J Cerebrovasc Endovasc Neurosurg.  2023 Mar;25(1):13-18. 10.7461/jcen.2022.E2022.08.002.

Analysis of failed mechanical thrombectomy with a focus on technical reasons: Ten years of experience in a single institution

• Park S
• Lee DH
• Sung JH
• Song SY

• KMID: 2540803
• DOI: http://doi.org/10.7461/jcen.2022.E2022.08.002

Abstract

Objective
Mechanical thrombectomy (MT) is an effective treatment for patients suffering from acute ischemic stroke secondary to large vessel occlusion. However, recanalization failure rates of interventions were about 20% in literature studies. We report our experience of unsuccessful MT with a focus on technical reasons.
Methods
From December 2010 to June 2021, six hundred eight patients with acute ischemic stroke due to large artery occlusion received MT using a stent retriever with or without an aspiration catheter in our institution. We divided the reasons for failure into six categories. We analyzed the reasons for failure by dividing our experience time into 3 periods.
Results
A total of 608 cases of thrombectomy for large vessel occlusion were identified in the study period. The successful recanalization rate was 90.4%. In most of the cases (20/57, 35%), the thrombus persisted despite several passes, and the second most common cause was termination of the procedure even after partial recanalization (10/57, 18%). Similar proportions of in-stent occlusion, distal embolization, and termination due to vessel rupture were observed. On analysis of three periods, the successful recanalization rate improved over time.
Conclusions
MT fails due to various reasons, and intracranial artery stenosis is the main cause of MT failure. With the development of rescue techniques, the failure rate has gradually decreased. Further development of new devices and techniques could improve the recanalization rates.

Keyword

Failed mechanical thrombectomy

Figure

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  Fig. 1. Flowchart of the ‘‘Stroke Code’’ Protocol. ER, emergency room; CT, computed tomography; tPA, tissue plasminogen activator; LS, Long Sheath; ADAPT, a direct aspiration first pass technique

Reference

1. Brekenfeld C, Schroth G, Mattle HP, Do DD, Remonda L, Mordasini P, et al. Stent placement in acute cerebral artery occlusion: use of a self-expandable intracranial stent for acute stroke treatment. Stroke. 2009; Mar. 40(3):847–52.

2. Burkhardt JK, Winklhofer S, Fierstra J, Wegener S, Esposito G, Luft A, et al. Emergency extracranial-intracranial bypass to revascularize salvageable brain tissue in acute ischemic stroke patients. World Neurosurg. 2018; Jan. 109:e476–85.

3. Chamorro Á, Blasco J, López A, Amaro S, Román LS, Llull L, et al. Complete reperfusion is required for maximal benefits of mechanical thrombectomy in stroke patients. Sci Rep. 2017; Sep. 7(1):11636.

4. Chang Y, Kim BM, Bang OY, Baek JH, Heo JH, Nam HS, et al. Rescue stenting for failed mechanical thrombectomy in acute ischemic stroke: a multicenter experience. Stroke. 2018; Apr. 49(4):958–64.

5. Feng Z, Duan G, Zhang P, Chen L, Xu Y, Hong B, et al. Enterprise stent for the treatment of symptomatic intracranial atherosclerotic stenosis: an initial experience of 44 patients. BMC Neurol. 2015; Oct. 15:187.

6. Heider DM, Simgen A, Wagenpfeil G, Dietrich P, Yilmaz U, Mühl-Benninghaus R, et al. Why we fail: mechanisms and co-factors of unsuccessful thrombectomy in acute ischemic stroke. Neurol Sci. 2020; Jun. 41(6):1547–55.

7. Humphries W, Hoit D, Doss VT, Elijovich L, Frei D, Loy D, et al. Distal aspiration with retrievable stent assisted thrombectomy for the treatment of acute ischemic stroke. J Neurointerv Surg. 2015; Feb. 7(2):90–4.

8. Katz JM, Hakoun AM, Dehdashti AR, Chebl AB, Janardhan V, Janardhan V, et al. Understanding the radial force of stroke thrombectomy devices to minimize vessel wall injury: mechanical bench testing of the radial force generated by a novel braided thrombectomy assist device compared to laser-cut stent retrievers in simulated MCA vessel diameters. Interv Neurol. 2020; Jan. 8(2-6):206–14.

9. Kim BM. Causes and Solutions of Endovascular Treatment Failure. J Stroke. 2017; May. 19(2):131–42.

10. Kim JH, Yoon W, Kim CK, Roh H, Bae HJ, Kwon TH, et al. Efficacy and safety of timely urgent superficial temporal artery-to-middle cerebral artery bypass surgery in patients with acute ischemic stroke: a single-institutional prospective study and a pooled analysis. Cerebrovasc Dis. 2021; 50(1):34–45.

11. Levy EI, Rahman M, Khalessi AA, Beyer PT, Natarajan SK, Hartney ML, et al. Midterm clinical and angiographic follow-up for the first Food and Drug Administration-approved prospective, single-arm trial of primary stenting for stroke: SARIS (stent-assisted recanalization for acute ischemic stroke). Neurosurgery. 2011; Oct. 69(4):915–20. discussion 920.

12. Perren F, Kargiotis O, Pignat JM, Pereira VM. Hemodynamic changes may indicate vessel wall injury after stent retrieval thrombectomy for acute stroke. J Neuroimaging. 2018; Jul. 28(4):412–5.

13. Ribo M, Flores A, Rubiera M, Pagola J, Mendonca N, Rodriguez-Luna D, et al. Difficult catheter access to the occluded vessel during endovascular treatment of acute ischemic stroke is associated with worse clinical outcome. J Neurointerv Surg. 2013; May. 5 Suppl 1(4):i70–3.

14. Salik AE, Selcuk HH, Zalov H, Kilinc F, Cirak M, Kara B. Medium-term results of undersized angioplasty and stenting for symptomatic high-grade intracranial atherosclerotic stenosis with Enterprise. Interv Neuroradiol. 2019; Oct. 25(5):484–90.

15. Tsang COA, Cheung IHW, Lau KK, Brinjikji W, Kallmes DF, Krings T. Outcomes of stent retriever versus aspiration-first thrombectomy in ischemic stroke: a systematic review and meta-analysis. AJNR Am J Neuroradiol. 2018; Nov. 39(11):2070–6.

16. Turk AS, Frei D, Fiorella D, Mocco J, Baxter B, Siddiqui A, et al. ADAPT FAST study: a direct aspiration first pass technique for acute stroke thrombectomy. J Neurointerv Surg. 2018; Jul. 10(Suppl 1):i4–7.

17. Woo HG, Sunwoo L, Jung C, Kim BJ, Han MK, Bae HJ, et al. Feasibility of permanent stenting with solitaire FR as a rescue treatment for the reperfusion of acute intracranial artery occlusion. AJNR Am J Neuroradiol. 2018; Feb. 39(2):331–6.

18. Yeo LLL, Bhogal P, Gopinathan A, Cunli Y, Tan B, Andersson T. Why does mechanical thrombectomy in large vessel occlusion sometimes fail?: a review of the literature. Clin Neuroradiol. 2019; Sep. 29(3):401–14.

19. Yi HJ, Sung JH, Lee DH. Preliminary experience of neuroform atlas stenting as a rescue treatment after failure of mechanical thrombectomy caused by residual intracranial atherosclerotic stenosis. J Korean Neurosurg Soc. 2021; Mar. 64(2):198–206.