J Korean Neurosurg Soc.  2017 May;60(3):335-347. 10.3340/jkns.2016.0809.005.

Endovascular Stroke Therapy Focused on Stent Retriever Thrombectomy and Direct Clot Aspiration: Historical Review and Modern Application

• Kang DH
• Park J

• KMID: 2382769
• DOI: http://doi.org/10.3340/jkns.2016.0809.005

Abstract

Intravenous recombinant tissue plasminogen activator had been the only approved treatment for acute ischemic stroke since its approval in 1995. However, the restrictive time window, numerous contraindications, and its low recanalization rate were all limitations of this modality. Under those circumstances, endovascular stroke therapy went through a great evolution during the past two decades of intravenous thrombolysis. The results of the 2013 randomized trials for endovascular stroke therapy were neutral, although they were limited by insufficient imaging screening at enrollment, early-generation devices with less efficacy, and treatment delays. Huge progress was made in 2015, as there were five randomized clinical trials which all demonstrated the safety and efficacy of endovascular stroke treatment. Despite differences in detail patient enrollment criteria, all 5 trials employed key factors for good functional recovery; (1) screening with non-invasive imaging to identify the proximal occlusion and exclude a large infarct core, (2) using highly effective modern thrombectomy devices mainly with stent retriever, and (3) establishment of a fast workflow to achieve effective reperfusion. The results of those trials indicate that modern thrombectomy devices can allow for faster and more effective reperfusion, which can lead to improved clinical outcomes compared to intravenous thrombolysis alone. These advances in mechanical thrombectomy are promising in the global fight against ischemic stroke-related disability and mortality. Two current mainstreams among such mechanical thrombectomy techniques, "stent retriever thrombectomy" and "direct clot aspiration", are the topic of this review. Stent retriever thrombectomy using Solitaire and Trevo retriever will be firstly discussed. And, the commonalities and the differences between two major clot aspiration thrombectomy techniques; a direct aspiration first pass technique (ADAPT) and forced arterial suction thrombectomy (FAST), will be additionally explained. Finally, details regarding the combination of direct clot aspiration and stent retriever thrombectomy, the switching strategy and the Solumbra technique, will be described.

Keyword

Acute ischemic stroke; Clot aspiration thrombectomy; Endovascular stroke therapy; Mechanical thrombectomy; Stent retriever thrombectomy

MeSH Terms

Humans
Mass Screening
Mortality
Reperfusion
Stents*
Stroke*
Suction
Thrombectomy*
Tissue Plasminogen Activator
Tissue Plasminogen Activator

Figure

• 

  Fig. 1 A: Solitaire FR. B: Trevo retriever. A case example of stent retriever thrombectomy is the following. C: Baseline angiography shows total occlusion of the M1 segment of the left middle cerebral artery. D: Solitaire FR 4×20 is deployed across the thrombus and partial blood flow is immediately restored. E: After waiting for 3 minutes, the stent is retrieved by pulling back the stent into the guide catheter under proximal aspiration through the guide catheter. F and G: Final angiography shows full recanalization and the whole thrombus is retrieved within the stent-strut.

• 

  Fig. 2 A: Baseline angiography shows total occlusion of the M1 segment of the left MCA. B and C: Angiogram and illustration of the FAST procedure show the occlusion site and surrounding angioarchitecture. D: Whole clot retrieved with Y-configuration, corresponds to MCA bifurcation anatomy. E: Final angiography shows complete revascularization. MCA: middle cerebral artery, FAST: forced arterial suction thrombectomy.

• 

  Fig. 3 A: Examples of steam shaping of the catheter tip with 45° curve. B: 90° curve. C: J shape. D: Examples of coaxial advancement technique are the following. Penumbra 5 Max or 5 Max Ace is assembled with a 2.3 French inner microcatheter and a 0.016 inch microguidewire. E: Penumbra 4 Max is assembled with a 2.0 French inner microcatheter and a 0.014 inch microguidewire.

• 

  Fig. 4 Examples of how steam shaping and coaxial assembly used during the FAST procedure. A: Penumbra 5 Max Ace is advancing to M1 segment of MCA in a patient of acute ICA terminus occlusion on the right. B: Penumbra 5 Max Ace is then advancing to A1 segment of ACA in the same patient. C and D: Penumbra 4 Max is introducing to the left M2 segment in a patient of acute occlusion at M2 segment of MCA on the left. FAST: forced arterial suction thrombectomy, MCA: middle cerebral artery, ICA: internal carotid artery, ACA: anterior cerebral artery.

Reference

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