The Aspirations of Direct Aspiration for Thrombectomy in Ischemic Stroke: A Critical Analysis

Abstract

The treatment of acute ischemic stroke by mechanical thrombectomy has been revolutionary, however most of the clinical trials were done with the use a stent retriever. At the same time, an alternative technique of thrombectomy through direct aspiration with a large bore distal access catheter at the face of the clot is rapidly gaining popularity. Nonetheless, the data supporting this new technique is not yet as mature as that available on stent retrievers. This review is a critical analysis of the evidence supporting the principle of direct aspiration thrombectomy and a discussion of its potential strengths and weaknesses in comparison to the available studies on stent retrievers. While this is by no means a conclusive review, it should serve as a yardstick of where the science is currently, and what are the next trials that are necessary.

Mechanical Thrombectomy using Distal Access Catheters: Current Status and Future Prospects

“…Brinjisnki et al report in a metanalysis of 2022 treated with MT using stent‐retriever, good outcome of mRS 0‐2 at 90 days was achieved in 60% of patients who underwent MT using a BGC and 44% of patients undergoing MT in the absence of BGC, the mortality rate was halved and there was a 20% absolute difference in the proportion of patients achieving mTICI 3 23 . Accordingly in the PROTECT study, Maegerlein et al report a further combined technique using BGC with which they achieved higher recanalisation rate of 100% using PROTECT versus 78% with ADAPT in their single‐centre retrospective analysis 24,30 . Using ARTS, Massari et al have published success rates of 97.6% with mTICI3 rates of 54.7 and 43%success on first pass 25,31 .…”

“…23 Accordingly in the PROTECT study, Maegerlein et al report a further combined technique using BGC with which they achieved higher recanalisation rate of 100% using PROTECT versus 78% with ADAPT in their singlecentre retrospective analysis. 24,30 Using ARTS, Massari et al have published success rates of 97.6% with mTICI3 rates of 54.7 and 43%success on first pass. 25,31 Retrospective analysis of the North American Solitaire Acute Stroke Registry demonstrates a shorter time to reperfusion compared to other conventional techniques though this did not translate to better outcomes.…”

“…Future studies should include the recanalization rates for the initial device only, before any rescue device has been used, especially if the rescue device is the primary one in the other arm of the study. 30 Further research is needed to better understand the optimal devices and techniques for stroke thrombectomy that have the highest First Pass Effect (TICI 3 on first pass or first operative attempt)and lowest rate of distal embolization.…”

A Technical Report on the Performance of a New Large Bore Cerebral Aspiration Catheter, the First Results

“…As mentioned in the analysis of Andersson et al [11], risk of distal emboli is of particular importance when performing direct distal aspiration. Especially when no additional balloon guide catheter with flow arrest is performed.…”

Direct Aspiration: Can It Be Aspired?

“…The reviews deserve a separate reading as they discuss this issue in different perspectives. Anderssen and his colleagues [3] provided a balanced yet critical view on previous trials on DA, such as The Randomized, Concurrent Controlled Trial to Assess the Penumbra System’s Safety and Effectiveness in the Treatment of Acute Stroke (THERAPY), Direct Aspiration First Pass Technique for Thrombectomy Revascularization of Large Vessel Occlusion in Acute Ischemic Stroke (ASTER), and their sub-studies, whereas the paper by Kang and Hwang [4] was more focused on the practical issues and the past and future development of DA techniques. Although the reviews do not give a definite conclusion, they allow us to correctly learn the current status of DA.…”