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• Using an intermediate catheter triaxial system for Direct Aspiration first Pass Technique: the easiest way for thrombectomy?
  Fabrizio Chegai, Mariano Ortenzi, Fabio Coratella, Marco Nezzo, Alessandro Valenza, Nicola Pio Falcone and Enrico Pofi
  Published on: 17 September 2018

• Published on: 17 September 2018

  Using an intermediate catheter triaxial system for Direct Aspiration first Pass Technique: the easiest way for thrombectomy?

  • Fabrizio Chegai, Neurointerventional Radiology Department of Radiological Sciences, Belcolle Hospital, Viterbo, Italy.
  • Other Contributors:
    • Mariano Ortenzi, Interventional Radiologist
    • Fabio Coratella, Interventional Radiologist
    • Marco Nezzo, Interventional Radiologist
    • Alessandro Valenza, Stroke Neurologist
    • Nicola Pio Falcone, Stroke Neurologist
    • Enrico Pofi, Radiologist

  Dear Editor,
  we read with great interest the paper from Sallustio et al 1 regarding the use of new thromboaspiration catheter, AXS Catalyst 6 (Stryker Neurovascular, Mountain View, CA, USA), for endovascular treatment (EVT) of large vessel stroke (LVS) with A Direct Aspiration first Pass Technique (ADAPT)2.
  In our center, a team composed by 4 vascular interventional radiologists, two physicians with certified experience in stroke treatment and two physicians with large carotid stent experience, and 4 stroke neurologist with large experience in intravenous thrombolysis, started to perform EVT in patients with LVS of anterior or posterior circulation from September 2017.
  Given the wide availability of different systems of neurothrombectomy we decided to use AXS Catalyst 6 both for its technical features, as reported by Sallustio et al, both for its lower costs than the others available (6F SOFIA plus catheter, MicroVention, Tustin, CA, USA; the X Penumbra ACE catheters, Penumbra Inc., Alameda, CA, USA).
  Between September 2017 and May 2018, 24 patients (72.1 ± 13.2 years old) affected by acute ischemic stroke with LVS underwent to EVT in our center. Median baseline NIHSS was 18 (range: 7-24). Intravenous thrombolysis was used in 5 patients.
  The most frequent site of occlusion was the middle cerebral artery (MCA) (70.8%), while in 16.7% of cases was basilar artery. Tandem occlusions occurred in 12.5% of patients and the most frequent stroke etiolo...

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  Dear Editor,
  we read with great interest the paper from Sallustio et al 1 regarding the use of new thromboaspiration catheter, AXS Catalyst 6 (Stryker Neurovascular, Mountain View, CA, USA), for endovascular treatment (EVT) of large vessel stroke (LVS) with A Direct Aspiration first Pass Technique (ADAPT)2.
  In our center, a team composed by 4 vascular interventional radiologists, two physicians with certified experience in stroke treatment and two physicians with large carotid stent experience, and 4 stroke neurologist with large experience in intravenous thrombolysis, started to perform EVT in patients with LVS of anterior or posterior circulation from September 2017.
  Given the wide availability of different systems of neurothrombectomy we decided to use AXS Catalyst 6 both for its technical features, as reported by Sallustio et al, both for its lower costs than the others available (6F SOFIA plus catheter, MicroVention, Tustin, CA, USA; the X Penumbra ACE catheters, Penumbra Inc., Alameda, CA, USA).
  Between September 2017 and May 2018, 24 patients (72.1 ± 13.2 years old) affected by acute ischemic stroke with LVS underwent to EVT in our center. Median baseline NIHSS was 18 (range: 7-24). Intravenous thrombolysis was used in 5 patients.
  The most frequent site of occlusion was the middle cerebral artery (MCA) (70.8%), while in 16.7% of cases was basilar artery. Tandem occlusions occurred in 12.5% of patients and the most frequent stroke etiology resulted to be cardioembolic (64%).
  Time from stroke onset-to-arterial puncture was 213.5 ± 72.0 min
  All procedures of patients with LVS that involved anterior circulation, were performed at first in conscious sedation, while 2 patients with involvement of the posterior circulation was treated under general anesthesia.
  After catheterizing the common femoral artery with 8Fr introducer, a long sheath introducer (AXS Infinity LS Stryker Neurovascular, Mountain View, CA, USA) was positioned in the distal common carotid artery, proximal cervical ICA, or V1 segment of the vertebral artery.
  Therefore, contrary to Sallustio et al, Catalyst 6 catheter was always advanced to the site of occlusion by creating a triaxial system, over a 0.014” guidewire (Transend Stryker, Neurovascular, Mountain View, CA, USA), and over a dedicated coaxial microcatheter (Offset, Stryker Neurovascular, Mountain View, CA, USA). Microcatheter over guidewire, was carefully advanced as close to the thrombus as possible, avoiding crossing it.
  When Catalyst 6 catheter tip was touching the thrombus, guidewire and microcatheter were removed, and aspiration was started using always a dedicated vacuum pump.
  When no-flow was obtained from aspiration system, Catalyst 6 catheter was slowly pushed forward, and aspiration continued during catheter removal until blood was obtained in the aspiration line or total removal with additional aspiration from the Infinity LS.
  Using this approach, we experienced a median procedural time of 52 minutes (range: 20 min to 169 min) with slightly longer time compared to Sallustio et al, maybe because the use of a triaxial system that, at first, could be unwieldy. As assessable, in relation to the low number of cases, we did not find any differences in the procedural times between procedures performed by the different four vascular interventional radiologists.
  During procedures we performed at least 3 attempts at revascularization using ADAPT technique before switching to stent retriever technique with Trevo stent (Stryker Neurovascular, Mountain View, CA, USA). We used stent retrieve technique associated with aspiration only in 2 cases (8.3 %). Time from door to reperfusion was 172.0 ± 45.2 min.
  We obtained a successful recanalization (TICI 2b/3) in 21 patients (87.5%). Symptomatic intracranial hemorrhage occurred in 1 patient. Functional independence was obtained in 70.8% and mortality occurred in 3 patients.
  Our technical success is comparable to results reported by Sallustio et al, although in a less numerous study population.
  In our experience, this triaxial system, composed of AXS Infinity LS, Catalyst 6 and Offset microcatheter, surely facilitates performing EVT even when used by “non-expert thrombectomy performers”.
  Offset microcatheter helps intermediate catheter ophthalmic passage, avoiding exaggerated thrusts of the catheter that could cause buckling of Catalyst 6, arterial spasms or dissections. Indeed, no arterial dissections or flow limiting arterial vasospasm were identified among 24 interventions.
  However, using a microcatheter it could occur that it be passed through the clot and therefore might result in a rate of distal emboli. In our initial experience, we observed only 1 case of thrombus fragmentation with distal M2 branches embolization, due to passing by Offset microcatheter through the thrombus, resulting in TICI 2b revascularization.
  In our experience, Catalyst 6 triaxial ADAPT technique was safe, technically feasible, rapid, and effective in patients with LVS.
  In ischemic stroke care, fast reperfusion is essential to improve disability free survival and due to the serious paucity of thrombectomy performers, we believe that continuous development of technology of aspiration catheters and microcatheter may reduce procedure time allowing that the neurothrombectomy procedure may be within the reach of vascular interventional radiologists.

  References
  1. Sallustio, F. et al. Mechanical thrombectomy of acute ischemic stroke with a new intermediate aspiration catheter: preliminary results. J. Neurointerv. Surg. neurintsurg-2017-013679 (2018). doi:10.1136/neurintsurg-2017-013679
  2. Turk, A. S. et al. ADAPT FAST study: a direct aspiration first pass technique for acute stroke thrombectomy. J. Neurointerv. Surg. 6, 260–264 (2014).

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  Conflict of Interest:
  None declared.

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