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Abstract
Despite improvements in technique and evolution of access catheters, certain LVO strokes remain risky for distal intra-procedural embolization. We describe a novel application of an old idea in neurointervention - utilizing flow reversal for cerebral protection - applied to certain cases of stroke intervention.
Methods We place a 6F vascular sheath in the contralateral common femoral vein during access. A balloon guide catheter is placed in the distal cervical/petrocavernous ICA, and an extension line is taken from the Tuohy on the guide catheter to the venous sheath. In order to connect the line, a male-to-male adapter is required. Gentle injection of contrast through the guide catheter with the balloon inflated and the line connected to the vein demonstrates flow reversal. Utilizing minimal forward injection throughout the procedure, thrombectomy can be performed under flow reversal with minimal risk of clot dislodgement or distal embolism. Either hand or vacuum aspiration can be utilized on the aspiration catheter, and aspiration or Solumbra techniques can be combined with this technique. In the posterior circulation, a similar technique can be used without balloon guide if the guide catheter is occlusive in the vertebral artery.
Results We have used this technique in 8 patients: 6 were male, 2 female. The average age was 71.5 ± 11 years. Location of occlusion was distal ICA in 6 (75%), M1 in 1 (12.5%), and PCA in 1 (12.5%). Radial access was used in 1 case for the thrombectomy; femoral access was used for the remainder. Technical success was achieved in all cases with documentation of flow reversal. The median number of passes 1.5 (range: 1–4). A final mTICI of 3 was achieved in 5 cases (62.5%), and 2c in 3 (37.5%). FPE (mTICI >2c on the first pass) was observed in 37.5% of cases. Mean fluoroscopy time was 14.4 ± 6.8 minutes. No procedural or clinical complications were encountered and no symptomatic ICH was observed. The median initial NIHSS was 15.5 and median discharge NIHSS was 2.5. The median LOS was 5 days.
Conclusions This technique of passive flow reversal is technically straightforward, appears to be safe, and may offer an additional layer of protection for LVO stroke undergoing thrombectomy. The best use cases for this technique are likely those with large clot burden in the supraclinoid ICA. Further comparative and prospective study will identify whether this technique confers reproducible advantages in reducing the incidence of clot dislodgment and distal embolism.
Disclosures D. Raper: 2; C; Phenox, Penumbra, Stryker Neurovascular, Q’Apel, Balt. R. Holayter: None. R. Malek: None.