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endovascular_technique_for_ischemic_stroke_treatment

Endovascular technique for ischemic stroke treatment

Studies have established the effectiveness and relative safety of endovascular intervention. These trials favor rapid endovascular intervention in acute ischemic stroke with proximal vessel occlusion, small infarct core and moderate to good collateral circulation 1) 2) 3) 4).

Techniques

Intraarterial recombinant human tissue plasminogen activator

Stent retriever

Stent retrievers. Due to higher success rate, stent retrievers have become the method of first choice for clot removal in embolic stroke. The recanalization rate is 88.8 – 100% 5) 6) 7) 8).

Currently available are Solitaire and Trevo. A 7 or 8 Fr sheath is placed in the femoral artery, through which a 6 Fr balloon guide catheter is positioned in the ICA (in case of anterior circulation strokes). Angiography is performed to identify site of occlusion. Using fluoroscopy and road mapping, a microcatheter is advanced over a microwire, across the site of occlusion. The microwire is removed and the stent retriever is advanced through the microcatheter such that it extends proximal and distal to the clot. The stent retriever is unsheathed by retracting the microcatheter as the retriever is maintained stationary. The stent retriever expands to its actual size and this results in restoration of flow in the occluded artery. After five minutes, the balloon on the guide catheter is inflated to arrest blood flow. Maintaining gentle aspiration on the guide catheter, the stent retriever and microcatheter are retracted simultaneously. Once both the microcatheter and retriever are with- in the guide catheter, vigorous aspiration is applied as the two devices are concurrently retracted and removed from the patient. Angiography is performed to confirm reconstitution of circulation. Some surgeons administer a small amount of i.a. tPA as ‘mop up’ after mechanical thrombolysis, to address potential distal debris. Vessel perforation during stent retriever withdrawal has been reported 9).

Penumbra aspiration

Penumbra aspiration. Until the introduction of stent retrievers, the penumbra device boasted the highest recanalization rate. A recanalization rate of > 80% is quoted in literature 10) 11).

This device includes a microcatheter that is advanced over a microwire, through the positioned guide catheter. The tip of the microcatheter is positioned adjacent to the proximal aspect of the clot. A separator is advanced through the microcatheter that is advanced back and forth through the clot to disrupt it. The proximal end of the microcatheter is connected to an aspiration pump that is turned on to aspirate the clot fragments. Unlike stent retrievers that a ect recanalization within minutes, Penumbra aspiration device takes longer, with median time of 49 min 12).

Its use is confined to the straight arterial segments because of risk of vessel perforation by the separator action.


In addition to above, other techniques to extract thrombus have also been employed with mixed results including, aspiration with a simple syringe attached to a microcatheter, usage of snares, angioplasty at site of thrombus, stenting etc…

1)
Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, Yan B, Dowling RJ, Parsons MW, Oxley TJ, Wu TY, Brooks M, Simpson MA, Mite F, Levi CR, Krause M, Harrington TJ, Faulder KC, Stein- fort BS, Priglinger M, Ang T, Scroop R, Barber PA, McGuinness B, Wijeratne T, Phan TG, Chong W, Chandra RV, Bladin CF, Badve M, Rice H, de Villiers L, MaH, DesmondPM, DonnanGA, Davis SM. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015; 372:1009–1018
2)
Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, Roy D, Jovin TG, Willinsky RA, Sapko- ta BL, Dowlatshahi D, Frei DF, Kamal NR, Montanera WJ, Poppe AY, Ryckborst KJ, Silver FL, Shuaib A, Tampieri D, Williams D, Bang OY, Baxter BW, Burns PA, Choe H, Heo JH, Holmstedt CA, Jankowitz B, Kelly M, Linares G, Mandzia JL, Shankar J, Sohn SI, Swartz RH, Barber PA, Coutts SB, Smith EE, Morrish WF, Weill A, Subramaniam S, Mitha AP, Wong JH, Lowerison MW, Sajobi TT, Hill MD. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015; 372:1019– 1030
3)
Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, Schonewille WJ, Vos JA, Nederkoorn PJ, Wermer MJ, van Walderveen MA, Staals J, Hofmeijer J, van Oostayen JA, Lycklama a Nijeholt GJ, Boiten J, Brouwer PA, Emmer BJ, de Bruijn SF, van Dijk LC, Kappelle LJ, Lo RH, van Dijk EJ, de Vries J, de Kort PL, van Rooij WJ, van den Berg JS, van Hasselt BA, Aerden LA, Dallinga RJ, Visser MC, Bot JC, Vroomen PC, Eshghi O, Schreuder TH, Heijboer RJ, Keizer K, Tielbeek AV, den Hertog HM, Gerrits DG, van den Berg-Vos RM, Karas GB, Steyer- berg EW, Flach HZ, Marquering HA, Sprengers ME, Jenniskens SF, Beenen LF, van den Berg R, Koudstaal PJ,vanZwamWH,RoosYB,vanderLugtA,vanOos- tenbrugge RJ, Majoie CB, Dippel DW. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015; 372:11–20
4)
Fransen PS, Beumer D, Berkhemer OA, van den Berg LA, Lingsma H, van der Lugt A, van Zwam WH, van Oostenbrugge RJ, Roos YB, Majoie CB, Dippel DW. MR CLEAN, a multicenter randomized clinical trial of endovascular treatment for acute ischemic stroke in the Netherlands: study protocol for a randomized controlled trial. Trials. 2014; 15. DOI: 10.1186/174 5-6215-15-343
5)
Stampfl S, Hartmann M, Ringleb PA, Haehnel S, Bendszus M, Rohde S. Stent placement for flow restoration in acute ischemic stroke: a single-center experience with the Solitaire stent system. AJNR Am J Neuroradiol. 2011; 32:1245–1248
6)
Mordasini P, Brekenfeld C, Byrne JV, Fischer U, Arnold M, Jung S, Schroth G, Gralla J. Experimental evaluation of immediate recanalization e ect and recanalization e cacy of a new thrombus retriever for acute stroke treatment in vivo. AJNR Am J Neuroradiol. 2013; 34:153–158
7)
Wehrschuetz M, Wehrschuetz E, Augustin M, Nie- derkorn K, Deutschmann H, Ebner F. Early single center experience with the solitaire thrombectomy device for the treatment of acute ischemic stroke. Interv Neuroradiol. 2011; 17:235–240
8)
Hausegger KA, Hauser M, Kau T. Mechanical thrombectomy with stent retrievers in acute ischemic stroke. Cardiovasc Intervent Radiol. 2014; 37:863– 874
9)
Leishangthem L, Satti SR. Vessel perforation during withdrawal of Trevo ProVue stent retriever during mechanical thrombectomy for acute ischemic stroke. J Neurosurg. 2014; 121:995–998
10)
Kulcsar Z, Bonvin C, Pereira VM, Altrichter S, Yilmaz H, Lovblad KO, Sztajzel R, Rufenacht DA. Penumbra system: a novel mechanical thrombectomy device for large-vessel occlusions in acute stroke. AJNR Am J Neuroradiol. 2010; 31:628–633
11)
The penumbra pivotal stroke trial: safety and effectiveness of a new generation of mechanical devices for clot removal in intracranial large vessel occlusive disease. Stroke. 2009; 40:2761–2768
12)
Psychogios MN, Kreusch A, Wasser K, Mohr A, Gro- schel K, Knauth M. Recanalization of large intracra- nial vessels using the penumbra system: a single- center experience. AJNR Am J Neuroradiol. 2012; 33:1488–1493
endovascular_technique_for_ischemic_stroke_treatment.txt · Last modified: 2019/07/03 16:23 by administrador