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The combined use of mechanical thrombectomy devices is feasible for treating acute carotid terminus occlusion

  • Clinical Article - Vascular
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Abstract

Background

Mechanical thrombectomy devices have recently been developed and approved for recanalization of intracranial arterial occlusion. Here, we investigated the feasibility of combined stent-assisted and clot aspiration mechanical thrombectomy for effective recanalization of acute carotid terminus occlusion (CTO).

Methods

Ten consecutive patients with acute ischemic stroke secondary to CTO who underwent intra-arterial (IA) treatment with both stent retrieval and negative-pressured clot aspiration systems were enrolled. Periprocedural and radiologic findings and clinical outcomes were evaluated.

Results

The median age was 69 years (range, 47–86 years), and the median initial NIHSS score was 17.5 (range, 12–33). Mechanical thrombectomy was performed using a combination of the Solitaire stents and Penumbra system. Thrombolysis in cerebral ischemia [TICI] grade II–III was achieved in eight patients (80.0 %); complete recanalization of the CTO (TICI III) was achieved in three of those patients. Any type of intracranial hemorrhages occurred in four patients (40.0 %), but parenchymal hematoma type 2 was not observed. Four patients died within 3 months (40.0 %).

Conclusions

Combined mechanical thrombectomy treatment was effective for recanalization of acute CTO. The combination of Solitaire and Penumbra devices can be considered as a treatment option for CTO.

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Correspondence to Jin Soo Lee.

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Comment

In this article by Dr. Jin Soo Lee et al., two groups of patients treated for CTO were compared: a group treated with IA fibrinolytic alone and a group that had mechanical thrombectomy. The stand-alone and combined use of two different mechanical thrombectomy systems (Penumbra aspiration and Solitaire stent-retriever) was applied to the treatment of this challenging clinical entity.

Excluding IA fibrinolytic treatment from CTO treated with mechanical thrombectomy was key to allowing the effects of the mechanical thrombectomy devices alone to be measured and outcomes reported.

Large emboli likely require multi-modality thrombectomy treatment as previous reports have indicated that these occlusions have been refractory to IV and IA fibrinolytic therapy as well as the combination of IV and IA fibrinolytic therapy (Jansen et al. 1995 AJNR 16:1977–1986 and Urbach et al. 1997 Neuroradiology 39: 105–110 and Zaidat et al. 2002 Stroke 33:1821–1826).

Recanalization rates achieved with mechanical thrombectomy for CTO were superior to IV, IA, and combination IV + IA fibrinolytic therapy.

It is interesting to note the inverse proportional relationship between reperfusion and ICH especially because the onset to decision interval was less for the fibrinolytic group.

Additionally, the clinical impact of the hemorrhages that were observed in this study were less detrimental to patients than when compared to previous reports of CTO treated with fibrinolytic therapy alone (i.e., type 2 IPH was not observed).

These devices can and should be used in tandem when advantages for one or the other can be exploited in a deserving clinical situation (e.g., when the length of the clot surpasses the length of the Solitaire, the Penumbra system can be used to remove small portions of the clot to facilitate deployment of a stent retriever). These techniques and systems, both in isolation and in combination, should be kept in the neuroendovascular practitioner’s armamentarium.

CTO proves to be a great challenge when considering clinical outcome. The mRS of the patients with the best outcomes were rated at 3. Decreasing symptom onset to needle time and swift, efficacious thrombectomy devices are possible factors that may impact outcome.

The current study, despite its acknowledged limitations, serves as an important collection of consecutive patients with a rarer, intractable, acute stroke that adds to the data that can facilitate a large-scale randomized study that may more fully elucidate the efficacy of neuroendovascular treatments.

John Braca MD

Christopher M. Loftus MD

Maywood, IL, USA

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Lee, J.S., Hong, J.M., Lee, SJ. et al. The combined use of mechanical thrombectomy devices is feasible for treating acute carotid terminus occlusion. Acta Neurochir 155, 635–641 (2013). https://doi.org/10.1007/s00701-013-1649-5

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  • DOI: https://doi.org/10.1007/s00701-013-1649-5

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