Predictors of Emboli in Mechanical Thrombectomy for Anterior Circulation Stroke


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Abstract

Objective:Emboli commonly occurs in mechanical thrombectomy (MT). The objective of this study was to analyze predicting factors of emboli after MT.

Methods:Patients who underwent MT with successful reperfusion for anterior circulation occlusion were enrolled. Emboli included distal emboli at digital subtraction angiography (DSA) and unexpected embolic infarct on diffusion-weighted image (DWI) without distal emboli at DSA. Baseline characteristics, procedural details, angiographic outcomes, and clinical outcomes were reviewed. Multivariable analyses were performed to evaluate predictive factors for the occurrence of emboli.

Results:Of 601 patients, 149 (24.8%) patients had distal emboli at DSA, and 169 (28.1%) patients had unexpected embolic infarction on DWI even without distal emboli at DSA. A total of 318 (52.9%) patients were enrolled in the embolic group, and 283 (47.1%) patients were assigned to the non-embolic group. In multivariate analysis, larger microcatheter (OR 1.26, 95% CI 1.12–1.94; p = 0.047), clot passage (OR 1.33, 95% CI 1.07–1.87; p = 0.041), use of balloon guide catheter (BGC) (OR 0.70, 95% CI 0.52–0.92; p = 0.014), early ballooning of BGC (OR 0.68, 95% CI 0.50–0.90; p = 0.009), and longer stent retriever (OR 0.72, 95% CI 0.54–0.90; p = 0.029) were associated with occurrence of emboli.

Conclusion:MT with only a stent retriever, use of a larger microcatheter, and clot passage might increase the risk of emboli. In contrast, contact aspiration thrombectomy, use of BGC, early ballooning of BGC, and use of longer stent retrievers could reduce the chance of emboli.

About the authors

Yongho Kwon

Department of Neurosurgery, Soonchunhyang University Bucheon Hospital

Email: info@benthamscience.net

Ho Yi

Department of Neurosurgery, Soonchunhyang University Bucheon Hospital

Author for correspondence.
Email: info@benthamscience.net

Dong-Seong Shin

Department of Neurosurgery, Soonchunhyang University Bucheon Hospital

Email: info@benthamscience.net

Bum-Tae Kim

Department of Neurosurgery, Soonchunhyang University Bucheon Hospital

Email: info@benthamscience.net

References

  1. Erkhemer OA, Fransen PS, Beumer D. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 2015; 372(1): 11-20.
  2. Campbell BCV, Mitchell PJ, Kleinig TJ, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 2015; 372(11): 1009-18. doi: 10.1056/NEJMoa1414792 PMID: 25671797
  3. Goyal M, Demchuk AM, Menon BK, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 2015; 372(11): 1019-30. doi: 10.1056/NEJMoa1414905 PMID: 25671798
  4. Jovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 2015; 372(24): 2296-306. doi: 10.1056/NEJMoa1503780 PMID: 25882510
  5. Saver JL, Goyal M, Bonafe A, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 2015; 372(24): 2285-95. doi: 10.1056/NEJMoa1415061 PMID: 25882376
  6. Goyal M, Menon BK, van Zwam WH, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: A meta-analysis of individual patient data from five randomised trials. Lancet 2016; 387(10029): 1723-31. doi: 10.1016/S0140-6736(16)00163-X PMID: 26898852
  7. Lapergue B, Blanc R, Gory B, et al. Effect of endovascular contact aspiration vs stent retriever on revascularization in patients with acute ischemic stroke and large vessel occlusion. JAMA 2017; 318(5): 443-52. doi: 10.1001/jama.2017.9644 PMID: 28763550
  8. Turk AS III, Siddiqui A, Fifi JT, et al. Aspiration thrombectomy versus stent retriever thrombectomy as first-line approach for large vessel occlusion (COMPASS): A multicentre, randomised, open label, blinded outcome, non-inferiority trial. Lancet 2019; 393(10175): 998-1008. doi: 10.1016/S0140-6736(19)30297-1 PMID: 30860055
  9. Deshaies EM. Tri-axial system using the solitaire-FR and penumbra aspiration microcatheter for acute mechanical thrombectomy. J Clin Neurosci 2013; 20(9): 1303-5. doi: 10.1016/j.jocn.2012.10.037 PMID: 23835465
  10. Wong GJ, Yoo B, Liebeskind D, et al. Frequency, determinants, and outcomes of emboli to distal and new territories related to mechanical thrombectomy for acute ischemic stroke. Stroke 2021; 52(7): 2241-9. doi: 10.1161/STROKEAHA.120.033377 PMID: 34011171
  11. Bala F, Kappelhof M, Ospel JM, et al. Distal embolization in relation to radiological thrombus characteristics, treatment details, and functional outcome. Stroke 2023; 54(2): 448-56. doi: 10.1161/STROKEAHA.122.040542 PMID: 36689583
  12. Qureshi AI, Lodhi A, Akhtar IN, et al. Mechanical thrombectomy with intra-arterial thrombolysis versus mechanical thrombectomy alone in patients with acute ischemic stroke: A systematic review and meta-analysis. Int J Stroke 2024; 19(1): 16-28. doi: 10.1177/17474930231184369 PMID: 37306490
  13. Guo W, Li N, Xu J, et al. Malignant middle cerebral artery infarction during early versus late endovascular treatment in acute ischemic stroke. Curr Neurovasc Res 2023; 20(2): 254-60. doi: 10.2174/1567202620666230710114443 PMID: 37431897
  14. Saver JL, Chapot R, Agid R, et al. Thrombectomy for distal, medium vessel occlusions. Stroke 2020; 51(9): 2872-84. doi: 10.1161/STROKEAHA.120.028956 PMID: 32757757
  15. Lee DH, Sung JH, Kim SU, Yi HJ, Hong JT, Lee SW. Effective use of balloon guide catheters in reducing incidence of mechanical thrombectomy related distal embolization. Acta Neurochir (Wien) 2017; 159(9): 1671-7. doi: 10.1007/s00701-017-3256-3 PMID: 28691137
  16. Chueh JY, Kang DH, Kim BM, Gounis MJ. Role of balloon guide catheter in modern endovascular thrombectomy. J Korean Neurosurg Soc 2020; 63(1): 14-25. doi: 10.3340/jkns.2019.0114 PMID: 31591997
  17. Kaesmacher J, Boeckh-Behrens T, Simon S, et al. Risk of thrombus fragmentation during endovascular stroke treatment. AJNR Am J Neuroradiol 2017; 38(5): 991-8. doi: 10.3174/ajnr.A5105 PMID: 28279987
  18. Hu W, Zhu C, Qin W. Perfusion deficits in different mechanisms of two subtypes of acute stroke with diffusion MRI confirmation. Curr Neurovasc Res 2023; 20(1): 35-42. doi: 10.2174/1567202620666221230141102 PMID: 36588332
  19. Ganesh A, Al-Ajlan FS, Sabiq F, et al. Infarct in a new territory after treatment administration in the ESCAPe randomized controlled trial (endovascular treatment for small core and anterior circulation proximal occlusion with emphasis on minimizing CT to recanalization times). Stroke 2016; 47(12): 2993-8. doi: 10.1161/STROKEAHA.116.014852 PMID: 27834743
  20. Dutra BG, Tolhuisen ML, Alves HCBR, et al. Thrombus imaging characteristics and outcomes in acute ischemic stroke patients undergoing endovascular treatment. Stroke 2019; 50(8): 2057-64. doi: 10.1161/STROKEAHA.118.024247 PMID: 31216961
  21. Yoo AJ, Khatri P, Mocco J, et al. Impact of thrombus length on outcomes after intra-arterial aspiration thrombectomy in the THERAPY trial. Stroke 2017; 48(7): 1895-900. doi: 10.1161/STROKEAHA.116.016253 PMID: 28596447
  22. Flint AC, Avins AL, Eaton A, et al. Risk of distal embolization from tPA (tissue-type plasminogen activator) administration prior to endovascular stroke treatment. Stroke 2020; 51(9): 2697-704. doi: 10.1161/STROKEAHA.120.029025 PMID: 32757749
  23. Yi HJ, Sung JH, Lee DH. Bridging intravenous thrombolysis before mechanical thrombectomy for large artery occlusion may be detrimental with thrombus fragmentation. Curr Neurovasc Res 2020; 17(1): 18-26. doi: 10.2174/1567202617666191223143831 PMID: 31870263
  24. Pilato F, Valente I, Calandrelli R, et al. Clot evaluation and distal embolization risk during mechanical thrombectomy in anterior circulation stroke. J Neurol Sci 2022; 432: 120087. doi: 10.1016/j.jns.2021.120087 PMID: 34933250
  25. Chueh JY, Marosfoi MG, Anagnostakou V, Arslanian RA, Marks MP, Gounis MJ. Quantitative characterization of recanalization and distal emboli with a novel thrombectomy device. Cardiovasc Intervent Radiol 2021; 44(2): 318-24. doi: 10.1007/s00270-020-02683-3 PMID: 33179161
  26. Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008; 359(13): 1317-29. doi: 10.1056/NEJMoa0804656 PMID: 18815396
  27. Kim SH, Lee H, Kim SB, et al. Hybrid mechanical thrombectomy for acute ischemic stroke using an intermediate aspiration catheter and Trevo stent simultaneously. J Clin Neurosci 2020; 76: 9-14. doi: 10.1016/j.jocn.2020.04.079 PMID: 32327379
  28. Yi HJ, Sung JH, Lee DH, Song SY. Effectiveness and technical considerations of solitaire platinum 4×40 mm stent retriever in mechanical thrombectomy with solumbra technique. J Korean Neurosurg Soc 2021; 64(1): 30-8. doi: 10.3340/jkns.2020.0046 PMID: 32759627
  29. Yi HJ, Kim BT, Shin DS. Effectiveness of anchoring with balloon guide catheter and stent retriever in difficult mechanical thrombectomy for large vessel occlusion. J Korean Neurosurg Soc 2022; 65(4): 514-22. doi: 10.3340/jkns.2021.0158 PMID: 35728980
  30. Yi HJ, Kang BM, Shin DS, Kim BT. Effect of early balloon inflation of balloon guide catheter in mechanical thrombectomy for large vessel occlusion. Curr Neurovasc Res 2023; 20(1): 124-31. doi: 10.2174/1567202620666230404125627 PMID: 37021421
  31. Kurre W, Vorlaender K, Aguilar-Pérez M, Schmid E, Bäzner H, Henkes H. Frequency and relevance of anterior cerebral artery embolism caused by mechanical thrombectomy of middle cerebral artery occlusion. AJNR Am J Neuroradiol 2013; 34(8): 1606-11. doi: 10.3174/ajnr.A3462 PMID: 23471019
  32. Fuller E, Vivanco-Suarez J, Fain NH, et al. Predictors of tissue infarction from distal emboli after mechanical thrombectomy. J Neurointerv Surg 2023. doi: 10.1136/jnis-2023-020782 PMID: 37620130
  33. Tian F, Chen H. The residual risks associated with atherothrombosis of recurrent ischemic stroke (IS) after non-cardiogenic IS. Curr Neurovasc Res 2023; 20(1): 149-61. doi: 10.2174/1567202620666221222114325 PMID: 36567291
  34. Yeo LLL, Holmberg A, Mpotsaris A, et al. Posterior circulation occlusions may be associated with distal emboli during thrombectomy. Clin Neuroradiol 2019; 29(3): 425-33. doi: 10.1007/s00062-018-0679-z PMID: 29569010
  35. Oh JS, Yoon SM, Shim JJ, Doh JW, Bae HG, Lee KS. Efficacy of balloon-guiding catheter for mechanical thrombectomy in patients with anterior circulation ischemic stroke. J Korean Neurosurg Soc 2017; 60(2): 155-64. doi: 10.3340/jkns.2016.0809.003 PMID: 28264235
  36. Brinjikji W, Starke RM, Murad MH, et al. Impact of balloon guide catheter on technical and clinical outcomes: A systematic review and meta-analysis. J Neurointerv Surg 2018; 10(4): 335-9. doi: 10.1136/neurintsurg-2017-013179 PMID: 28754806
  37. Kim YW, Son S, Kang DH, Hwang YH, Kim YS. Endovascular thrombectomy for M2 occlusions: comparison between forced arterial suction thrombectomy and stent retriever thrombectomy. J Neurointerv Surg 2017; 9(7): 626-30. doi: 10.1136/neurintsurg-2016-012466 PMID: 27382124
  38. Kang DH, Kim BM, Heo JH, et al. Effects of first pass recanalization on outcomes of contact aspiration thrombectomy. J Neurointerv Surg 2020; 12(5): 466-70. doi: 10.1136/neurintsurg-2019-015221 PMID: 31563889
  39. Gross BA, Jadhav AP, Jovin TG, Jankowitz BT. Dump the pump: Manual aspiration thrombectomy (MAT) with a syringe is technically effective, expeditious, and cost-efficient. J Neurointerv Surg 2018; 10(4): 354-7. doi: 10.1136/neurintsurg-2017-013520 PMID: 29127194
  40. Okada H, Matsuda Y, Malisch A, Chung J, Heiferman DM, Lopes DK. Evaluation of the intracranial flow alteration during manual syringe and continuous pump aspiration. J Stroke Cerebrovasc Dis 2019; 28(9): 2574-9. doi: 10.1016/j.jstrokecerebrovasdis.2019.05.015 PMID: 31239220
  41. Hopf-Jensen S, Preiß M, Marques L, et al. Impact and effectiveness of dual aspiration technique in stent-assisted mechanical thrombectomy: Recent improvements in acute stroke management. Cardiovasc Intervent Radiol 2016; 39(11): 1620-8. doi: 10.1007/s00270-016-1404-4 PMID: 27370750
  42. Haussen DC, Al-Bayati AR, Grossberg JA, et al. Longer stent retrievers enhance thrombectomy performance in acute stroke. J Neurointerv Surg 2019; 11(1): 6-8. doi: 10.1136/neurintsurg-2018-013918 PMID: 29858398
  43. Chueh JY, Kühn AL, Puri AS, Wilson SD, Wakhloo AK, Gounis MJ. Reduction in distal emboli with proximal flow control during mechanical thrombectomy: A quantitative in vitro study. Stroke 2013; 44(5): 1396-401. doi: 10.1161/STROKEAHA.111.670463 PMID: 23493730
  44. Caroff J, King RM, Arslanian R, et al. Microcatheter navigation through the clot: Does size matter? J Neurointerv Surg 2019; 11(3): 271-4. doi: 10.1136/neurintsurg-2018-014105 PMID: 30177546

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