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Carotid artery revascularization using the Walrus balloon guide catheter: safety and feasibility from a US multicenter experience
  1. Mohamed M Salem1,
  2. Svetlana Kvint1,
  3. Ammad A Baig2,3,
  4. Andre Monteiro2,3,
  5. Gustavo M Cortez4,
  6. Anna L Kuhn5,
  7. Oded Goren6,
  8. Shamsher Dalal6,
  9. Brian T Jankowitz1,
  10. Omar Choudhri1,
  11. Daniel Raper7,
  12. Omar Tanweer7,
  13. Pascal Jabbour8,
  14. Peter Kan9,
  15. Robert M Starke10,
  16. Elad I Levy2,3,
  17. Christoph J Griessenauer6,11,
  18. Ajit S Puri5,
  19. Ricardo Hanel4,
  20. Adnan H Siddiqui2,3,
  21. Jan-Karl Burkhardt1
  1. 1 Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
  2. 2 Department of Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Science, Buffalo, New York, USA
  3. 3 Department of Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
  4. 4 Department of Cerebrovascular and Endovascular Surgery, Baptist Neurological Institute and Lyerly Neurosurgery, Jacksonville, Florida, USA
  5. 5 Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
  6. 6 Department of Neurosurgery, Geisinger Medical Center, Danville, Pennsylvania, USA
  7. 7 Department of Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA
  8. 8 Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
  9. 9 Department of Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
  10. 10 Department of Neurosurgery and Radiology, University of Miami Miller School of Medicine, Miami, Florida, USA
  11. 11 Department of Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University, Salzburg, Austria
  1. Correspondence to Dr Jan-Karl Burkhardt, Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA; Jan.Burkhardt{at}


Introduction The Walrus balloon guide catheter (BGC) is a new generation of BGC, designed to eliminate conventional limitations during mechanical thrombectomy.

Objective To report a multi-institutional experience using this BGC for proximal flow control (PFC) in the setting of carotid artery angioplasty/stenting (CAS) in elective (eCAS) and tandem strokes (tCAS).

Methods Prospectively maintained databases at 8 North American centers were queried to identify patients with cervical carotid disease undergoing eCAS/tCAS with a Walrus BGC.

Results 110 patients (median age 68, 64.6% male), 80 (72.7%) undergoing eCAS and 30 (27.3%) tCAS procedures, were included (median cervical carotid stenosis 90%; 46 (41.8%) with contralateral stenosis). Using a proximal flow-arrest technique in 95 (87.2%) and flow-reversal in 14 (12.8%) procedures, the Walrus was navigated into the common carotid artery successfully in all cases despite challenging arch anatomy (31, 28.2%), with preferred femoral access (103, 93.6%) and in monitored anesthesia care (90, 81.8%). Angioplasty and distal embolic protection devices (EPDs) were used in 91 (83.7%) and 58 (52.7%) procedures, respectively. tCAS led to a modified Thrombolysis in Cerebral Infarction 2b/3 in all cases. Periprocedural ischemic stroke (up to 30 days postoperatively) rate was 0.9% (n=1) and remote complications occurred in 2 (1.8%) cases. Last follow-up modified Rankin Scale score of 0–2 was seen in 95.3% of eCAS cohort, with no differences in complications in the eCAS subgroup between PFC only versus PFC and distal EPD (median follow-up 4.1 months).

Conclusion Walrus BGC for proximal flow control is safe and effective during eCAS and tCAS. Procedural success was achieved in all cases, with favorable safety and functional outcomes on short-term follow-up.

  • atherosclerosis
  • balloon
  • stroke
  • cervical

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • Twitter @amdbaig, @PascalJabbourMD, @PeterKa80460001, @cgriessenauer

  • Correction notice Since this article was first published online, the author Omar Tanweer has been added to the manuscript.

  • Contributors All authors contributed to the study conception and design and/or data acquisition. The conception of the idea was done by J-KB and MMS. Literature review and data extraction were performed by MMS and SK. The first draft of the paper was done by MMS. All authors contributed to the editing of prior versions, read and approved the final version of the manuscript. Jan-Karl Burkhardt acts as guarantor and accepts full responsibility for the finished work and/or the conduct of the study, had access to the data, and controlled the decision to publish.

  • 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 PK is a member of the JNIS editorial board (education chair).

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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