Abstract
Purpose
First pass complete (mTICI 3) reperfusion must be regarded as the ultimate goal in mechanical thrombectomy (MT) in patients suffering from an emergent large vessel occlusion (ELVO). With this in mind a technical modification of the previously published PROTECT (PRoximal balloon Occlusion TogEther with direCt Thrombus aspiration during stent retriever thrombectomy) approach, the PROTECTPLUS technique was evaluated. Under proximal flow arrest using a balloon guide catheter (BGC), a stent retriever was only partially inserted into a large-bore aspiration catheter. This construction was subsequently retracted as a unit into the BGC with aspiration both at the aspiration catheter and at the BGC.
Methods
A case-control study was performed comparing the PROTECT technique with the PROTECTPLUS technique with respect to the technical and procedural parameters. Patients n = 165 (101 PROTECT, 64 PROTECTPLUS) with ELVO of either the terminus of the internal carotid artery or the proximal middle cerebral artery were included.
Results
Using the PROTECTPLUS resulted in a higher rate of first pass complete reperfusions (59.4% vs. 27.7%, p < 0.001) as compared with PROTECT. The PROTECTPLUS also led to shorter procedure times (21 min vs. 37 min, p = 0.001) and higher rates of overall complete reperfusion (73.5% vs. 49.5%, p = 0.014) compared to PROTECT.
Conclusion
The PROTECTPLUS technique is a promising technical modification to further optimize endovascular stroke treatment.
Similar content being viewed by others
References
Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, Schonewille WJ, Vos JA, Nederkoorn PJ, Wermer MJ, van Walderveen MA, Staals J, Hofmeijer J, van Oostayen JA, Lycklama à Nijeholt GJ, Boiten J, Brouwer PA, Emmer BJ, de Bruijn SF, van Dijk LC, Kappelle LJ, Lo RH, van Dijk EJ, de Vries J, de Kort PL, van Rooij WJ, van den Berg JS, van Hasselt BA, Aerden LA, Dallinga RJ, Visser MC, Bot JC, Vroomen PC, Eshghi O, Schreuder TH, Heijboer RJ, Keizer K, Tielbeek AV, den Hertog HM, Gerrits DG, van den Berg-Vos RM, Karas GB, Steyerberg EW, Flach HZ, Marquering HA, Sprengers ME, Jenniskens SF, Beenen LF, van den Berg R, Koudstaal PJ, van Zwam WH, Roos YB, van der Lugt A, van Oostenbrugge RJ, Majoie CB, Dippel DW; MR CLEAN Investigators. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372:11–20.
Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, Roy D, Jovin TG, Willinsky RA, Sapkota BL, Dowlatshahi D, Frei DF, Kamal NR, Montanera WJ, Poppe AY, Ryckborst KJ, Silver FL, Shuaib A, Tampieri D, Williams D, Bang OY, Baxter BW, Burns PA, Choe H, Heo JH, Holmstedt CA, Jankowitz B, Kelly M, Linares G, Mandzia JL, Shankar J, Sohn SI, Swartz RH, Barber PA, Coutts SB, Smith EE, Morrish WF, Weill A, Subramaniam S, Mitha AP, Wong JH, Lowerison MW, Sajobi TT, Hill MD; ESCAPE Trial Investigators. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372:1019–30.
Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, Albers GW, Cognard C, Cohen DJ, Hacke W, Jansen O, Jovin TG, Mattle HP, Nogueira RG, Siddiqui AH, Yavagal DR, Baxter BW, Devlin TG, Lopes DK, Reddy VK, du Mesnil de Rochemont R, Singer OC, Jahan R; SWIFT PRIME Investigators. Stent-retriever thrombectomy after intravenous t‑PA vs. t‑PA alone in stroke. N Engl J Med. 2015;372:2285–95.
Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, San Román L, Serena J, Abilleira S, Ribó M, Millán M, Urra X, Cardona P, López-Cancio E, Tomasello A, Castaño C, Blasco J, Aja L, Dorado L, Quesada H, Rubiera M, Hernandez-Pérez M, Goyal M, Demchuk AM, von Kummer R, Gallofré M, Dávalos A; REVASCAT Trial Investigators. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372:2296–306.
Campbell BC, Mitchell PJ, Yan B, Parsons MW, Christensen S, Churilov L, Dowling RJ, Dewey H, Brooks M, Miteff F, Levi C, Krause M, Harrington TJ, Faulder KC, Steinfort BS, Kleinig T, Scroop R, Chryssidis S, Barber A, Hope A, Moriarty M, McGuinness B, Wong AA, Coulthard A, Wijeratne T, Lee A, Jannes J, Leyden J, Phan TG, Chong W, Holt ME, Chandra RV, Bladin CF, Badve M, Rice H, de Villiers L, Ma H, Desmond PM, Donnan GA, Davis SM; EXTEND-IA investigators. A multicenter, randomized, controlled study to investigate EXtending the time for thrombolysis in emergency neurological deficits with intra-arterial therapy (EXTEND-IA). Int J Stroke. 2014;9:126–32.
Zaidat OO, Castonguay AC, Linfante I, Gupta R, Martin CO, Holloway WE, Mueller-Kronast N, English JD, Dabus G, Malisch TW, Marden FA, Bozorgchami H, Xavier A, Rai AT, Froehler MT, Badruddin A, Nguyen TN, Taqi MA, Abraham MG, Yoo AJ, Janardhan V, Shaltoni H, Novakovic R, Abou-Chebl A, Chen PR, Britz GW, Sun CJ, Bansal V, Kaushal R, Nanda A, Nogueira RG. First pass effect: a new measure for stroke thrombectomy devices. Stroke. 2018;49:660–6.
Kaesmacher J, Maegerlein C, Zibold F, Wunderlich S, Zimmer C, Friedrich B. Improving mTICI2b reperfusion to mTICI2c/3 reperfusions: a retrospective observational study assessing technical feasibility, safety and clinical efficacy. Eur Radiol. 2018;28:274-82.
Kleine JF, Wunderlich S, Zimmer C, Kaesmacher J. Time to redefine success? TICI 3 versus TICI 2b recanalization in middle cerebral artery occlusion treated with thrombectomy. J Neurointerv Surg. 2017;9:117-21.
Tung EL, McTaggart RA, Baird GL, Yaghi S, Hemendinger M, Dibiasio EL, Hidlay DT, Tung GA, Jayaraman MV. Rethinking thrombolysis in cerebral infarction 2b: which thrombolysis in cerebral infarction scales best define near complete recanalization in the modern Thrombectomy era? Stroke. 2017;48:2488–93.
Dargazanli C, Consoli A, Barral M, Labreuche J, Redjem H, Ciccio G, Smajda S, Desilles JP, Taylor G, Preda C, Coskun O, Rodesch G, Piotin M, Blanc R, Lapergue B. Impact of modified TICI 3 versus modified TICI 2b reperfusion score to predict good outcome following endovascular therapy. AJNR Am J Neuroradiol. 2017;38:90–6.
Velasco A, Buerke B, Stracke CP, Berkemeyer S, Mosimann PJ, Schwindt W, Alcázar P, Cnyrim C, Niederstadt T, Chapot R, Heindel W. Comparison of a balloon guide catheter and a non-balloon guide catheter for mechanical thrombectomy. Radiology. 2016;280:169–76.
Nguyen TN, Zaidat OO. Balloon guide catheter in large-vessel occlusion stroke therapy. Radiology. 2017;284:607–8.
Brinjikji W, Starke RM, Murad MH, Fiorella D, Pereira VM, Goyal M, Kallmes DF. Impact of balloon guide catheter on technical and clinical outcomes: a systematic review and meta-analysis. J Neurointerv Surg. 2018;10:335-9.
Kim YW, Kang DH, Hwang YH, Park J, Kim YS. Efficacy of proximal aspiration thrombectomy for using balloon-tipped guide catheter in acute Intracranial internal carotid artery occlusion. J Korean Neurosurg Soc. 2016;59:379–84.
Nguyen TN, Malisch T, Castonguay AC, Gupta R, Sun CH, Martin CO, Holloway WE, Mueller-Kronast N, English JD, Linfante I, Dabus G, Marden FA, Bozorgchami H, Xavier A, Rai AT, Froehler MT, Badruddin A, Taqi M, Abraham MG, Janardhan V, Shaltoni H, Novakovic R, Yoo AJ, Abou-Chebl A, Chen PR, Britz GW, Kaushal R, Nanda A, Issa MA, Masoud H, Nogueira RG, Norbash AM, Zaidat OO. Balloon guide catheter improves revascularization and clinical outcomes with the Solitaire device: analysis of the North American Solitaire Acute Stroke Registry. Stroke. 2014;45:141–5.
Santhosh K, Joseph S. Manual aspiration thrombectomy through balloon tipped guide catheter for rapid clot burden reduction in endovascular therapy for ICA L/T occlusion. Neuroradiology. 2012;54:1287.
Maegerlein C, Mönch S, Boeckh-Behrens T, Lehm M, Hedderich DM, Berndt MT, Wunderlich S, Zimmer C, Kaesmacher J, Friedrich B. PROTECT: PRoximal balloon Occlusion TogEther with direCt Thrombus aspiration during stent retriever thrombectomy—evaluation of a double embolic protection approach in endovascular stroke treatment. J Neurointerv Surg. 2018;10:751-5.
Stampfl S, Pfaff J, Herweh C, Pham M, Schieber S, Ringleb PA, Bendszus M, Möhlenbruch MA. Combined proximal balloon occlusion and distal aspiration: a new approach to prevent distal embolization during neurothrombectomy. J Neurointerv Surg. 2017;9:346-51.
Maus V, Behme D, Kabbasch C, Borggrefe J, Tsogkas I, Nikoubashman O, Wiesmann M, Knauth M, Mpotsaris A, Psychogios MN. Maximizing first-pass complete reperfusion with SAVE. Clin Neuroradiol. 2018;28:327-38.
Barber PA, Demchuk AM, Zhang J, Buchan AM. Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS Study Group. Alberta Stroke Programme Early CT Score. Lancet. 2000;355(9216):1670–4.
Ozdemir O, Giray S, Arlier Z, Baş DF, Inanc Y, Colak E. Predictors of a good outcome after endovascular stroke treatment with stent retrievers. ScientificWorldJournal. 2015;2015:403726.
Ganesh A, Al-Ajlan FS, Sabiq F, Assis Z, Rempel JL, Butcher K, Thornton J, Kelly P, Roy D, Poppe AY, Jovin TG, Devlin T, Baxter BW, Krings T, Casaubon LK, Frei DF, Choe H, Tampieri D, Teitelbaum J, Lum C, Mandzia J, Phillips SJ, Bang OY, Almekhlafi MA, Coutts SB, Barber PA, Sajobi T, Demchuk AM, Eesa M, Hill MD, Goyal M, Menon BK; ESCAPE Trial Investigators. Infarct in a new territory after treatment administration in the ESCAPE randomized controlled trial (Endovascular treatment for small core and anterior circulation proximal occlusion with emphasis on minimizing CT to Recanalization times). Stroke. 2016;47:2993–8.
Goyal M, Menon BK, Demchuk A, Saver JL, Eesa M, Majoie C, Jayaraman M, Hill MD. Proposed methodology and classification of Infarct in New Territory (INT) after endovascular stroke treatment. J Neurointerv Surg. 2017;9:449–50.
Massari F, Henninger N, Lozano JD, Patel A, Kuhn AL, Howk M, Perras M, Brooks C, Gounis MJ, Kan P, Wakhloo AK, Puri AS. ARTS (Aspiration-Retriever Technique for Stroke): initial clinical experience. Interv Neuroradiol. 2016;22:325-32.
Bogousslavsky J, Regli F. Prognosis of symptomatic intracranial obstruction of internal carotid artery. Eur Neurol. 1983;22:351–8.
Jansen O, von Kummer R, Forsting M, Hacke W, Sartor K. Thrombolytic therapy in acute occlusion of the intracranial internal carotid artery bifurcation. AJNR Am J Neuroradiol. 1995;16:1977–86.
Rodríguez-López C, Ballenilla Marco F, Díaz Guzmán J. Prognosis of Tandem Occlusions versus Isolated Intracranial Occlusions. J Stroke Cerebrovasc Dis. 2018 Sep 22. https://doi.org/10.1016/j.jstrokecerebrovasdis.2018.08.039. [Epub ahead of print]
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
C. Maegerlein reports minor travel grants and personal fees from Stryker Neurovascular and Penumbra. M.T. Berndt, S. Mönch, K. Kreiser, T. Boeckh-Behrens, M. Lehm, S. Wunderlich, C. Zimmer and B. Friedrich declare that they have no competing interests.
Ethical standards
Neither approval of the institutional review board nor patient informed consent are required by the ethics committee of the institution for retrospective analyses of patient records and imaging data.
Rights and permissions
About this article
Cite this article
Maegerlein, C., Berndt, M.T., Mönch, S. et al. Further Development of Combined Techniques Using Stent Retrievers, Aspiration Catheters and BGC. Clin Neuroradiol 30, 59–65 (2020). https://doi.org/10.1007/s00062-018-0742-9
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00062-018-0742-9