Endovascular Recanalization of Tandem Internal Carotid Occlusions Using the Balloon-assisted Tracking Technique

Enhancing recanalization success: Thrombectomy plus stent angioplasty by coaxial balloon technique for acute ischemic stroke with tandem occlusions

Recanalizing acute ischemic stroke with carotid tandem occlusion (CTO) is technically challenging because distal embolic migration during revascularization can significantly influence outcomes. In this study, we aimed to introduce our coaxial balloon technique using a balloon-guiding catheter (BCG), angioplasty catheter, and aspiration catheter sequentially to prevent thrombus migration to a new vascular territory. We used this technique for six patients with CTO. Technical success with good revascularization of the CTO was achieved in all six patients (100%) without neurological complications, including one and five cases of modified Thrombolysis in Cerebral Infarction 2b and 3, respectively. The median duration of the procedure was 61 (interquartile range, 52-90) min. The mean National Institutes of Health Stroke Scale score at discharge was 3.5 (2-8), with favorable clinical outcomes at 90 days for three of six patients (50%). The coaxial balloon technique for CTO is safe and effective for revascularization in patients with acute ischemic stroke. Thrombectomy before proximal stenting was associated with shorter reperfusion times and better clinical outcomes. Therefore, this approach is recommended for tandem occlusions requiring stent angioplasty.

Treatment of In-stent Restenosis of the Internal Carotid Artery Using Drug-eluting Balloons

PURPOSE

In-stent restenosis (ISR) following internal carotid artery (ICA) stenting is relatively common with an estimated incidence of 5%. Treatment options include repeat angioplasty with conventional or drug-eluting balloons (DEB), repeat stent angioplasty and surgical intervention. Application of DEB in ISR of the coronary and peripheral arteries is an established method; however, data on DEB treatment of ICA ISR are sparse. In this work, results from a retrospective cohort of 45 patients harboring 46 ICA ISR lesions treated with DEB angioplasty are presented.

METHODS

Clinical, procedural and imaging data from DEB angioplasty treatment of 46 high-grade ICA ISR lesions in 45 patients, performed between 2013 and 2021 were collected. A single type of DEB (Elutax, Aachen Resonance, Aachen, Germany) was used in all procedures. Imaging follow-up was performed by regular Doppler ultrasound (DUS), verified by computed tomography angiography (CTA) in cases suspicious for a recurrent ISR.

RESULTS

Technical success was 100%. Intraprocedural and postprocedural complications were not encountered. Clinical follow-up was obtained in all patients. Recurrent stroke in the affected territory was not encountered. A recurrent ISR following DEB treatment was confirmed by DUS and CTA in 4/46 (8.7%) of the lesions and were retreated with DEB. A third recurrent ISR occurred in a single case (2%) and following a second DEB retreatment there were no signs of a fourth recurrence after 36 months follow-up.

CONCLUSION

The use of DEB angioplasty is a safe and effective treatment of ICA ISR lesions, yielding significantly better results compared to other modalities. Randomized multicenter studies are warranted.

The short-term outcome of intracranial stenosis with distal thrombosis treated with balloon-assisted tracking

Background and purposes

Treating intracranial stenosis with distal thrombosis (IS&DT) using traditional mechanical thrombectomy (MT) techniques has proven challenging. This study aimed to summarize the experience of utilizing the balloon-assisted tracking (BAT) technique for IS&DT.

Methods

Demographic and morphologic characteristics of patients with IS&DT were collected for this study. The BAT technique, involving a half-deflated balloon outside the intermediate catheter tip, was used in all patients to navigate through the proximal stenosis. Various parameters were recorded, including the sequence of vascular reperfusion, the puncture-to-reperfusion time (PRT), the residual stenosis rate, and the occurrence of re-occlusion. The thrombolysis in cerebral infarction (TICI) scale was used to assess the reperfusion of intracranial vessels, with a TICI score of ≥2b considered as successful perfusion. The clinical status of patients was evaluated at three time points: pre-procedure, post-procedure, and at discharge using the modified Rankin score (mRS).

Results

In this study, a total of 10 patients were diagnosed with IS&DT, consisting of 9 male patients (90.0%) and 1 female patient (10.0%). The patients' mean age was 63.10 years (ranging from 29 to 79 years). The mean National Institute of Health Stroke Scale (NIHSS) score before treatment was 24.3 (ranging from 12 to 40), indicating the severity of their condition. Following the procedure, all patients achieved successful reperfusion with a thrombolysis in cerebral infarction (TICI) score of ≥2b. The average puncture-to-reperfusion time (PRT) was 51.8 min (ranging from 25 to 100 min), indicating the time taken for the procedure. During the perioperative period, three patients (30.0%) experienced complications. One patient had hemorrhage, while two patients had contrast extravasation. Among these cases, only the patient with hemorrhage (10%) suffered from a permanent neurological function deficit. At discharge, the patient's condition showed improvement. The mean NIHSS score decreased to 13.2 (ranging from 1 to 34), indicating a positive response to treatment. The mean mRS score at discharge was 3.2 (ranging from 1 to 5), showing some level of functional improvement.

Conclusion

In conclusion, the use of the balloon-assisted tracking (BAT) technique for treating intracranial stenosis with distal thrombosis (IS&DT) showed promising results. However, a moderate rate of perioperative complications was observed, warranting further investigation and refinement of the procedure.

Balloon-Assisted Catheterization of Occluded Carotid Artery (BOCA) Technique in Acute Stroke

BACKGROUND

Acute ischemic stroke from tandem occlusion of internal carotid artery (ICA) poses a technical challenge to neurointerventionalists.

OBJECTIVE

To present a novel balloon-assisted catheterization of occluded carotid artery (BOCA) technique used for rapid and effective catheterization of occluded/critically stenosed ICA in tandem occlusion.

METHODS

A retrospective review of 10 patients with tandem carotid occlusion, treated with BOCA technique for revascularization between July 2020 and June 2021, was performed. Clinical, radiographic, and procedural data; details of BOCA technique; complications; and outcomes were reviewed.

RESULTS

Of the 10 patients, 8 (80%) had complete occlusion of the cervical ICA and the remaining 2 had high-grade stenosis with poor intracranial flow. The mean age was 63.2 years. The mean presenting NIH Stroke Scale was 13.4. The BOCA technique resulted in recanalization of ICA in all patients and allowed mechanical thrombectomy of middle cerebral artery. Thrombolysis in cerebral infarction grade 2b/3 was achieved in all 10 patients. The mean groin-to-reperfusion time was 41.4 minutes. The mean internal carotid artery stenosis was 99.7% preoperatively and 41.1% postoperatively. Only one patient needed stent at the end of the procedure because of dissection.

CONCLUSION

The BOCA technique can be used in distal first approach for acute stroke from tandem ICA occlusion. This technique allows direct guide catheterization of occluded ICA by tracking over a partially inflated balloon.