Choosing an Effective and Safe Direct Aspiration Setup for Tortuous Anatomy in Acute Ischemic Stroke: In vitro Study in a Physiological Flow Model

Abstract

Purpose A direct aspiration first pass technique (ADAPT) is an effective thrombectomy option in patients with acute ischemic stroke. Balloon guide catheters (BGC) seem to improve the efficacy of stent retrievers and ADAPT. The last generation 6F aspiration catheters require 9F BGCs, which are rigid devices that are challenging to position in a tortuous anatomy. In this experimental study the efficacy of 6F ADAPT alone and 5F ADAPT combined with 8F BGC was evaluated.

Materials and Methods Either a fibrin rich (white) clot or an RBC rich (red) clot was placed in the M1 segment of a transparent silicon phantom. Physiological hemodynamic conditions were maintained. The clots were retrieved by 6F aspiration catheter via 8F long sheath or 5F aspiration catheter via a flexible 8F BGC. Thrombectomy was performed under direct visual control. The primary endpoints were the number of passes and the number of distal emboli.

Results Ten experiments were made with each clot model and thrombectomy technique (n = 40). Full recanalization could be achieved in every experiment. First pass mTICI 3 could be achieved by 6F ADAPT in 80 % of red clots and 90 % of white clots. Distal emboli were caused in 10 % and 20 %, respectively. When using 5F ADAPT combined with BGC, a first pass mTICI 3 rate of 90 % in red clots and 100 % in white clots could be achieved. A 10 % rate of distal emboli occurred in both groups. In almost all experiments (both techniques), the thrombi clogged the aspiration catheter. No statistically significant differences could be found between the techniques and clot models.

Conclusion 6F ADAPT without BGC was as effective as 5F ADAPT combined with a flexible 8F BGC, with both techniques showing high first-pass recanalization rates and low distal emboli rates. Especially in the case of a tortuous anatomy, these setups should be considered as alternatives to a rigid 9F BGC. The thrombus compositions seemed to be irrelevant in this setting.

Key Points: 

• 6F ADAPT with no BGC and 5F ADAPT with BGC were very effective and performed equally.

• Both techniques should be considered in tortuous anatomy.

• In this setting the clot composition showed no effect on the recanalization rate.

Citation Format

• Madjidyar J, Nerkada L, Larsen N et al. Choosing an Effective and Safe Direct Aspiration Setup for Tortuous Anatomy in Acute Ischemic Stroke: In vitro Study in a Physiological Flow Model. Fortschr Röntgenstr 2021; 193: 544 – 550

Zusammenfassung

Ziel Die direkte Kontaktaspiration (ADAPT) ist eine effektive Thrombektomieoption bei Patienten mit akutem ischämischem Schlaganfall. Ballon-Führungskatheter (BGC) scheinen die Effektivität von Stent-Retrievern und ADAPT zu verbessern. Die letzte Generation der 6F-Aspirationskatheter passt nur durch 9F-BGC. Diese sind rigide und in elongierter Anatomie schwierig zu positionieren. In dieser experimentellen Studie wurde die Effektivität von 6F-ADAPT ohne BGC mit der von 5F-ADAPT mit einem flexiblen 8F-BGC verglichen.

Material und Methoden Ein fibrinreicher (weißer) oder ein Erythrozyten-reicher (roter) Thrombus wurde in das M1-Segment eines transparenten Silikonphantoms mit physiologischer Architektur platziert. Physiologische hämodynamische Bedingungen sind eingestellt worden. Die Thrombektomie wurde mit einem 6F-Aspirationskatheter über eine lange 8F-Schleuse oder mit einem 5F-Aspirationskatheter über einen flexiblen 8F-BGC unter direkter visueller Kontrolle durchgeführt. Primäre Endpunkte waren die Anzahl von Rekanalisationsmanövern und die Anzahl distaler Embolien.

Ergebnisse Es sind 10 Experimente pro Thrombusart und Thrombektomietechnik durchgeführt worden (n = 40). mTICI 3 nach einem Manöver mittels 6F-ADAPT wurde zu 80 % in roten Thromben und 90 % in weißen Thromben erreicht; es traten distale Embolien in 10 % bzw. 20 % der Fälle auf. Mittels 5F-ADAPT kombiniert mit BGC wurde mTICI 3 nach einem Manöver zu 90 % in roten Thromben und 100 % in weißen Thromben erreicht; es traten distale Embolien in jeweils 10 % der Fälle auf. In fast allen Experimenten (beide Techniken) verstopften die Thromben den Aspirationskatheter. Es konnten keine statistisch signifikanten Unterschiede abhängig von der Thrombuskomposition oder der Thrombektomietechnik festgestellt werden.

Diskussion 6F-ADAPT ohne BGC war genauso effektiv wie 5F-ADAPT kombiniert mit BGC, jeweils mit hohen Rekanalisationsraten nach einem Manöver und geringer Rate an distalen Embolien. Insbesondere bei schwieriger Anatomie sollten diese Techniken als Alternative zu einem rigiden 9F-BGC in Betracht gezogen werden. Die Thrombuskomposition schien nicht relevant zu sein.

Kernaussagen: 

• 6F-ADAPT ohne BGC und 5F-ADAPT mit BGC waren sehr effektiv und gleichwertig.

• Beide Techniken sollten für schwierige Gefäßanatomien erwogen werden.

• Die Thrombuskomposition zeigte in diesem Aufbau keinen Effekt auf die Rekanalisationsrate.

Key words

ischemia/infarction - thrombolysis - angiography - brain

Publication History

Received: 29 May 2020

Accepted: 29 September 2020

Article published online:
19 November 2020

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