Efficacy of combined use of a stent retriever and aspiration catheter in mechanical thrombectomy for acute ischemic stroke

Abstract

BackgroundThe efficacy of combined stent retriever (SR) and aspiration catheter (AC; combined technique: CBT) use for acute ischemic stroke (AIS) is unclear. We investigated the safety and efficacy of single-unit CBT (SCBT)—retrieving the thrombus as a single unit with SR and AC into the guide catheter—compared with single use of either SR or contact aspiration (CA).MethodsWe analysed 763 consecutive patients who underwent mechanical thrombectomy for AIS between January 2013 and January 2020, at six comprehensive stroke centers. Patients were divided into SCBT and single device (SR/CA) groups. The successful recanalization with first pass (SRFP) and other procedural outcomes were compared between groups.ResultsOverall, 240 SCBT and 301 SR/CA (SR 128, CA 173) patients were analyzed. SRFP (modified Thrombolysis In Cerebral Infarction (mTICI) ≥2c, 43.3% vs 27.9%, p<0.001; mTICI 3, 35.8% vs 25.5%, p=0.009) and final mTICI ≥2b recanalization (89.1% vs 82.0%, p=0.020) rates were significantly higher, puncture-to-reperfusion time was shorter (median (IQR) 43 (31.5–69) vs 55 (38–82.2) min, p<0.001), and the number of passes were fewer (mean±SD 1.72±0.92 vs 1.99±1.01, p<0.001) in the SCBT group. Procedural complications were similar between the groups. In subgroup analysis, SCBT was more effective in women, cardioembolic stroke patients, and internal carotid artery and M2 occlusions.ConclusionsSCBT increases the SRFP rate and shortens the puncture-to-reperfusion time without increasing procedural complications.

Poor clinical outcome despite successful basilar occlusion recanalization in the early time window: incidence and predictors

“…Pending the results of the future pc-ASTER trial, to date, data in the literature are insufficient to support a technical recommendation for a specific thrombectomy technique which might improve first-pass reperfusion rates. For anterior circulation occlusions, a recent large multicentric study12 found significantly higher first pass excellent reperfusion rates when combined stent retriever (SR)+contact aspiration (CA) technique was used as a frontline strategy, in conjunction with a balloon guide catheter, but this result was not replicated in other retrospective studies13 14 nor in the two ASTER (Contact Aspiration vs Stent Retriever for Successful Revascularization) randomized clinical trials (ASTER115 and ASTER216). For posterior circulation thrombectomies, a recently published multicentric cohort of 128 patients17 compared outcomes according to front-line technique (SR, CA, combined SR+CA).…”

Combined balloon guide catheter, aspiration catheter, and stent retriever technique versus balloon guide catheter and stent retriever alone technique: a systematic review and meta-analysis

“…After removing duplicates and screening for the titles and abstracts, 63 papers remained for full text review from which we excluded 58 papers (overlapping population, n=2; wrong outcome or no outcome reported, n=41; review, n=4; combined technique only used as salvage, n=2; unable to extract data, n=2; other endpoints, n=4; other, n=1). Finally, we included five studies in our meta-analysis,17 18 26–28 which included four cohort studies and one randomized trial. The quality of all of the included articles was high.…”

Thrombectomy for distal medium vessel occlusion stroke: Combined vs. single-device techniques - A systematic review and meta-analysis

“…Although successful reperfusion has traditionally been defined as mTICI 2b-3 (Powers et al, 2019), a higher angiographic score of mTICI 2c-3 has been associated with even better functional outcomes and lower mortality rates, and has been proposed as the new benchmark for a successful mechanical thrombectomy (Dargazanli et al, 2018;Rizvi et al, 2019). Combined techniques included blind exchange with mini-pinning (BEMP) (Haussen et al, 2020;Pérez-García et al, 2020), the singleunit combined technique (Okuda et al, 2022), and the stent-retriever assisted vacuum-locked extraction (SAVE) technique (Brehm et al, 2019). With two devices in the occluded vessel, thromboembolic clots can be securely captured from both sides via a stent retriever inserted distally and an aspiration catheter placed proximally, thus enhancing clot removal (Massari et al, 2016;McTaggart et al, 2017;Maus et al, 2018).…”

“…One study included 137 patients with 144 occluded arteries in the singledevice arm, but only specified the number of vessels treated by each technique (n = 92 stent retriever, n = 52 direct aspiration; Haussen et al, 2020). Four studies (Miura et al, 2019;Haussen et al, 2020;Pérez-García et al, 2020;Okuda et al, 2022) used balloonguide catheters (BGC) for all or nearly-all procedures in the same proportions across both arms, but none compared BGC against non-BGC procedural techniques.…”

“…Mechanical thrombectomy has evolved since it was first used for the treatment of large vessel occlusions (LVOs) in acute ischemic stroke (AIS): thrombectomy with stent retriever or direct aspiration is now established as standard-of-care (Class I, Level A evidence) (Powers et al, 2019). More recently, combined techniques, which incorporate simultaneous use of a stent retriever and aspiration catheter, have reported higher reperfusion rates and fewer treatment passes in treating LVO-AIS patients (Yeo et al, 2021;Okuda et al, 2022).…”