Arterial Collapse during Thrombectomy for Stroke: Clinical Evidence and Experimental Findings in Human Brains and In Vivo Models

Abstract

BACKGROUND AND PURPOSE: Aspiration thrombectomy has become a preferred approach to recanalize large-vessel occlusion in stroke with a growing trend toward using larger-bore catheters and stronger vacuum pumps. However, the mechanical response of the delicate cerebral arteries to aspiration force has not been evaluated. Here, we provide preclinical and clinical evidence of intracranial arterial collapse in aspiration thrombectomy. MATERIALS AND METHODS:We presented a clinical case of arterial collapse with previously implanted flow diverters. We then evaluated the effect of vacuum with conventional aspiration catheters (with and without stent retrievers) in a rabbit model (n ¼ 3) using fluoroscopy and intravascular optical coherence tomography. Then, in a validated human cadaveric brain model, we conducted 168 tests of direct aspiration thrombectomy following an experimental design modifying the catheter inner diameter (0.064 inch, 0.068 inch, and 0.070 inch), cerebral perfusion pressures (mean around 60 and 90 mm Hg), and anterior-versus-posterior circulation. Arterial wall response was recorded and graded via direct transluminal observation. RESULTS: Arterial collapse was observed in both the patient and preclinical experimental models. In the human brain model, arterial collapse was observed in 98% of cases in the M2 and in all the cases with complete proximal flow arrest. A larger bore size of the aspiration catheter, a lower cerebral perfusion pressure, and the posterior circulation in comparison with the anterior circulation were associated with a higher probability of arterial collapse.CONCLUSIONS: Arterial collapse does occur during aspiration thrombectomy and is more likely to happen with larger catheters, lower perfusion pressure, and smaller arteries.

The proximal balloon occlusion together with direct thrombus aspiration (protect plus) technique: Experience at a tertiary comprehensive stroke center

“…23 While we are enabled aspiration only at the moment before engagement, others have reported a successful version of this technique where aspiration is enabled for the entire intracranial catheter navigation. 24 This study has several limitations. First is the aforementioned selection bias because of the retrospective nature of the study.…”

Impact of aspiration catheter size on clinical outcomes in aspiration thrombectomy

“…Counterbalancing the benefits of larger bore aspiration catheters is a concern for vessel injury. By using an in vivo rabbit model, Liu et al showed that due to the stronger vacuum forces of large bore catheters (such as 0.07 inch catheters), there is higher chance of arterial collapse during aspiration thrombectomy, which may theoretically result in absent flow and frictional arterial wall injury from the aspiration catheter 42. Likewise, while no significant overall association was found, subgroup analysis indicated that catheters with an ID ≥0.068 inch had a higher proportion of postprocedural intracranial hemorrhage compared with smaller catheters.…”

Most Promising Approaches to Improve Stroke Outcomes: The Stroke Treatment Academic Industry Roundtable XII Workshop

“…50 Catheters have also improved to better to determine safety and efficacy, particularly needed considering growing evidence for arterial collapse when a catheter is closer to vessel size. 53 Head-to-head clinical studies of specific devices are rare since next-generation devices are developed faster than completion of randomized controlled trials. Often, in vitro models are used to show superiority.…”