nguyen TN, Malisch T, Castonguay AC, et al. Balloon guide catheter improves revascularization and clinical outcomes with the Solitaire device: analysis of the North American Solitaire Acute Stroke Registry. Stroke. 2014;45(1):141-145.
TE D
M AN U
SC
RI PT
1.
EP
10. Velasco A, Buerke B, Stracke CP, et al. Comparison of a Balloon Guide Catheter and a Non–Balloon Guide Catheter for Mechanical Thrombectomy. Radiology. 2016;280(1):169176.
AC C
11. Pereira V, Siddiqui A, Jovin T, et al. P-016 role of balloon guiding catheter in mechanical thrombectomy using stentretrivers subgroup analysis of swift prime: Abstract P-016 Table 1. J Neurointerv Surg. 2015;7(Suppl 1):A30-A30. 12. Turk AS, Turner R, Spiotta A, et al. Comparison of endovascular treatment approaches for acute ischemic stroke: cost effectiveness, technical success, and clinical outcomes. J Neurointerv Surg. 2015;7(9):666-670. 13. Lapergue B, Blanc R, Guedin P, et al. A Direct Aspiration, First Pass Technique (ADAPT) versus Stent Retrievers for Acute Stroke Therapy: An Observational Comparative Study. AJNR Am J Neuroradiol. June 2016. doi:10.3174/ajnr.A4840. 14. Turk AS, Frei D, Fiorella D, et al. ADAPT FAST study: a direct aspiration first pass technique for acute stroke thrombectomy. J Neurointerv Surg. 2014;6(4):260-264. 15. Turk AS, Spiotta A, Frei D, et al. Initial clinical experience with the ADAPT technique: a direct aspiration first pass technique for stroke thrombectomy. J Neurointerv Surg.
ACCEPTED MANUSCRIPT
2014;6(3):231-237. 16. Chueh J-Y, Puri AS, Wakhloo AK, Gounis MJ. Risk of distal embolization with stent retriever thrombectomy and ADAPT. J Neurointerv Surg. 2016;8(2):197-202.
RI PT
17. Chueh JY, Wakhloo AK, Gounis MJ. Effectiveness of mechanical endovascular thrombectomy in a model system of cerebrovascular occlusion. AJNR Am J Neuroradiol. 2012;33(10):1998-2003.
AC C
EP
TE D
M AN U
SC
18. Delgado Almandoz JE, Kayan Y, Young ML, et al. Comparison of clinical outcomes in patients with acute ischemic strokes treated with mechanical thrombectomy using either Solumbra or ADAPT techniques. J Neurointerv Surg. 2016;8(11):1123-1128.
S1878-8750(17)30275-9
DOI:
10.1016/j.wneu.2017.02.102
Reference:
WNEU 5333
To appear in:
World Neurosurgery
Please cite this article as: Alvarez CM, McCarthy DJ, Sur S, Snelling BM, Starke RM, Comparing Mechanical Thrombectomy Techniques in the Treatment of Large Vessel Occlusion for Acute Ischemic Stroke, World Neurosurgery (2017), doi: 10.1016/j.wneu.2017.02.102. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Comparing Mechanical Thrombectomy Techniques in the Treatment of Large Vessel Occlusion for Acute Ischemic Stroke
RI PT
Carlos M. Alvarez, M.D., David J. McCarthy, Samir Sur, M.D., Brian M. Snelling, M.D., Robert M. Starke, M.D., M.Sc.
Department of Neurosurgery and Radiology, University of Miami Miller School of Medicine, Miami, FL
M AN U
SC
The role of mechanical thrombectomy for large vessel occlusion in acute ischemic stroke has come to the forefront after five randomized controlled trials published in 2015 demonstrated better outcomes compared to medical management alone.1–5 Although stent retriever (SR) devices were used in 88% to 100% of these trials, there is no consensus on the optimal method for thrombectomy. The use of balloon guide catheters (BCG) in conjunction with SR deployment has been widely described, but alternative strategies exist, including the direct aspiration firstpass technique (ADAPT), SR use with simultaneous aspiration at the clot face (Solumbra), and multi-modal thrombectomy, employing these techniques in combination.
TE D
There are several advantages to BGC use in the endovascular treatment of acute stroke. First, BGCs provide sturdy proximal support for accessing distal, intracranial thrombi and facilitate either direct microcatheter advancement for stent-retriever deployment, or use of an intermediate aspiration or distal access catheter. Second, inflation of the balloon creates flow arrest and subsequent aspiration through the BCG creates flow reversal, which can prevent the downstream embolization of thrombotic material during clot retrieval and has been demonstrated in an in-vitro model.6 BCG use can also enable proximal control in this fashion in cases complicated by vessel perforation.
AC C
EP
Flow arrest and aspiration via a balloon-guide catheter has also been described as a useful initial therapeutic option for proximal or long segment occlusions. Thus, the BCGs may be able to function as a stand-alone thrombectomy device via cervical aspiration as well as increase the effectiveness of stent-retriever thrombectomy.7,8 In conjunction with SR, BGCs have been shown to lead to improved rates of revascularization, time to revascularization, reduced infarct size and improved outcomes when compared to standard guide catheters.9-11 Disadvantages of balloon-guide catheter use include difficulty in navigating the relatively large guide system into the parent internal carotid artery which may increase procedural times and theoretical risk of damage to the ICA from balloon inflation. Additionally, newer support catheters that are able to track farther may improve first and subsequent pass thrombectomy rates. However, the development of a smaller, navigable 6F balloon guide system which can be utilized in conjunction with transradial access may alleviate some of these concerns. The direct aspiration first-pass thrombectomy (ADAPT) is a technique which involves aspiration of the thrombus from the clot face, often using intermediate sized, specially designed catheters.
ACCEPTED MANUSCRIPT
RI PT
This more distal aspiration may allow for increased suction effect, flow reversal, and reduced non-target emboli compared to BCG use, in which collateral blood flow via the ophthalmic, anterior cerebral, anterior choroidal, and posterior communicating arteries can mitigate the aspiration effect.9 Reported ADAPT recanalization rates range between 82-95%.12,13 Interestingly, in several studies, ADAPT was deemed to offer higher recanalization rates with decreased costs and similar clinical outcomes when compared to SR use.12,13 Two current trials randomizing patients to SR versus ADAPT will hopefully provide further data on the optimal initial thrombectomy devices.
M AN U
SC
Stent retrieval with simultaneous aspiration at the face of the clot is often called the “Solumbra” technique. Solumbra is the most recently developed mechanical thrombectomy technique and therefore comprehensive reporting on its efficacy and outcomes is currently unavailable. One recent series has compared ADAPT and Solumbra techniques, showing that the ADAPT technique is associated with better clinical outcomes and lower rates of symptomatic intracranial hemorrhage.18
TE D
Finally, a multi-modality approach can be used, including BGC, SR, and aspiration at the clot face. Studies show that SR following a failed ADAPT attempt results in improved revascularization suggesting that resistant clots may be optimally approached by multiple or differing techniques.13,14 Further, although ADAPT is rarely employed under conditions of proximal flow arrest via BCG, this adjunct flow arrest may offer improved efficacy. Though this approach is costly, the authors contend that having all of the tools within the thrombectomy armamentarium at one’s disposal maximizes the likelihood that successful recanalization will occur, and that this strategy also warrants further investigation.
AC C
EP
To date, studies attempting to elucidate the potential differences in outcome between patients treated with SR with standard guide catheters, versus BGC, ADAPT, and Solumbra in mechanical thrombectomy have been retrospective, nonrandomized, or comparisons between centers which used one or the other technique exclusively.10,13,18 In order to draw more definitive conclusions about the comparative benefits of these techniques, future well designed trials will be necessary to define the optimal therapeutic strategies. The outcomes recorded should include metrics for patient improvement such as modified Rankin functional outcome, technical parameters such as procedure duration, and complications such as emboli in a new vascular territory. With adequately randomized trials with sufficient size to provide adequate power and effect size, these data would shed light on the optimal strategies for mechanical thrombectomy in acute ischemic stroke.
ACCEPTED MANUSCRIPT
References Goyal M, Demchuk AM, Menon BK, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372(11):1019-1030.
2.
Campbell BCV, Mitchell PJ, Kleinig TJ, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372(11):1009-1018.
3.
A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke. N Engl J Med. 2015;372(4):394-394.
4.
Saver JL, Goyal M, Bonafe A, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015;372(24):2285-2295.
5.
Jovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372(24):2296-2306.
6.
Chueh J-Y, Kühn AL, Puri AS, Wilson SD, Wakhloo AK, Gounis MJ. Reduction in distal emboli with proximal flow control during mechanical thrombectomy: a quantitative in vitro study. Stroke. 2013;44(5):1396-1401.
7.
Haussen DC, Bouslama M, Grossberg JA, Nogueira RG. Remote aspiration thrombectomy in large vessel acute ischemic stroke. J Neurointerv Surg. 2017;9(3):250-252.
8.
Kim Y-W, Kang D-H, Hwang Y-H, Park J, Kim Y-S. Efficacy of Proximal Aspiration Thrombectomy for Using Balloon-Tipped Guide Catheter in Acute Intracranial Internal Carotid Artery Occlusion. J Korean Neurosurg Soc. 2016;59(4):379-384.
9.
Nguyen TN, Malisch T, Castonguay AC, et al. Balloon guide catheter improves revascularization and clinical outcomes with the Solitaire device: analysis of the North American Solitaire Acute Stroke Registry. Stroke. 2014;45(1):141-145.
TE D
M AN U
SC
RI PT
1.
EP
10. Velasco A, Buerke B, Stracke CP, et al. Comparison of a Balloon Guide Catheter and a Non–Balloon Guide Catheter for Mechanical Thrombectomy. Radiology. 2016;280(1):169176.
AC C
11. Pereira V, Siddiqui A, Jovin T, et al. P-016 role of balloon guiding catheter in mechanical thrombectomy using stentretrivers subgroup analysis of swift prime: Abstract P-016 Table 1. J Neurointerv Surg. 2015;7(Suppl 1):A30-A30. 12. Turk AS, Turner R, Spiotta A, et al. Comparison of endovascular treatment approaches for acute ischemic stroke: cost effectiveness, technical success, and clinical outcomes. J Neurointerv Surg. 2015;7(9):666-670. 13. Lapergue B, Blanc R, Guedin P, et al. A Direct Aspiration, First Pass Technique (ADAPT) versus Stent Retrievers for Acute Stroke Therapy: An Observational Comparative Study. AJNR Am J Neuroradiol. June 2016. doi:10.3174/ajnr.A4840. 14. Turk AS, Frei D, Fiorella D, et al. ADAPT FAST study: a direct aspiration first pass technique for acute stroke thrombectomy. J Neurointerv Surg. 2014;6(4):260-264. 15. Turk AS, Spiotta A, Frei D, et al. Initial clinical experience with the ADAPT technique: a direct aspiration first pass technique for stroke thrombectomy. J Neurointerv Surg.
ACCEPTED MANUSCRIPT
2014;6(3):231-237. 16. Chueh J-Y, Puri AS, Wakhloo AK, Gounis MJ. Risk of distal embolization with stent retriever thrombectomy and ADAPT. J Neurointerv Surg. 2016;8(2):197-202.
RI PT
17. Chueh JY, Wakhloo AK, Gounis MJ. Effectiveness of mechanical endovascular thrombectomy in a model system of cerebrovascular occlusion. AJNR Am J Neuroradiol. 2012;33(10):1998-2003.
AC C
EP
TE D
M AN U
SC
18. Delgado Almandoz JE, Kayan Y, Young ML, et al. Comparison of clinical outcomes in patients with acute ischemic strokes treated with mechanical thrombectomy using either Solumbra or ADAPT techniques. J Neurointerv Surg. 2016;8(11):1123-1128.