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Original research
PROTECT: PRoximal balloon Occlusion TogEther with direCt Thrombus aspiration during stent retriever thrombectomy – evaluation of a double embolic protection approach in endovascular stroke treatment
  1. Christian Maegerlein1,
  2. Sebastian Mönch1,
  3. Tobias Boeckh-Behrens1,
  4. Manuel Lehm1,
  5. Dennis M Hedderich1,
  6. Maria Teresa Berndt1,
  7. Silke Wunderlich2,
  8. Claus Zimmer1,
  9. Johannes Kaesmacher1,3,4,
  10. Benjamin Friedrich1
  1. 1Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
  2. 2Department of Neurology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
  3. 3Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland
  4. 4Department of Neurology, University of Bern, Inselspital, Bern, Switzerland
  1. Correspondence to Dr Christian Maegerlein, Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, 81675 Munich, Germany; christian.maegerlein{at}


Purpose Stent retriever-based mechanical thrombectomy (MT) for emergent large vessel occlusions (ELVO) is often complicated by thrombus fragmentation causing distal embolization and embolization to new vascular territories. Well-established embolic protection approaches include proximal flow arrest and distal aspiration techniques during stent retriever maneuvers. Aiming at the reduction of thrombus fragmentation during MT we evaluated a technical approach combining proximal balloon occlusion together with direct thrombus aspiration during MT: the PROTECT technique.

Methods We performed a case-control study comparing the PROTECT technique with sole distal aspiration during MT regarding technical and procedural parameters, n=200 patients with ELVO of either the terminus of the internal carotid artery or the proximal middle artery were included.

Results PROTECT resulted in a shorter procedure time (29 vs 40 min; P=0.002), in a higher rate of successful recanalizations (100% vs 78%; P=0.001) and a higher rate of complete reperfusions (70% vs 39%; P<0.001) compared with sole distal aspiration during MT.

Conclusion The PROTECT technique is a promising new approach to significantly reduce thrombus fragmentation and, hence distal embolization during MT. This safe and efficient technique needs to be validated in larger trials to confirm our results.

  • balloon
  • embolic
  • intervention
  • stroke

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  • Contributors All authors have provided a substantial contribution to the conception and design of the studies and/or the acquisition and/or the analysis of the data and/or the interpretation of the data; drafted the work or revised it for significant intellectual content; approved the final version of the manuscript; and agree to be accountable for all aspects of the work, including its accuracy and integrity.

  • Competing interests None declared.

  • Ethics approval local ethics committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Correction notice Since this paper was first published online the author name Sebastian Moench has been updated to Sebastian Mönch.

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