Neurointervention.  2021 Mar;16(1):64-69. 10.5469/neuroint.2020.00409.

Pull-Through Buddy Wire Technique for Endovascular Thrombectomy in Patients with Acute Ischemic Stroke: Technical Note

• Chiang PY
• Lin YH
• Huang YC
• Lee CW

• KMID: 2513346
• DOI: http://doi.org/10.5469/neuroint.2020.00409

Abstract

Excessive tortuosity is a notable cause of failed endovascular thrombectomy for acute large-vessel occlusion stroke. Transcervical access (TCA) is a commonly proposed solution for overcoming this difficulty. However, the large-bore catheter usually used in TCA increases the risk of serious local complications. This paper presents a modified technique for TCA that uses a pull-through buddy wire (PTBW) to track a large-bore femoral guiding sheath (GS) into the carotid artery via a small carotid puncture site. The carotid puncture site can be easily managed through gentle manual compression. Two illustrative cases using this technique to deal with a large aortic arch and tortuous left common carotid artery are reported. In both cases, recanalization was achieved after successful GS placement. Using a PTBW is feasible in TCA.

Keyword

Intracranial embolism; Thrombectomy; Endovascular procedures; Stroke

Figure

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  Fig. 1. Illustration of the pull-through technique in the CCA. (A) A microwire through the puncture route in the common carotid artery goes down to the ascending aorta. The snare through the guiding catheter from the transfemoral approach catches the microwire. (B) The guiding catheter can be guided along the tensed microwire.

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  Fig. 2. Application of the pull-through technique during EVT for left MCA M1 occlusion. (A) Volume rendering image showing a type III aorta and low-lying, tortuous left CCA. (B) The snare (arrow) through the guiding catheter from the transfemoral approach catches the microwire (arrowheads). (C) The guiding catheter can be guided along the tensed microwire (arrowheads). (D) The pull-through buddy wire technique (arrowheads) allows a stable system for the guiding catheter and subsequent suction thrombectomy (arrows). (E) Frontal left ICA angiography image after thrombectomy showing reopening of the occluded left MCA. CCA, the common carotid artery; EVT, endovascular thrombectomy; MCA, the middle cerebral artery; ICA, the internal carotid artery.

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  Fig. 3. Switch to the pull-through technique during stenting for acute occlusion of the left MCA M1 with underlying severe stenosis. (A) MRA findings showing underlying severe stenosis of the left MCA M1 (arrow). (B) Reformatted intracranial CTA revealing acute occlusion of the MCA (arrow). (C) Volume-rendered CTA showing a low-lying left CCA orifice with excessive tortuosity. (D) The left neck puncture site fixed with a torque device. (E) Frontal left ICA angiography image showing the recanalization of the MCA after stent placement (arrows). CTA, computed tomography angiography; CCA, common carotid artery; ICA, internal carotid artery; MCA, middle cerebral artery; MRA, magnetic resonance angiography

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