Background Evidence is mounting that first-pass complete recanalization during mechanical thrombectomy is associated with better clinical outcomes in patients presenting with an emergent large vessel occlusion. We hypothesize that aspiration achieving complete clot ingestion results in higher first-pass successful recanalization with quantitative reduction in distal emboli.
Methods A patient-specific cerebrovascular replica was connected to a flow loop. Occlusion of the middle cerebral artery was achieved with clot analogs. Independent variables were the diameter of the aspiration catheter (0.054–0.088in) and aspiration pattern (static versus cyclical). Outcome measures were the first-pass rates of complete clot ingestion, the extent of recanalization, and the particle-size distribution of distal emboli.
Results All aspiration catheters were successfully navigated to the occlusion. Complete clot ingestion during aspiration thrombectomy resulted in first-pass complete recanalization in every experiment, only achieved in 21% of experiments with partial ingestion (P<0.0001). Aspiration through the large bore 0.088in device resulted in the highest rates of complete clot ingestion (90%). Cyclical aspiration (18–29 inHg, 0.5 Hz) significantly increased the rate of complete clot ingestion (OR21 [1.6, 266]; P=0.04). In all experiments, complete clot ingestion resulted in fewer and smaller distal emboli.
Conclusions Complete clot ingestion results in fewer distal emboli and the highest rates of first-pass complete recanalization. The rate of complete ingestion during aspiration thrombectomy is a function of both the inner diameter of the aspiration catheter and use of cyclical aspiration.
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Contributors RA: designed and performed the experiments, analyzed the data, drafted the manuscript, and approved the final manuscript. MM: designed and performed the experiments, interpreted the data, revised the manuscript, approved the final manuscript. and agreed to be accountable for the accuracy and integrity of the work. JC: designed and performed the experiments, analyzed and interpreted the data, and approved the final manuscript. RMK: performed the experiments, revised the manuscript, and approved the final manuscript.CR: performed the experiments, revised the manuscript, and approved the final manuscript. ASP: designed the study, interpreted the data, revised the manuscript, and approved the final manuscript. MJG: designed the study, designed and performed the experiments, analyzed and interpreted the data, drafted the manuscript, approved the final manuscript, and agreed to be accountable for the accuracy and integrity of the work. J-YC: designed the study, designed and performed the experiments, analyzed and interpreted the data, revised the manuscript, approved the final manuscript, and agreed to be accountable for the accuracy and integrity of the work.
Funding Partially supported by research funding from Route 92 Medical. The aspiration pump was generously provided by Insera Therapeutics. The content is solely the responsibility of the authors and does not reflect the opinions of Route 92 Medical or Insera Therapeutics.
Competing interests MM, J-YC: Fee-for-service consulting for Stryker Neurovascular and InNeuroCo Inc. JC has received educational grants from Microvention/Terumo. and Medtronic Neurovascular and ASP: consultant for Medtronic Neurovascular and Stryker Neurovascular; research grants from Medtronic Neurovascular and Stryker Neurovascular. MJG: Has been a consultant on a fee-per-hour basis for Cerenovus, Imperative Care, MIVI Neurosciences, phenox, Route 92 Medical, Stryker Neurovascular; holds stock in Imperative Care and Neurogami; and has received research support from the National Institutes of Health (NIH), the United States – Israel Binational Science Foundation, Anaconda, Cerenovus, Cook Medical, Gentuity, Imperative Care, InNeuroCo, Magneto, Microvention, Medtronic Neurovascular, MIVI Neurosciences, Neuravi, Neurogami, Philips Healthcare, Rapid Medical, Route 92 Medical, Stryker Neurovascular, Syntheon, and the Wyss Institute.
Patient consent Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement All data presented in manuscript.
Presented at This work has been presented in part at Society of NeuroInterventional Surgery 15th Annual Meeting (SNIS 2018), 2018 World Congress of Biomechanics, and Society of Vascular and Interventional Neurology Meeting (SVIN 2018).