Introduction/Purpose The development and introduction of super large-bore aspiration catheters to the neurointerventional field is an important technological advancement in acute ischemic stroke treatment. The Route 92 Medical triaxial aspiration platform consists of an 0.106-inch 8 French Base Camp guide sheath, an 0.088-inch HiPoint aspiration catheter and a Tenzing 8 insert catheter. While such platforms were designed to deliver a super large-bore aspiration catheter into the intracranial vasculature for mechanical thrombectomy, they are also very useful for treatment of tandem lesions. Large clot burden extracranially or intracranially can be eliminated faster. The Tenzing delivery catheter may be able to find the vessel lumen more easily, be advanced more atraumtically, and the combination of Tenzing and HighPoint catheters allows for dottering of the proximal lesion which theoretically could decrease the need for stenting. If carotid stenting is still needed, the large guide catheter can accommodate proximal or distal protection devices as well as any carotid stent or stent-graft available. We report experience with this triaxial catheter assembly for treatment of tandem lesions.

Materials and Methods Retrospective review of our comprehensive stroke center database between February 2021 and February 2024. We then identified all patients with tandem ICA and intracranial occlusions or carotid stent occlusions on pre-procedural cross-sectional imaging who were treated with the Basecamp guide sheath, and 0.088-inch super large-bore aspiration catheter. Clinical and procedural data was collected.

Results We identified 6 patients (4 females) with a mean age of 65 years (range 49 to 77 years) and baseline median mRS of 0 who underwent mechanical thrombectomy for treatment of tandem lesions. Mean pre-procedural NIHSS was 19 (range 4–29). One patient received intravenous tPA. Three patients had tandem lesions involving the cervical ICA (2 stenoses, 1 dissection) and an intracranial M1 occlusion. These cases were all successfully treated with single pass aspiration thrombectomy and cervical ICA reconstruction. Excellent reperfusion was achieved in all cases (mTICI 2C or 3). Mean time from puncture to first pass was 30 minutes and mean time from puncture to recanalization 34 minutes. Three patients presented with carotid stent occlusions and concomitant intracranial occlusion in 2 of the cases. Successful recanalization (mTICI≥2B) was achieved in all cases. Mean time from puncture to first pass was 14 minutes and mean time from puncture to recanalization 51 minutes. One patient died due to the large stroke burden. Of the surviving patients, median mRS at discharge was 2 and median mRS at 3 months was 2.5.

Conclusion Tandem lesions are a challenging subtype of ischemic stroke cases associated with high morbidity and mortality. Quick removal of extra- and intracranial clot burden to restore antegrade flow as well as safe treatment of an underlying carotid lesion are key to offer patients the best possible chance of recovery. Use of a triaxial platform with a large guide and super-large bore aspiration catheter offer the ability to remove large clot burden quickly and do not limit the operator in their choice of devices to use.

Disclosures A. Kuhn: None. J. Singh: None. D. Unar: None. S. Marwah: None. A. Puri: 1; C; NIH, Microvention, Cerenovus, Medtronic Neurovascular and Stryker Neurovascular. 2; C; Medtronic Neurovascular, Stryker NeurovascularBalt, Q’Apel Medical, Cerenovus, Microvention, Imperative Care, Agile, Merit, CereVasc and Arsenal Medical. 4; C; InNeuroCo, Agile, Perfuze, Galaxy and NTI.