Initial Experience of ACE68 Reperfusion Catheter in Patients with Acute Ischemic Stroke Related to Internal Carotid Artery Occlusion

OBJECTIVE: Penumbra ACE68 reperfusion catheter is a new large bore aspiration catheter used for reperfusion of large vessel occlusion. The objective of this study was to investigate the efficacy of this catheter in comparison to that of previous Penumbra catheters in patients with acute ischemic stroke related to internal carotid artery (ICA) occlusion. METHODS: Data of all eligible patients who received endovascular treatment (EVT) for ICA occlusion using Penumbra aspiration catheters between January 2015 and December 2018 were retrospectively reviewed. After dividing into two groups according to use of penumbra ACE68, baseline characteristics of patients, successful recanalization rate, puncture to recanalization time, and switch to stent base technique rate were assessed. Successful recanalization was defined by a thrombolysis in cerebral infarction (TICI) score ≥2b and favorable functional outcome was defined according to modified Rankin scale (score, 0–2). RESULTS: ACE68 reperfusion catheter was used in 29 of 75 eligible patients (39%). The puncture to recanalization time was significantly shorter (26±18.2 minutes vs. 40±24.9 minutes, p=0.011) and the rate of switch to stent-based retrieval was significantly lower (3% vs. 20%, p=0.046) in ACE68 catheter group. Moreover, although not statistically significant, the successful recanalization rate was higher (83% vs. 76%, p=0.492) in ACE68 catheter group. Favorable functional outcome was observed in 48% of patients treated with ACE68 reperfusion catheter and in 30% of patients treated using other Penumbra systems (p=0.120). Baseline Alberta Stroke Program Early CT Scores ≥8 (odds ratio [OR], 9.74; 95% confidence interval [CI], 1.72–54.99; p=0.010) and successful recanalization (OR, 10.20; 95% CI, 1.13–92.46; p=0.039) were independent predictors of favorable outcome. CONCLUSION: EVT using ACE68 reperfusion catheter can be considered a first-line therapy in patients with acute ICA occlusion as it can achieve rapid recanalization and reduce the frequency of conversion to stent-retrieve therapy.

Initial Experience of ACE68 Reperfusion Catheter in Patients with Acute Ischemic Stroke Related to Internal Carotid Artery Occlusion

OBJECTIVE: Penumbra ACE68 reperfusion catheter is a new large bore aspiration catheter used for reperfusion of large vessel occlusion. The objective of this study was to investigate the efficacy of this catheter in comparison to that of previous Penumbra catheters in patients with acute ischemic stroke related to internal carotid artery (ICA) occlusion.METHODS: Data of all eligible patients who received endovascular treatment (EVT) for ICA occlusion using Penumbra aspiration catheters between January 2015 and December 2018 were retrospectively reviewed. After dividing into two groups according to use of penumbra ACE68, baseline characteristics of patients, successful recanalization rate, puncture to recanalization time, and switch to stent base technique rate were assessed. Successful recanalization was defined by a thrombolysis in cerebral infarction (TICI) score ≥2b and favorable functional outcome was defined according to modified Rankin scale (score, 0–2).RESULTS: ACE68 reperfusion catheter was used in 29 of 75 eligible patients (39%). The puncture to recanalization time was significantly shorter (26±18.2 minutes vs. 40±24.9 minutes, p=0.011) and the rate of switch to stent-based retrieval was significantly lower (3% vs. 20%, p=0.046) in ACE68 catheter group. Moreover, although not statistically significant, the successful recanalization rate was higher (83% vs. 76%, p=0.492) in ACE68 catheter group. Favorable functional outcome was observed in 48% of patients treated with ACE68 reperfusion catheter and in 30% of patients treated using other Penumbra systems (p=0.120). Baseline Alberta Stroke Program Early CT Scores ≥8 (odds ratio [OR], 9.74; 95% confidence interval [CI], 1.72–54.99; p=0.010) and successful recanalization (OR, 10.20; 95% CI, 1.13–92.46; p=0.039) were independent predictors of favorable outcome.CONCLUSION: EVT using ACE68 reperfusion catheter can be considered a first-line therapy in patients with acute ICA occlusion as it can achieve rapid recanalization and reduce the frequency of conversion to stent-retrieve therapy.

Reperfusing the myocardium - a damocles Sword

Return of blood flow after periodic ischemia is often accompanied by myocardial injury, commonly known as lethal reperfusion injury (RI). Experimental studies have shown that 50% of muscle die of ischemia and another 50% die because of reperfusion. It is characterized by myocardial, vascular, or electrophysiological dysfunction that is induced by the restoration of blood flow to previously ischemic tissue. This phenomenon reduces the efficiency of the present modalities used to combat the ischemic myocardium. Moreover, despite an improved understanding of the pathophysiology of this process and encouraging preclinical trials of multiple agents, most of the clinical trials to prevent RI have been disappointing and leaves us at ground zero to explore newer approaches.

Forced Arterial Suction Thrombectomy Using Distal Access Catheter in Acute Ischemic Stroke / 신경중재치료의학

Historical innovations in mechanical thrombectomy devices and strategies for ischemic stroke have resulted in improved angiographic outcomes and better clinical outcomes. Various devices have been used, but the two most common approaches are aspiration thrombectomy and stent-retrieval thrombectomy. Aspiration thrombectomy has advanced from the traditional Penumbra system to forced arterial suction thrombectomy and a direct aspiration first-pass technique. Newer generation aspiration catheters with flexible distal tips and a larger bore have demonstrated faster and better recanalization relative to older devices. Recently, several species of distal access catheters have similar structural characteristics to the Penumbra reperfusion catheter. Therefore, we used the distal access catheter for forced arterial suction thrombectomy in three patients with acute ischemic stroke. In each case, we achieved fast and complete recanalization without significant complications. Forced arterial suction thrombectomy using a distal access catheter might provide another option for mechanical thrombectomy in patients with acute ischemic stroke.

Endovascular Stroke Therapy Focused on Stent Retriever Thrombectomy and Direct Clot Aspiration: Historical Review and Modern Application

Intravenous recombinant tissue plasminogen activator had been the only approved treatment for acute ischemic stroke since its approval in 1995. However, the restrictive time window, numerous contraindications, and its low recanalization rate were all limitations of this modality. Under those circumstances, endovascular stroke therapy went through a great evolution during the past two decades of intravenous thrombolysis. The results of the 2013 randomized trials for endovascular stroke therapy were neutral, although they were limited by insufficient imaging screening at enrollment, early-generation devices with less efficacy, and treatment delays. Huge progress was made in 2015, as there were five randomized clinical trials which all demonstrated the safety and efficacy of endovascular stroke treatment. Despite differences in detail patient enrollment criteria, all 5 trials employed key factors for good functional recovery; (1) screening with non-invasive imaging to identify the proximal occlusion and exclude a large infarct core, (2) using highly effective modern thrombectomy devices mainly with stent retriever, and (3) establishment of a fast workflow to achieve effective reperfusion. The results of those trials indicate that modern thrombectomy devices can allow for faster and more effective reperfusion, which can lead to improved clinical outcomes compared to intravenous thrombolysis alone. These advances in mechanical thrombectomy are promising in the global fight against ischemic stroke-related disability and mortality. Two current mainstreams among such mechanical thrombectomy techniques, “stent retriever thrombectomy” and “direct clot aspiration”, are the topic of this review. Stent retriever thrombectomy using Solitaire and Trevo retriever will be firstly discussed. And, the commonalities and the differences between two major clot aspiration thrombectomy techniques; a direct aspiration first pass technique (ADAPT) and forced arterial suction thrombectomy (FAST), will be additionally explained. Finally, details regarding the combination of direct clot aspiration and stent retriever thrombectomy, the switching strategy and the Solumbra technique, will be described.

Efficacy of Proximal Aspiration Thrombectomy for Using Balloon-Tipped Guide Catheter in Acute Intracranial Internal Carotid Artery Occlusion

OBJECTIVE: Mechanical thrombectomy (MT) for acute intracranial internal carotid artery (ICA) occlusion is often complicated by difficult revascularization and non-involved territory embolization possibly related with larger clot-burden. This study aims to evaluate the efficacy of proximal aspiration thrombectomy (PAT) using a balloon-tipped guide catheter for clot-burden reduction in such cases with period-to-period analysis (period 1 : standard MT without PAT; period 2 : PAT first, then standard MT for the remaining occlusion). METHODS: Eighty-six patients who underwent MT for acute intracranial ICA occlusion were included in this analysis from the prospectively maintained stroke registry (33 patients in period 1 and 53 in period 2). In period 2, 'responder' was defined as a case where some amount of clot was retrieved by PAT and the following angiography showed partial or full recanalization. RESULTS: Fifteen of fifty-three patients in period 2 (28.3%) were 'responders' to PAT. There was a significantly higher incidence of atrial fibrillation in the 'responder' subgroup. Period 2 showed a significantly shorter puncture-to-reperfusion time (94.5 minutes vs. 56.0 minutes; p=0.002), a significantly higher Thrombolysis in Cerebral Infarction of 2b-3 reperfusion (45.5% vs. 73.6%; p=0.009), but only a trend for better 3-month favorable outcome (mRS 0-2; 36.4% vs. 54.7%; p=0.097). There was no increase in the incidence of procedure-related complications or intracranial hemorrhage in period 2. CONCLUSION: A strategy of PAT before standard MT may result in shorter puncture-to-reperfusion time and better angiographic outcome than a strategy of standard MT for acute intracranial ICA occlusion.

Mid-and long-term result of endovascular therapy for lower extremity deep venous thrombosis / 中华普通外科杂志

Objective To evaluate the mid-term and long-term result of mechanical aspiration thrombectomy or combined with balloon thrombectomy,venoplasty and catheter-directed thrombolysis therapy for lower extremity deep venous thrombosis.Methods Clinical data of 1 068 admitted patients were analysed retrospectively from January 2000 to June 2010.Among these patients,271 cases were treated by thrombectomy only,537 cases received thrombectomy with arterial catheter-directed thrombolysis,260 cases were treated by thrombectomy with dorsalis pedis vein thrombolysis,492 patients with stenosis or obstruction of iliac vein underwent venoplasty treatment.Results After 36 month follow-up edema,pigmentation and chronic ulcers were 10.26％,7.28％,1.55％ respectively.The patency without reflux,patency with reflux,residual thrombus,occlusion rate of the iliofemoral vein were 84.25％,8.95％,4.3％,2.5％ respectively; The patency,residual thrombus and occlusion rate of popliteal vein were 93.32％,5.49％,1.19％.Iliac vein stent patency rate was 92.28％.Conclusions Endovascular treatment for lower extremity deep venous thrombosis was a reasonable therapy with a satisfactory mid-term and long-term result,protecting venous valve function and reducing the morbidity of post-thrombotic syndrome.

The Results of Aspiration Thrombectomy for the Endovascular Treatment of Ileofemoral Deep Vein Thrombosis

PURPOSE: This study was performed to evaluate the effect of aspiration thrombectomy for the treatment of ileofemoral deep vein thrombosis. METHODS: We reviewed the records of sixty-two patients who were treated with catheter-directed thrombolysis (CDT) at our institution between November 2001 and October 2007. The patients were divided into two groups: those who were treated by CDT with aspiration thrombectomy (AT) (the aspiration group; 33 patients) or those who were treated with using CDT alone (the CDT alone group; 29 patients). The obtained data included the demographics, the procedural details, the periprocedural evaluation and the thrombus resolution. RESULTS: The treatment time with using CDT only was 40.93+/-15.59 hours compared with 23.18+/-8.22 hours with using AT (P<0.001). The mean dose of urokinase with using CDT only was 2.48+/-0.82 million IU as compared with 1.60+/-0.54 million IU with using AT (P<0.001). The use of AT did not improve the overall lytic success (P=0.084), but more patients had complete thrombus resolution (13 vs. 22 patients, respectively). There was no difference in symptom improvement or the long term patency rate between the two groups. There was no major morbidity or mortality. The prophylactic IVC filters were inserted in 31 patients and entrapped thrombi were founded in 3 patients of the aspiration group. Evidence of venous reflux was identified in the CDT only group (3 patients; 10.4%). CONCLUSION: These results suggest that the use of AT offers more effective thrombus removal in less time and with using a lower dose of thrombolytic agents. When performing AT treatment, prophylactic IVC filter insertion should be considered for preventing floating thrombi.

Pseudo-no-Reflow Phenomenon in Carotid Artery Stenting using FilterWire EX: Successful Recovery by Aspiration Thrombectomy

Distal protection devices such as FilterWire EX have been widely used in carotid artery stenting, however, the large amount of atherothrombotic debris entrapped in the filter could reduce or stop antegrade flow. We present a case of pseudo-no-reflow phenomenon after postdilatation of the stent in a patient with asymptomatic carotid artery stenosis. After several passes using an Export Aspiration catheter, normal flow in the internal carotid artery was restored. Aspiration thrombectomy can successfully recover pseudo-no-reflow phenomenon.