scholarly journals Endovascular Device Choice and Tools for Recanalization of Medium Vessel Occlusions: Insights From the MeVO FRONTIERS International Survey

2021 ◽  
Vol 12 ◽  
Author(s):  
Nima Kashani ◽  
Petra Cimflova ◽  
Johanna M. Ospel ◽  
Nishita Singh ◽  
Mohammed A. Almekhlafi ◽  
...  
Keyword(s):  
Binary Logistic Regression ◽  
The United States ◽  
International Survey ◽  
First Line ◽  
Vessel Occlusion ◽  
Global Perspectives ◽  
Stent Retrievers ◽  
Endovascular Approach ◽  
Endovascular Device ◽  
Arterial Thrombolysis

Background: Endovascular treatment (EVT) for stroke due to medium vessel occlusion (MeVO) can be technically challenging. Devices and tools are rapidly evolving. We aimed to gain insight into preferences and global perspectives on the usage of endovascular tools in treating MeVOs.Methods: We conducted an international survey with seven scenarios of patients presenting A3, M2/3, M3, M3/4, or P2/3 occlusions. Respondents were asked for their preferred first-line endovascular approach, and whether they felt that the appropriate endovascular tools were available to them. Answers were analyzed by occlusion location and geographical region of practice, using multinomial/binary logistic regression.Results: A total of 263 neurointerventionists provided 1836 responses. The first-line preferences of physicians were evenly distributed among stent-retrievers, combined approaches, and aspiration only (33.2, 29.8, and 26.8%, respectively). A3 occlusions were more often treated with stent-retrievers (RR 1.21, 95% CI: 1.07–1.36), while intra-arterial thrombolysis was more often preferred in M3 (RR 2.47, 95% CI: 1.53–3.98) and M3/4 occlusions (RR 7.71, 95% CI: 4.16–14.28) compared to M2/3 occlusions. Respondents who thought appropriate tools are currently not available more often chose stent retrievers alone (RR 2.07; 95% CI: 1.01–4.24) or intra-arterial thrombolysis (RR 3.35, 95% CI: 1.26–8.42). Physicians who stated that they do not have access to optimal tools opted more often not to treat at all (RR 3.41, 95% CI: 1.11–10.49). Stent-retrievers alone were chosen more often and contact aspiration alone less often as a first-line approach in Europe (RR 2.12, 95% CI: 1.38–3.24; and RR 0.49, 95% CI 0.34–0.70, respectively) compared to the United States and Canada.Conclusions: In EVT for MeVO strokes, neurointerventionalists choose a targeted vessel specific first-line approach depending on the occlusion location, region of practice, and availability of the appropriate tools.

Abstract WP437: Shear-activated Nanoparticle Aggregate Lysis Combined With Temporary Stent-bypass to Treat Emergent Large Vessel Occlusions (ELVO)

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Miklos G Marosfoi ◽  
Netanel Korin ◽  
Matthew J Gounis ◽  
Oktay Uzun ◽  
Srinivasan Vedantham ◽  
...  
Keyword(s):  
Vascular Injury ◽  
Targeted Delivery ◽  
Vascular Trauma ◽  
Stent Retriever ◽  
Arterial Infusion ◽  
Vessel Occlusion ◽  
Occlusion Model ◽  
Stent Retrievers ◽  
Endovascular Approach ◽  
Temporary Stent

Introduction: Despite the high effectiveness of stent-retrievers in ELVO, half of the patients remained functionally dependent (mRS≥3) after 90-days. Beyond futile recanalizations, variable endoluminal damage caused by stent-retrievers may contribute to reperfusion injury, and recruit iniflammatory cell infiltration. The goal of this study was to assess a less traumatic endovascular approach in combination with a novel shear activated-nanotherapeutic (SA-NT) that releases r-tPA when exposed to high levels of hemodynamic stress. Hypothesis: SA-NT treatment coupled with temporary endovascular bypass provides high recanalization rates while reducing vascular injury. Methods: a rabbit carotid vessel occlusion model was used. We evaluated angiographic recanalization with stent-bypass alone, intra-arterial delivery of soluble r-tPA alone, or stent-bypass combined with two doses (2 and 20 mg r-tPA) of intra-arterial infusion of either the SA-NT or soluble r-tPA. Vascular injury was compared against stent-retriever thrombectomy by assessing the level of damage on histology. Results: Shear-targeted delivery of r-tPA using the SA-NT resulted in the highest rate of complete recanalization when compared to controls (p=0.0011). SA-NT (20mg) had a higher likelihood of obtaining complete recanalization (mTICI:3) as compared to stent-bypass alone (OR: 65.019,95%CI:[1.77,>1000], p=0.0231), intra-arterial r-tPA alone (OR: 65.019, 95% CI [1.77,>1000], p=0.0231), or stent-bypass with soluble r-tPA (2 mg) (OR: 18.78, 95%CI [1.28,275.05], p=0.0322) (Figure). Histologically, there was significantly less vascular injury using a stent-bypass as compared to stent-retriever procedure (OR 12.97, 95%CI [8.01,21.02], p<0.0001). Conclusion: Nanoparticle-based thrombolytic therapy combined with stent-bypass achieves high rates of complete (mTICI:3) recanalization. This technology reduces vascular trauma as compared to stent-retriever thrombectomy

Mechanical Thrombectomy in Acute Ischemic Stroke: A Meta-Analysis of Stent Retrievers vs Direct Aspiration vs a Combined Approach

Neurosurgery ◽  
2019 ◽  
Author(s):  
Pavlos Texakalidis ◽  
Stefanos Giannopoulos ◽  
Theofilos Karasavvidis ◽  
Leonardo Rangel-Castilla ◽  
Dennis J Rivet ◽  
...  
Keyword(s):  
Mechanical Thrombectomy ◽  
Meta Analysis ◽  
Combined Approach ◽  
First Line ◽  
Vessel Occlusion ◽  
Stent Retrieval ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Stent Retrievers ◽  
Meta Analyses ◽  
Event Rates

Abstract BACKGROUND Recent randomized control trials (RCTs) established that mechanical thrombectomy is superior to medical therapy for patients with stroke due to a large vessel occlusion. OBJECTIVE To compare the safety and efficacy profile of the different mechanical thrombectomy strategies. METHODS A random-effects meta-analysis was performed and the I2 statistic was used to assess heterogeneity according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. RESULTS Nineteen studies with a total of 2449 patients were included. No differences were identified between the stent retrieval and direct aspiration groups in terms of modified Thrombolysis in Cerebral Infarction (mTICI) 2b/3 and mTICI 3 recanalization rates, and favorable outcomes (modified Rankin Scale [mRS] ≤ 2). Adverse event rates, including 90-d mortality, symptomatic intracerebral hemorrhage (sICH), and subarachnoid hemorrhage (SAH), were similar between the stent retrieval and direct aspiration groups. The use of the stent retrieval was associated with a higher risk of vasospasm (odds ratio [OR]: 2.98; 95% confidence interval [CI]: 1.10-8.09; I2: 0%) compared to direct aspiration. When compared with the direct aspiration group, the subgroup of patients who underwent thrombectomy with the combined approach as a first-line strategy had a higher likelihood of successful mTICI 2b/3 (OR: 1.47; 95% CI: 1.02-2.12; I2: 0%) and mTICI 3 recanalization (OR: 3.65; 95% CI: 1.56-8.54), although with a higher risk of SAH (OR: 4.33; 95% CI: 1.15-16.32). CONCLUSION Stent retrieval thrombectomy and direct aspiration did not show significant differences. Current available evidence is not sufficient to draw conclusions on the best surgical approach. The combined use of a stent retriever and aspiration as a first-line strategy was associated with higher mTICI 2b/3 and mTICI 3 recanalization rates, although with a higher risk of 24-h SAH, when compared with direct aspiration.

Ideal body position for epinephrine autoinjector administration

2020 ◽  
Author(s):  
Qing Wang ◽  
Luke Pittman ◽  
Andrew Healey ◽  
James Chang ◽  
T. Ted Song
Keyword(s):  
Body Position ◽  
Vastus Lateralis ◽  
The United States ◽  
Thigh Muscle ◽  
First Line ◽  
Medical Treatment Facility ◽  
First Line Therapy ◽  
Epinephrine Autoinjector ◽  
Ideal Body ◽  
The Ideal

Background: Epinephrine is the first-line therapy for patients with anaphylaxis, and intramuscular (IM) delivery is shownto be superior to subcutaneous (SC) delivery. There currently is no consensus on the ideal body position for epinephrine autoinjector (EAI) administration.Objective: We designed this study to investigate whether SC tissue depth (SCTD) is affected by body position (e.g., standing, sitting, supine), which can potentially impact delivery of EAI into the IM space.Methods: Volunteer adults (ages >/= 18 years) from a military medical treatment facility in the United States were recruitedto participate in this study. SCTD of the vastus lateralis was measured via ultrasound at standing, sitting, and supine bodypositions. Subjects’ age, sex, and body mass index (BMI) were collected. Statistical analysis was performed to compare averageSCTD between body positions, sex, and BMI.Results: An analysis of variance of 51 participants (33 men and 18 women) did not reveal statistically significant differencein SCTD among standing, sitting, and supine body positions. It did show a significantly greater SCTD in women than in men (2.72 +/- 1.36 cm versus 1.10 +/- 0.38 cm; p < 0.001). There was no significant association observed between BMI and SCTD in this study.Conclusion: Body position did not seem to significantly change the distance between skin and thigh muscle in adults. Thiswould suggest that there might not be an ideal body position for EAI administration. Therefore, in case of anaphylaxis, promptadministration of epinephrine is recommended at any position.

Front-line thrombectomy for acute large-vessel occlusion with underlying severe intracranial stenosis: stent retriever versus contact aspiration

2020 ◽  
Vol 132 (4) ◽  
pp. 1202-1208 ◽  
Author(s):  
Dong-Hun Kang ◽  
Woong Yoon ◽  
Byung Hyun Baek ◽  
Seul Kee Kim ◽  
Yun Young Lee ◽  
...  
Keyword(s):  
Binary Logistic Regression ◽  
Stent Retriever ◽  
Large Vessel ◽  
Binary Logistic Regression Analysis ◽  
Large Vessel Occlusion ◽  
Front Line ◽  
Vessel Occlusion ◽  
Aspiration Thrombectomy ◽  
Atherosclerotic Stenosis ◽  
Antegrade Flow

OBJECTIVEThe optimal front-line thrombectomy choice for primary recanalization of a target artery remains unknown for patients with acute large-vessel occlusion (LVO) and an underlying intracranial atherosclerotic stenosis (ICAS). The authors aimed to compare procedural characteristics and outcomes between patients who received a stent-retriever thrombectomy (SRT) and patients who received a contact aspiration thrombectomy (CAT), as the front-line approach for treating LVO due to severe underlying ICAS.METHODSOne hundred thirty patients who presented with acute LVO and underlying severe ICAS at the occlusion site were included. Procedural characteristics and treatment outcomes were compared between patients treated with front-line SRT (n = 70) and those treated with front-line CAT (n = 60). The primary outcomes were the rate of switching to an alternative thrombectomy technique, time from groin puncture to initial reperfusion, and duration of the procedure. Initial reperfusion was defined as revealing the underlying culprit stenosis with an antegrade flow after thrombectomy.RESULTSThe rate of switching to an alternative thrombectomy after failure of the front-line technique was significantly higher in the CAT group than in the SRT group (40% vs 4.3%; OR 2.543, 95% CI 1.893–3.417, p < 0.001). The median time from puncture to initial reperfusion (17 vs 31 minutes, p < 0.001) and procedure duration (39 vs 75.5 minutes, p < 0.001) were significantly shorter in the SRT group than in the CAT group. In the binary logistic regression analysis, a longer time from puncture to initial reperfusion was an independent predictor of a 90-day poor (modified Rankin Scale score 3–6) functional outcome (per 1-minute increase; OR 1.029, 95% CI 1.008–1.050, p = 0.006).CONCLUSIONSThe authors’ results suggest that SRT may be more effective than CAT for identifying underlying culprit stenosis and therefore considered the optimal front-line thrombectomy technique in acute stroke patients with LVO and severe underlying ICAS.

EXPRESS: Stent Retriever Alone vs. Aspiration and Stent-Retriever Combination in Large Vessel Occlusion Stroke: A Matched Analysis

2021 ◽  
pp. 174749302110192
Author(s):  
Mahmoud H Mohammaden ◽  
Diogo C. Haussen ◽  
Leonardo Pisani ◽  
Alhamza Al-Bayati ◽  
Aaron Anderson ◽  
...  
Keyword(s):  
Randomized Clinical Trials ◽  
Functional Independence ◽  
Stent Retriever ◽  
Sensitivity Analyses ◽  
First Line ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Guide Catheter ◽  
First Pass ◽  
Combined Technique

Background Three randomized clinical trials have reported similar safety and efficacy for contact aspiration (CA) and Stent-retriever (SR) thrombectomy. Aim We aimed to determine whether the Combined Technique (SR+CA) was superior to SR alone as first-line thrombectomy strategy in a patient cohort where balloon-guide catheter was universally used. Methods A prospectively maintained mechanical thrombectomy database from January 2018-December 2019 was reviewed. Patients were included if they had anterior circulation proximal occlusion ischemic stroke (intracranial ICA or MCA-M1/M2 segments) and underwent SR alone thrombectomy or SR+CA as first-line therapy. The primary outcome was the first-pass effect (FPE) (mTICI2c-3). Secondary outcomes included modified FPE (mTICI2b-3), successful reperfusion (mTICI2b-3) prior to and after any rescue strategy, and 90-day functional independence (mRS ≤2). Safety outcomes included rate of parenchymal hematoma (PH) type-2 and 90-day mortality. Sensitivity analyses were performed after dividing the overall cohort according to first-line modality into two matched groups. Results A total of 420 patients were included in the analysis (mean age 64.4 years; median baseline NIHSS 16[11-21]). As compared to first-line SR alone, first-line SR+CA resulted in similar rates of FPE (53% vs. 51%,aOR 1.122, 95%CI[0.745-1.691],p=0.58), mFPE (63% vs. 60.4%,aOR1.250, 95%CI[0.782-2.00],p=0.35), final successful reperfusion (97.6% vs. 98%,p=0.75) and higher chances of successful reperfusion prior to any rescue strategy (81.8% vs. 72.5%,aOR 2.033, 95%CI[1.209-3.419],p=0.007). Functional outcome and safety measures were comparable between both groups. Likewise, the matched analysis (148 patient-pairs) demonstrated comparable results for all clinical and angiographic outcomes except for significantly higher rates of successful reperfusion prior to any rescue strategies with the first-line SR+CA treatment (81.8% vs. 73.6%,aOR 1.881, 95%CI[1.039-3.405],p=0.037). Conclusions Our findings reinforce the findings of ASTER-2 trial in that the first-line thrombectomy with a Combined Technique did not result in increased rates of first-pass reperfusion or better clinical outcomes. However, addition of contact aspiration after initial SR failure might be beneficial in achieving earlier reperfusion.

SOFIA catheter for direct aspiration of large vessel occlusion stroke: A single-center cohort and meta-analysis

2021 ◽  
pp. 159101992110053
Author(s):  
Federico Bolognini ◽  
Pablo A Lebedinsky ◽  
Mariano Musacchio ◽  
Mariette Delaitre ◽  
Abdoulaye M Traoré ◽  
...  
Keyword(s):  
Rescue Therapy ◽  
Meta Analysis ◽  
Functional Independence ◽  
Large Vessel ◽  
Study Cohort ◽  
Large Vessel Occlusion ◽  
First Line ◽  
Vessel Occlusion ◽  
Global Rate ◽  
Symptomatic Intracranial Hemorrhage

Background and Purpose Direct aspiration (DA) using large-bore distal aspiration catheters is an established strategy for the endovascular thrombectomy (EVT) of large-vessel occlusion stroke (LVOS). However, the performance of individual catheters like SOFIA has yet to be examined. Methods We present a cohort of 144 consecutive patients treated with first-line DA and SOFIA 6 F Plus catheter for LVOS. We also conducted a systematic review of the literature searching multiple databases for reports on thrombectomy with DA and SOFIA catheters and performed a meta-analysis of recanalization, safety, and clinical outcomes. Results In the study cohort a successful recanalization (mTICI 2b-3) rate of 75.7% was achieved with DA alone, the global rate for functional independence (90-day mRS 0-2) was 40.3%. For the metanalysis we selected nine articles that included a total of 758 patients treated with first-line thrombectomy with the SOFIA catheters. The mTICI 2b-3 rate was 71.6% (95%CI, 66.3-76.5%) while a rescue stent-retriever was used in 24.1% (95%CI, 17.7-31.9%) of cases. The overall mTICI2b-3 rate after DA and rescue therapy was 88.9% (95%CI, 82.6-93.1%). We found a pooled estimate of 45.6% (95%CI, 38.6-52.8%) for functional independence, a mortality within 90 days of 19% (95%CI, 14.1-25.0%) and a rate of 5.8% (95%CI, 4.2-8.0%) of symptomatic intracranial hemorrhage. Conclusion The DA approach for LVOS with the SOFIA catheters is highly effective with an efficacy and safety profile comparable to those found in contemporary thrombectomy trials and observational studies that use other devices or approaches.

scholarly journals Stroke thrombectomy complication management

2021 ◽  
pp. neurintsurg-2021-017349
Author(s):  
Sara M Pilgram-Pastor ◽  
Eike I Piechowiak ◽  
Tomas Dobrocky ◽  
Johannes Kaesmacher ◽  
Juergen Den Hollander ◽  
...  
Keyword(s):  
Treatment Efficacy ◽  
Mechanical Thrombectomy ◽  
Complication Management ◽  
Line Treatment ◽  
Large Vessel Occlusion ◽  
First Line ◽  
Invasive Treatment ◽  
Vessel Occlusion ◽  
Endovascular Mechanical Thrombectomy ◽  
First Line Treatment

Endovascular mechanical thrombectomy (EVT) is widely accepted as the first-line treatment for acute ischemic stroke in patients with large vessel occlusion. Being an invasive treatment, this method is associated with various preoperative, perioperative, and postoperative complications. These complications may influence peri-interventional morbidity and mortality and therefore treatment efficacy and clinical outcome. The aim of this review is to discuss the most common types of complications associated with EVT, the probable mechanisms of injury, and effective methods to manage and prevent complications.

scholarly journals Inadvertent Detachment of Stent Retrievers during Mechanical Thrombectomy—A Clinical and Biomechanical Perspective

Life ◽  
2021 ◽  
Vol 11 (7) ◽  
pp. 658
Author(s):  
Piotr Piasecki ◽  
Marek Wierzbicki ◽  
Piotr Tulik ◽  
Katarzyna Potocka ◽  
Adam Stępień ◽  
...  
Keyword(s):  
Mechanical Thrombectomy ◽  
Clinical Course ◽  
Phantom Study ◽  
Stent Retriever ◽  
Vessel Occlusion ◽  
Intracranial Vessel ◽  
Mechanical Study ◽  
Stent Retrievers ◽  
Phantom Studies ◽  
Stroke Centre

Background: The inadvertent detachment of stent retrievers during mechanical thrombectomy is an extremely rare but feared complication associated with poor clinical outcomes. We discuss management considerations after an unexpected disconnection of the pRESET stent retriever during mechanical thrombectomy, based on clinical experience and mechanical and phantom studies. Methods: We present a clinical course of rare accidents of stent-retriever separation inside an intracranial vessel that occurred in patients in a comprehensive stroke centre between 2018 and 2020. We designed a phantom study to assess the Tigertriever’s ability to remove a detached stent retriever from intercranial vessels. In the mechanical study, several types of stent retrievers were evaluated in order to find the weakest point at which detachment occurred. Results: Two patients (~0.7%) with inadvertent stent-retriever detachment were found in our database. Failed attempts of endovascular removal with no recanalization at the end of procedure were reported in both cases. mRS after 3 months was three and four respectively. In the mechanical study, the Tigertriever was the most resistant to detachment and was followed by Embotrap > pRESET > 3D Separator. In the phantom study, the pRESET device detached in a configuration resembling the M1 segment was successfully removed with the Tigertriever. Conclusions: Conservative management of the inadvertent detachment of stent retrievers during mechanical thrombectomy in large vessel occlusion may be acceptable in order to avoid further periprocedural complications after unsuccessful device removal attempts. Based on the phantom and mechanical studies, the Tigertriever may be a useful tool for the removal of detached pRESET devices.

Should endovascular approach be the first line of treatment for retroperitoneal bleeding with hemodynamic shock following percutaneous intervention? A case series

2016 ◽  
Vol 90 (1) ◽  
pp. 104-111 ◽  
Author(s):  
Ignacio M. Seropian ◽  
Dominick J. Angiolillo ◽  
Martin M. Zenni ◽  
Theodore A. Bass ◽  
Luis A. Guzman
Keyword(s):  
Case Series ◽  
Percutaneous Intervention ◽  
First Line ◽  
Retroperitoneal Bleeding ◽  
Endovascular Approach
Sign in / Sign up

Export Citation Format

Share Document