Introduction Previous report from a single-center study has demonstrated that intracranial positioning of the guide catheter can improve final reperfusion rates, increase the first-pass effect, and reduce the time needed to achieve final reperfusion in patients with emergent large vessel occlusion. Positioning the guide catheter closer to the clot face can reduce the risk of clot shearing and distal embolism during mechanical thrombectomy. To further investigate the benefits of intracranial guide catheter positioning in aspiration thrombectomy procedures, we conducted a retrospective analysis from prospectively maintained databases in a multicenter setting.

Method To be eligible, patients had to present with intracranial ICA, M1 and M2 occlusions, be over 18 years old, and have been treated with thrombectomy. The three participating centers were asked to include consecutive patients with data confirming guide catheter positioning during clot engagement and treated between January 2020 and January 2023. Participants were allocated into two groups: the intracranial group (n=271), in which the distal tip of the guide catheter was positioned in the petrous segment or further distal, and the control group (n=157), in which the distal tip of the guide catheter was positioned in the cervical ICA or more proximal. The primary outcomes were the rate of final excellent reperfusion (TICI 2C or better), first-pass effect (TICI 2C or better after one pass), and access to final reperfusion time. Data were presented as mean (standard deviation) or median (IQR) and percentage (counts). The unpaired t-test, Mann-Whitney U Test, and Fisher’s exact test were used to compare the means, medians and proportions of the two groups, respectively. P values <0.05 were considered statistically significant.

Results A total of 428 patients were included in the analysis. The intracranial and control group were well matched at entry. Patients with a guide catheter location in the petrous segment or further distal had a significantly higher first pass effect than those with a more proximal location (117/271, 43.2% vs. 40/157, 25.5%, p<0.001). A guide catheter location in the petrous segment or further distal was associated with better rates of final excellent recanalization (193/271, 71.2.% vs. 102/157, 65.0%, p=0.194). Furthermore, intracranial positioning of guide catheter was associated with significantly shorter times from groin puncture to final recanalization [median 21.0 (13.0-44.0) minutes vs. 35.5 (21.0-65.0) minutes, p<0.001], and a lower total number of passes [median 2 (1-3) vs. 3 (1-4) passes, p=0.013].

Conclusion Positioning a large bore guide catheter within the petrous segment or further distal resulted in significantly higher rates of first pass effect, lower procedural times, lower total number of passes, and better rates of excellent recanalization.

Disclosures M. Al-Kawaz: None. J. Milburn: None. D. Tomalty: None. K. Yaeger: None. D. Goldman: None. T. Hardigan: None. J. Scaggiante: None. M. Caton: None. H. Shoirah: None. T. Shigematsu: None. C. Kellner: 1; C; Research Funding from Penumbra and Siemens. S. Majidi: 2; C; Consultant for Rapid Medical, Cerenovus, Imperative Care.