E-020 A novel technique to treat tandem occlusion by utilizing stentriever as the distal protection device with aspiration catheter

Abstract

BackgroundRevascularization in acute ischemic stroke (AIS) with tandem occlusion (TO) is technically challenging due to the involvement of two large vessel occlusions (LVO) in the same vascular territory, usually with a large clot burden. There are two traditional approaches to re-establish the blood flow from TO;initial intracranial mechanical thrombectomy (MT) (head-first) or initial angioplasty ± stenting (neck-first). We developed a novel technique to simultaneously revascularize distal and proximal occlusions. This is accomplished by utilizing a stent-retriever as a distal protection device and a large inner diameter aspiration catheter with a balloon guiding catheter to retrieve clot and prevent distal migration (flow-arrest proximal protection).Subject and MethodsSince January of 2018, we performed MT for 142 LVO in AIS of the anterior circulation, of which we treated 12 TO. For the last six cases of TO, the Novel technique was applied to revascularize and restore perfusion. Patient demographics, procedure time (artery puncture to closure), procedure safety including symptomatic intracranial hemorrhage (sICH), angiographic outcomes (TICI score), and clinical outcomes (mRS) were evaluated.ResultsThe novel technique procedure in detail: an 8-9-French balloon-guided catheter is advanced to the distal common carotid artery and the balloon is inflated for flow arrest proximal protection. A microcatheter and micro-guidewire are passed through the steno-occlusive site of the proximal internal carotid artery (ICA) and advanced into the M1 segment. After removing the micro-guidewire, a stent-retriever is navigated into the microcatheter and deployed at the distal M1 occlusion. Subsequently, the microcatheter is removed. The stent-retriever promotes flow restoration and captures distal emboli. During several minutes of flow restoration, a balloon angioplasty catheter is navigated to the proximal ICA steno-occlusive site over a stent-retriever wire, and balloon angioplasty is performed. After balloon angioplasty catheter removal, an aspiration catheter is advanced into the internal carotid artery, followed by the M1 segment, over the stent-retriever wire. Clot aspiration, retrieval, and capture of the stent-retriever is then performed. Carotid stenting is not used due to concerns for intracranial hemorrhage related to antiplatelet therapy in the acute phase. Among six patients, the mean age was 68 yo (41 - 83), median NIHSS at presentation was 18 (5 - 24), sICH was 1/6, and mortality was 1/6. One patient died from concomitant COVID-19 pneumonia despite successful revascularization and neurological improvement. TICI IIb or III was achieved in 5/6 patients, and mRS 0-2 was observed in 3/6 patients. The mean procedure time was 122 minutes (89 - 157), which was shorter than the TO group treated with traditional approaches 144 minutes (95 - 184), though this was not statistically significant (p=0.05 t-test). However, with improved experience, the procedure time decreased, and the last two cases’ procedure times were 89 and 91 minutes respectively.ConclusionThe novel technique to revascularize tandem occlusion utilizing a stent-retriever as a distal protection device along with an aspiration catheter and a balloon-guided catheter is feasible. Immediate flow restoration at the distal occlusion site with simultaneous revascularization of the proximal ICA steno-occlusive lesion potentially improves the puncture to reperfusion timeDisclosuresS. Suzuki: None. J. Granstein: None. A. Chan: None. B. Ball: None. V. Vu: None. K. Golshani: None. I. Yuki: None.