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IntroductionTechnical improvements to enhance distal occlusion thrombectomy are desirable. We describe the blind catheter exchange technique and report the pinning technique with small devices (‘mini-pinning’) for distal occlusions.MethodsA retrospective review of a prospective database from January 2015 to August 2018 was performed for cases of distal occlusion in which the ‘blind exchange/mini-pinning’ (BEMP) techniques were used. The technique involves the deployment of a 3 mm Trevo retriever followed by microcatheter removal and blind advancement of a 3MAX aspiration catheter over the bare retriever delivery wire (‘blind exchange’) until clot contact under aspiration. The retriever is subsequently partially recaptured in order to ‘cork’ the thrombus (‘mini-pinning’) and the system pulled as a unit. Patients with distal occlusions treated with BEMP and standard techniques (either 3 mm Trevo or 3MAX) were compared.ResultsTwenty-five vessels were treated in 22 patients. The majority of patients had isolated distal occlusions predominantly in the distal middle cerebral artery (MCA) segments, half of which involved the superior division. The comparison between BEMP (n=25 vessels) and standard techniques (n=144 vessels) revealed balanced groups. One of the highlighted differences was the more distal MCA occlusions among those who underwent BEMP (M3 occlusions 52% vs 22%; p=0.001). Otherwise, the vessel, segments, divisions and luminal diameter were comparable. There was a higher rate of first-pass modified Thrombolysis in Cerebral Infarction 2b–3 (80% vs 56%; p=0.03) and a trend towards higher rates of first-pass full reperfusion (60% vs 40%; p=0.07) with BEMP compared with standard techniques. Final reperfusion and clinical outcomes were comparable.ConclusionBEMP appears to be a safe and effective technique for the treatment of distal occlusions. Additional studies are warranted.

BackgroundAlthough aspiration and stent retriever thrombectomy perform similarly in proximal occlusions, no comparative series are available in distal occlusions. We aimed to compare the 3 mm Trevo Retriever against the 3MAX thromboaspiration catheter in distal arterial occlusions.MethodsA single-center retrospective review of a prospectively maintained databank for patients treated with the 3 mm Trevo stent retriever or 3MAX thromboaspiration as the upfront approach for distal occlusions (middle cerebral artery mid/distal M2/M3, anterior cerebral artery A1/A2/A3 or posterior cerebral artery P1/P2) from January 2014 to July 2018 was performed. The primary outcome was the rate of distal occlusion first-pass reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI) 2b–3).ResultsOf 1100 patients treated within the study period, 137 patients/144 different arteries were treated with the 3 mm Trevo (n=92) or 3MAX device (n=52). The groups had comparable demographics and baseline characteristics. There was a higher rate of first-pass mTICI 2b–3 reperfusion (62% vs 44%; p=0.03), a trend towards a higher rate of final mTICI 2b–3 reperfusion (84% vs 69%; p=0.05), and lower use of adjuvant therapy (15% vs 31%; p=0.03) with the 3 mm Trevo compared with the 3MAX. The median number of passes (p=0.46), frequency of arterial spasm (p=1.00), rates of parenchymal hematomas (p=0.22)/subarachnoid hemorrhage (p=0.37) in the territory of the approached vessel were similar across the two groups. The 90-day rate of good outcomes (45% vs 46% in the 3 mm Trevo and 3MAX groups, respectively; p=0.84) was comparable. Multivariable regression identified baseline NIH Stroke Scale (NIHSS) score (OR 0.9; 95% CI 0.8 to 0.97; p<0.01) and use of 3 mm Trevo (OR 2.2; 95% CI 1.1 to 4.6; p=0.02) independently associated with first-pass mTICI 2b–3 reperfusion.ConclusionsIn the setting of distal arterial occlusions, the 3 mm Trevo may lead to higher rates of first-pass reperfusion than direct 3MAX thromboaspiration. Lower NIHSS was found to be associated with improved reperfusion rates as observed in more proximal lesions. Further studies are warranted.

BackgroundAdvanced and recurrent cutaneous squamous cell carcinoma of the scalp and forehead require aggressive surgical excision often resulting in complex defects requiring reconstruction. This study evaluates various microvascular free flap reconstructions in this patient population, including the rarely utilized radial forearm free flap.Patients and methodsA retrospective review of patients undergoing free flap surgeries (n = 47) of the scalp between 1997 and 2011 were included. Patients were divided primarily into two cohorts: a new primary lesion (n = 21) or recurrence (n = 26). Factors examined include patient demographics, indication for surgery, defect, type of flap used, complications (major and minor), and outcomes.ResultsThe patients were primarily male (n = 34), with a mean age of 67 years (25–91). A total of 58 microvascular free flap reconstructions were performed (radial forearm free flap: n = 28, latissimus dorsi: n = 20, rectus abdominis: n = 9, scapula: n = 1). Following reconstruction with a radial forearm free flap, duration of hospitalization was shorter (P = 0.04) and complications rates were similar (P = 0.46). Donor site selection correlated with defect area (P < 0.001), but not with the extent of skull defect (P = 0.70). Larger defect areas correlated with higher complications rates (P = 0.03) and longer hospitalization (P = 0.003). Patients were more likely to require multiple reconstructions if referred for a recurrent lesions (P = 0.01) or received prior radiation therapy (P = 0.02).ConclusionAdvanced and recurrent malignancies of the scalp are aggressive and challenging to treat. The radial forearm free flap is an underutilized free flap in the reconstruction of complex scalp defects.