The Dilator-Dotter Technique: A Modified Method of Rapid Internal Carotid Artery Revascularization in Acute Ischemic Stroke

Abstract

BACKGROUND AND PURPOSE: Acute ischemic stroke due to tandem occlusive lesions involves high-grade ICA stenosis or occlusion with a distal intracranial occlusion. Several approaches and devices exist in the treatment of tandem occlusions; however, a consensus on the optimal technique does not exist. The Dotter technique is a method of catheter-based angioplasty to recanalize cervical ICA occlusions. We present a modified dilator-Dotter technique, which involves a polyethylene, tapered inner dilator to initially cross the occlusion, followed by guide catheterization and subsequent intracranial thrombectomy. The purpose of this study was to examine the safety and efficacy of this dilator-Dotter technique. MATERIALS AND METHODS:We performed a retrospective review of patients with acute stroke due to tandem ICA intracranial occlusions, treated with our dilator-Dotter technique and thrombectomy between June 2018 and December 2019. We examined clinical, radiographic, and procedural data, as well as complications and outcomes.RESULTS: Thirty-two patients were included. In 100% of cases, the dilator-Dotter technique resulted in ICA recanalization allowing successful thrombectomy. TICI 2b-3 revascularization was obtained in 31 patients (96%), within an average time of 25 minutes. The average preprocedural ICA stenosis was 98%, including 23 patients (72%) with complete occlusion. Following the dilator-Dotter technique, average ICA stenosis improved to 59%. There were no instances of death, iatrogenic dissection, emboli to new territory, or symptomatic intracranial hemorrhage. CONCLUSIONS:The dilator-Dotter technique may be a safe and effective modification of the traditional Dotter technique in allowing rapid ICA recanalization in cases of acute ischemic stroke due to tandem occlusions. ABBREVIATIONS: ADAPT ¼ direct aspiration first-pass technique; AIS ¼ acute ischemic stroke; ICH ¼ intracranial hemorrhage; LVO ¼ large-vessel occlusion; sICH ¼ symptomatic intracranial hemorrhage

The Dilator-Dotter technique can successfully treat tandem lesions of posterior circulation

“…Compared with the traditional Dotter angioplasty, the design of the tapered tip can greatly reduce trauma to the vessel wall and occurrence of surgical complications. In a slight departure from the Dilator-Dotter technique, [5] we first tried to pass the guide wire through the occluded segment when using the 4F 125-cm MPA catheter to select the subclavian artery, because the Neuron MAX 088 catheter is not selective. If the passage was successful, the 4F MPA catheter was made to cross through the occluded segment along the guide wire.…”

“…[4] A modified Dotter technique, called the Dilator-Dotter technique, has been successfully applied to tandem lesions of anterior circulation and has led to faster recanalization times. [5] To our knowledge, there is only 1 published case report on the application of the Dilator-Dotter technique to tandem lesions of posterior circulation. [6] In our study, we examine 9 patients with such lesions treated using the Dilator-Dotter technique, and further illustrate the operational advantages associated with this technology.…”

Balloon-Assisted Catheterization of Occluded Carotid Artery (BOCA) Technique in Acute Stroke

“…Dilator-Dotter technique in tandem occlusion uses glidewire and inner dilator of Neuron MAX 088 guide catheter (Penumbra) to catheterize the occluded ICA. 37 This technique is very efficient and reduces the risk of clot embolization. However, several neurointerventionalists prefer to avoid a 038 glidewire for catheterization of an occluded ICA as a first choice because of the risk of dissection and clot propagation.…”

Direct dotterising or angioplasty of acute stroke due to tandem atherosclerotic occlusions

“…One drawback of using the guide catheter to deploy the stent is that the operator is not able to withdraw the guide catheter to first re-assess the stenosis and see if it can be treated conservatively. Other centers have described a similar dilator-dotter method with identical rapid procedure times using a guide catheter (Woodward et al, 2016;Amuluru et al, 2020) however our study has used a balloon guide catheter and has a comparison to a control group.…”