Introduction Technical improvements to enhance distal occlusion thrombectomy are desirable. We describe the blind catheter exchange technique and report the pinning technique with small devices (‘mini-pinning’) for distal occlusions.
Methods A retrospective review of a prospective database from January 2015 to August 2018 was performed for cases of distal occlusion in which the ‘blind exchange/mini-pinning’ (BEMP) techniques were used. The technique involves the deployment of a 3 mm Trevo retriever followed by microcatheter removal and blind advancement of a 3MAX aspiration catheter over the bare retriever delivery wire (‘blind exchange’) until clot contact under aspiration. The retriever is subsequently partially recaptured in order to ‘cork’ the thrombus (‘mini-pinning’) and the system pulled as a unit. Patients with distal occlusions treated with BEMP and standard techniques (either 3 mm Trevo or 3MAX) were compared.
Results Twenty-five vessels were treated in 22 patients. The majority of patients had isolated distal occlusions predominantly in the distal middle cerebral artery (MCA) segments, half of which involved the superior division. The comparison between BEMP (n=25 vessels) and standard techniques (n=144 vessels) revealed balanced groups. One of the highlighted differences was the more distal MCA occlusions among those who underwent BEMP (M3 occlusions 52% vs 22%; p=0.001). Otherwise, the vessel, segments, divisions and luminal diameter were comparable. There was a higher rate of first-pass modified Thrombolysis in Cerebral Infarction 2b–3 (80% vs 56%; p=0.03) and a trend towards higher rates of first-pass full reperfusion (60% vs 40%; p=0.07) with BEMP compared with standard techniques. Final reperfusion and clinical outcomes were comparable.
Conclusion BEMP appears to be a safe and effective technique for the treatment of distal occlusions. Additional studies are warranted.
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Contributors DCH: Study conception, design of the work, acquisition of data, interpretation of data, drafting of the manuscript. ARA-B: Data acquisition, critical revision of manuscript. BE: Data acquisition, critical revision of manuscript. KR: Statistical analysis, critical revision of manuscript. GMR: Data acquisition, critical revision of manuscript. MRF: Data acquisition, critical revision of manuscript. RN: Design of the work, acquisition of data, interpretation of data, critical revision of manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests ARA-B, BE, KR, GMR, MRF: none. DCH: Consultant for Stryker and Vesalio. RN: Principal Investigator, Stryker Neurovascular (DAWN trial, no compensation, Trevo‑2 trial), Cerenovus/Neuravi (ENDOLOW trial, no compensation); consultant to Stryker Neurovascular; steering committee member, Stryker Neurovascular (no compensation), Medtronic (SWIFT trial, SWIFT Prime trial, no compensation), Cerenovus/Neuravi (ARISE‑2 trial, no compensation); angiographic core lab, Medtronic (STAR trial); executive committee member, Penumbra (no compensation); physician advisory board, Cerenovus/Neuravi, Phenox, Anaconda, Genentech, Biogen, Prolong Pharmaceuticals, Allm Inc (no compensation), Viz-AI; stock options, Viz-AI.
Ethics approval Emory University IRB.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement The unpublished data from this dataset are held by Grady Memorial Hospital/Emory University and DCH/RN. Requests for data sharing would be required to be discussed with them directly.
Patient consent for publication Not required.