J Korean Neurosurg Soc.  2022 Jul;65(4):514-522. 10.3340/jkns.2021.0158.

Effectiveness of Anchoring with Balloon Guide Catheter and Stent Retriever in Difficult Mechanical Thrombectomy for Large Vessel Occlusion

• Yi HJ
• Kim BT
• Shin DS

• KMID: 2531620
• DOI: http://doi.org/10.3340/jkns.2021.0158

Abstract

Objective
: A distal navigation of a large bore aspiration catheter during mechanical thrombectomy (MT) is important. However, delivering a large bore aspiration catheter is difficult to a tortuous or atherosclerotic artery. We report the experience of anchoring with balloon guide catheter (BGC) and stent retriever to facilitate the passage of an aspiration catheter in MT.
Methods
: When navigating an aspiration catheter failed with a conventional co-axial microcatheter delivery, an anchoring technique was used. Two types of anchoring technique were applied to facilitate distal navigation of a large bore aspiration catheter during MT. First, a passage of aspiration catheter was attempted with a proximal BGC anchoring technique. If this technique also failed, another anchoring technique with distal stent retriever was tried. Consecutive patients who underwent MT with an anchoring technique were identified. Details of procedure, radiologic outcomes, and safety variables were evaluated.
Results
: A total of 67 patients underwent MT with an anchoring technique. Initial trial of aspiration catheter passage with proximal BGC anchoring technique was successful for 35 patients (52.2%) and the second trial with distal stent retriever anchoring was successful for 32 patients (47.8%). Overall, navigation of a large bore aspiration catheter was successful for all patients (100%) without any procedure related complications.
Conclusion
: Our study showed the usefulness of anchoring technique with proximal BGC and distal stent retriever during MT, especially in those with an unfavorable anatomical structure. This technique could be an alternative option for delivering an of aspiration catheter to a distal location

Keyword

Ischemic stroke; Intervention; Reperfusion; Stent; Thrombectomy

Figure

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  Fig. 1. Flow sheet for detailed application of anchoring technique during mechanical thrombectomy, and summary of enrolled patients. *AXS Catalyst 6 (Stryker Neurovascular, Mountain View, CA, USA). LVO : large vessel occlusion, BGC : balloon guide catheter.

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  Fig. 2. Representative case of anchoring technique with proximal balloon guide catheter (BGC) for distal delivery of aspiration catheter during aspiration thrombectomy. A : An 84-years old male with proximal M1 occlusion. B : With an 8F BGC (FlowGate2, FG2; Stryker Neurovascular, Fremont, CA, USA) guiding, a Penumbra 5MAX ACE reperfusion catheter (Penumbra Inc., Alameda, CA, USA) was delivered under guidance of a co-axial Excelsior 27 (Stryker Neurovascular) microcatheter and a synchro 2 microwire (Stryker Neurovascular). However, the tip of the Penumbra 5MAX (white dot circle) could not pass the orifice of the ophthalmic artery. C : A push of the Penumbra 5MAX for distal delivery induced herniation of the FG2 BGC to the aortic arch. D : In the next trial, BGC was re-positioned at cervical ICA and balloon of FG2 BGC was inflated (black arrow). E : The Penumbra 5MAX catheter (black dot circle) was easily navigated past the orifice of ophthalmic artery to M1 when we pushed it in the inflation state of FG2 BGC balloon. F : Angiography after aspiration thrombectomy revealing a recanalization status of M1 and an intact internal carotid artery.

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  Fig. 3. Demonstration of anchoring technique with distal stent retriever during combined approach thrombectomy. A : Initial angiography of an 85-year-old female showing left proximal M2 occlusion status (black dot arrow) with diffuse tortuosity of proximal and distal ICA. B : Under guidance of a co-axial Excelsior 27 (Stryker Neurovascular, Fremont, CA, USA) microcatheter and a synchro 2 microwire (Stryker Neurovascular), the tip (black circle) of 6F aspiration catheter (AXS Catalyst 6, CAT6; Stryker Neurovascular) could not pass the ophthalmic segment of internal carotid artery (ICA). C : A 4 × 30 mm sized Trevo XP Provue (Stryker Neurovascular) stent retriever (black arrow) was deployed at left M1. D : The Trevo stent retriever was then gently pull back and straightening of the catheter was observed. The CAT6 catheter (white dot circle) was pushed forward, passing the ophthalmic segment and engaging the left M1. E : After re-capture of the Trevo stent retriever, an Excelsior 27 microcatheter and a synchro 2 microwire could be pass the occluded left M2 segment. CAT6 catheter was advanced to distal M1 (black dot circle). F : Trevo stent retriever (white arrow) could be deployed to sufficiently cover the occlusion site of M2.

Reference

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