1
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Patki P, Simon S, Costanzo F, Manning KB. Current Approaches and Methods to Understand Acute Ischemic Stroke Treatment Using Aspiration Thrombectomy. Cardiovasc Eng Technol 2024:10.1007/s13239-024-00735-0. [PMID: 38886306 DOI: 10.1007/s13239-024-00735-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 05/21/2024] [Indexed: 06/20/2024]
Abstract
Acute ischemic stroke occurs when a blood clot occludes a cerebral artery. Mechanical interventions, primarily stent retrievers and aspiration thrombectomy, are used currently for removing the occluding clot and restoring blood flow. Aspiration involves using a long catheter to traverse the cerebral vasculature to reach the blood clot, followed by application of suction through the catheter bore. Aspiration is also used in conjunction with other techniques such as stent retrievers and balloon guide catheters. Despite the wide use of aspiration, our physical understanding of the process and the causes of the failure of aspiration to retrieve cerebral clots in certain scenarios is not well understood. Experimental and computational studies can help develop the capability to provide deeper insights into the procedure and enable development of new devices and more effective treatment methods. We recapitulate the aspiration-based thrombectomy techniques in clinical practice and provide a perspective of existing engineering methods for aspiration. We articulate the current knowledge gap in the understanding of aspiration and highlight possible directions for future engineering studies to bridge this gap, help clinical translation of engineering studies, and develop new patient-specific stroke therapy.
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Affiliation(s)
- Priyanka Patki
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, PA, 16802, USA
| | - Scott Simon
- Department of Neurosurgery, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Francesco Costanzo
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, PA, 16802, USA
- Center for Neural Engineering, The Pennsylvania State University, University Park, PA, 16802, USA
- Department of Engineering Science and Mechanics, The Pennsylvania State University, University Park, PA, 16802, USA
| | - Keefe B Manning
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, PA, 16802, USA.
- Center for Neural Engineering, The Pennsylvania State University, University Park, PA, 16802, USA.
- Department of Surgery, Penn State Hershey Medical Center, Hershey, PA, USA.
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2
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Kim LH, Choi J, Zhou J, Wolman D, Pendharkar AV, Lansberg MG, Albers GW, Dodd R, Do HM, Pulli B, Heit JJ, Telischak NA. Matched-pair analysis of patients with ischemic stroke undergoing thrombectomy using next-generation balloon guide catheters. J Neurointerv Surg 2024; 16:595-598. [PMID: 37793796 DOI: 10.1136/jnis-2023-020635] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 09/08/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND Balloon guide catheters (BGCs) have not been widely adopted, possibly due to the incompatibility of past-generation BGCs with large-bore intermediate catheters. The next-generation BGC is compatible with large-bore catheters. We compared outcomes of thrombectomy cases using BGCs versus conventional guide catheters. METHODS We conducted a retrospective study of 110 thrombectomy cases using BGCs (n=55) and non-BGCs (n=55). Sixty consecutive thrombectomy cases in whom the BOBBY BGC was used at a single institution between February 2021 and March 2022 were identified. Of these, 55 BGC cases were 1:1 matched with non-BGC cases by proceduralists, age, gender, stent retriever + aspiration device versus aspiration-only, and site of occlusion. First-pass effect was defined as Thrombolysis In Cerebral Infarction 2b or higher with a single pass. RESULTS The BGC and non-BGC cohorts had similar mean age (67.2 vs 68.9 years), gender distribution (43.6% vs 47.3% women), median initial National Institutes of Health Stroke Scale score (14 vs 15), and median pretreatment ischemic core volumes (12 mL vs 11.5 mL). BGC and non-BGC cases had similar rates of single pass (60.0% vs 54.6%), first-pass effect (58.2% vs 49.1%), and complications (1.8% vs 9.1%). In aspiration-only cases, the BGC cohort had a significantly higher rate of first-pass effect (100% vs 50.0%, p=0.01). BGC was associated with a higher likelihood of achieving a modified Rankin Scale score of 2 at discharge (OR 7.76, p=0.02). No additional procedural time was required for BGC cases (46.7 vs 48.2 min). CONCLUSION BGCs may be safely adopted with comparable procedural efficacy, benefits to aspiration-only techniques, and earlier functional improvement compared with conventional guide catheters.
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Affiliation(s)
- Lily H Kim
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - John Choi
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - James Zhou
- California Northstate University College of Medicine, Elk Grove, California, USA
| | - Dylan Wolman
- Radiology, Kaiser Permanente, Portland, Oregon, USA
| | - Arjun V Pendharkar
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Maarten G Lansberg
- Neurology and Neurological Sciences, Stanford University, Stanford, California, USA
| | - Gregory W Albers
- Neurology and Neurological Sciences, Stanford University, Stanford, California, USA
| | - Robert Dodd
- Neurosurgery and Radiology, Stanford University, Stanford, California, USA
| | - Huy M Do
- Radiology, Neuroadiology and Neurointervention Division, Stanford University, Stanford, California, USA
| | - Benjamin Pulli
- Radiology, Neuroadiology and Neurointervention Division, Stanford University, Stanford, California, USA
| | - Jeremy J Heit
- Radiology, Neuroadiology and Neurointervention Division, Stanford University, Stanford, California, USA
| | - Nicholas A Telischak
- Radiology, Neuroadiology and Neurointervention Division, Stanford University, Stanford, California, USA
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Liu R, He H, Zhang L, Fan Y, Wang J, Wang W. In vitro models for the experimental evaluation of mechanical thrombectomy devices in acute ischemic stroke. Interv Neuroradiol 2023; 29:759-767. [PMID: 35971288 PMCID: PMC10680957 DOI: 10.1177/15910199221118404] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/13/2022] [Accepted: 07/17/2022] [Indexed: 11/16/2022] Open
Abstract
Mechanical thrombectomy has become an important method for the treatment of acute ischemic stroke for large vessel occlusions. The current hotspots of mechanical thrombectomy are optimizing the treatment methods, improving the recanalization rate and reducing complications. The in vitro model has become a common and convenient method for mechanical thrombectomy research. This review summarizes the in vitro model in the following aspects: the preparation of clot analogues; the experimental platform; the application of the in vitro model in the testing of thrombectomy devices; and the advantages, limitations and future trends of the in vitro experimental model. This review describes the characteristics and applications of the in vitro experimental model with the hope that the in vitro experimental model will be further improved and play a more effective role in the study of mechanical thrombectomy.
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Affiliation(s)
- Ronghui Liu
- School of Biological Science and Medical Engineering, Beijing Advanced Innovation Center for Biomedical Engineering, Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, Beihang University, Beijing, China
- Key Laboratory of Biomedical Engineering and Translational Medicine, Ministry of Industry and Information Technology, Research Center for Biomedical Engineering, Medical Innovation & Research Division, Chinese PLA General Hospital, Beijing, China
| | - Hongping He
- Key Laboratory of Biomedical Engineering and Translational Medicine, Ministry of Industry and Information Technology, Research Center for Biomedical Engineering, Medical Innovation & Research Division, Chinese PLA General Hospital, Beijing, China
| | - Luo Zhang
- Key Laboratory of Biomedical Engineering and Translational Medicine, Ministry of Industry and Information Technology, Research Center for Biomedical Engineering, Medical Innovation & Research Division, Chinese PLA General Hospital, Beijing, China
| | - Yubo Fan
- School of Biological Science and Medical Engineering, Beijing Advanced Innovation Center for Biomedical Engineering, Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, Beihang University, Beijing, China
| | - Jun Wang
- Department of Neurology, the First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Weidong Wang
- Key Laboratory of Biomedical Engineering and Translational Medicine, Ministry of Industry and Information Technology, Research Center for Biomedical Engineering, Medical Innovation & Research Division, Chinese PLA General Hospital, Beijing, China
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Mao Y, Liu Y, Zhai M, Yang J. Application of and Prospects for 3-Dimensional Printing in Transcatheter Mitral Valve Interventions. Rev Cardiovasc Med 2023; 24:61. [PMID: 39077424 PMCID: PMC11273148 DOI: 10.31083/j.rcm2402061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/19/2022] [Accepted: 09/27/2022] [Indexed: 07/31/2024] Open
Abstract
Mitral valve (MV) disease is one of the most common valvular diseases that endangers health status. A variety of catheter-based interventions have been developed to treat MV disease. The special anatomical structures of the MV complex increase the difficulty of interventional surgery, and the incidence of perioperative complications remains high. With the continuous development of cardiovascular 3-dimensional (3D) printing technology and of multidisciplinary cooperation, 3D printing for transcatheter mitral valve interventions (TMVI) has become a revolutionary technology to promote innovation and improve the success rate. Patient-specific 3D printed models have been used in measuring sizes and predicting perioperative complications before TMVI. By simulating a bench test and using multi-material printing, surgeons may learn how the device interacts with the specific anatomical structures of the MV. This review summarizes relevant cutting-edge publications in this field and illustrates the application of 3D printing in TMVI with examples. In addition, we discuss the limitations and future directions of 3D printing in TMVI. Clinical Trial Registration ClinicalTrials.gov Protocol Registration System (NCT02917980).
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Affiliation(s)
- Yu Mao
- Department of Cardiovascular Surgery, Xijing Hospital, Air Force Medical University, 710032 Xi'an, Shaanxi, China
| | - Yang Liu
- Department of Cardiovascular Surgery, Xijing Hospital, Air Force Medical University, 710032 Xi'an, Shaanxi, China
| | - Mengen Zhai
- Department of Cardiovascular Surgery, Xijing Hospital, Air Force Medical University, 710032 Xi'an, Shaanxi, China
| | - Jian Yang
- Department of Cardiovascular Surgery, Xijing Hospital, Air Force Medical University, 710032 Xi'an, Shaanxi, China
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Comparison of mechanical thrombectomy techniques in an in vitro stroke model: How to obtain a first pass recanalization? J Neuroradiol 2022; 50:438-443. [PMID: 36526015 DOI: 10.1016/j.neurad.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 12/12/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Since mechanical thrombectomy (MT) has proven to be effective in the treatment of acute ischemic stroke (AIS), significant research has been dedicated to establishing procedural techniques offering best rate of first pass effect (FPE). In this study, we compared the efficacy of different techniques in vitro to achieve the first pass recanalisation (FPR). METHODS In vitro MT procedures were performed using a realistic silicone model of the human cerebral vasculature. The MT with stent retriever (SR) were performed with manual co-aspiration through the respective access catheter and intermediate catheter (IC), with Solumbra or partial retrieval techniques into the IC. Two SRs (Solitaire and EmboTrap) were selected to retrieve both red blood cells (RBC) rich and fibrin-rich clots. FPR rates were recorded for each case. RESULTS Overall, 144 MT were performed. FPR rates using the partial retrieval and Solumbra technique were of 100% and 87%, respectively (p = 0.01). The rate of FPR was of 92% using the balloon-guide catheter (BGC) compared to 64% with the guide catheter (GC) (p = 0.0001). With an IC, no differences were found between using a BGC or a GC (87.9% vs 89,6%, p = 0.75). No significant difference was observed between the Embotrap and the Solitaire device for the rate of FPR (82% and 74%, respectively; p = 0.23). CONCLUSIONS In this study, FPR rates were higher with the use of an IC associated with the partial retrieval technique, regardless the guide catheter, the SR, or the clot composition. The less effective technique was the association of GC and SR, without an IC.
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6
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Kim JH, Kim BM, Kim DJ. In Vitro Analysis of the Efficacy of Endovascular Thrombectomy Techniques according to the Vascular Tortuosity Using 3D Printed Models. AJNR Am J Neuroradiol 2022; 43:1431-1436. [PMID: 36574330 PMCID: PMC9575538 DOI: 10.3174/ajnr.a7633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 07/17/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE Achieving complete recanalization with the front-line endovascular thrombectomy device improves the outcome of acute stroke. The aim of this study was to evaluate whether various thrombectomy techniques including contact aspiration, stent retriever thrombectomy, and combination therapy differ in first-pass effect and distal emboli in acute large-vessel occlusion simulated using 3D printed nontortuous and tortuous cerebrovascular anatomy models. MATERIALS AND METHODS 3D printed flow models were manufactured using angiographic data of nontortuous and acutely angulated tortuous vascular anatomy from real patients. Three thrombectomy techniques, contact aspiration, stent retriever, and combined methods, were tested under proximal protection with the balloon-guiding catheter. The first-pass effect and distal emboli rates were analyzed in addition to the thrombectomy-failure mechanisms of the respective techniques. RESULTS A total of 30 thrombectomy experiments were performed. The overall incidence of first-pass effect in the nontortuous and tortuous anatomy was 80.0% versus 46.7%. The overall incidence of distal emboli in the nontortuous and tortuous anatomy was 26.7% versus 46.7%. The contact aspiration technique showed better first-pass effect (80.0%) and distal emboli rates (20%) in the tortuous model compared with other techniques. The combined technique did not show remarkable superiority of the first-pass effect and distal emboli in either the nontortuous or tortuous anatomy. Shearing off of the thrombus was the main mechanism of thrombectomy failure in the combined group. CONCLUSIONS The tortuous vascular anatomy may worsen the first-pass effect and distal emboli rates. The combined techniques failed to show improvement in outcome due to the shearing-off phenomenon of the thrombus during retrieval.
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Affiliation(s)
- J H Kim
- From the Department of Radiology (J.H.K.), Yongin Severance Hospital, Yonsei University College of Medicine, Yongin-si, Gyeonggi-do, Republic of Korea
| | - B M Kim
- Department of Radiology (B.M.K., D.J.K.), Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - D J Kim
- Department of Radiology (B.M.K., D.J.K.), Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Johnson S, Dwivedi A, Mirza M, McCarthy R, Gilvarry M. A Review of the Advancements in the in-vitro Modelling of Acute Ischemic Stroke and Its Treatment. FRONTIERS IN MEDICAL TECHNOLOGY 2022; 4:879074. [PMID: 35756535 PMCID: PMC9214215 DOI: 10.3389/fmedt.2022.879074] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/29/2022] [Indexed: 11/13/2022] Open
Abstract
In-vitro neurovascular models of large vessel occlusions (LVOs) causing acute ischemic stroke (AIS) are used extensively for pre-clinical testing of new treatment devices. They enable physicians and engineers to examine device performance and the response of the occlusion to further advance design solutions for current unmet clinical needs. These models also enable physicians to train on basic skills, to try out new devices and new procedural approaches, and for the stroke team to practice workflows together in the comfort of a controlled environment in a non-clinical setting. Removal of the occlusive clot in its entirety is the primary goal of the endovascular treatment of LVOs via mechanical thrombectomy (MT) and the medical treatment via thrombolysis. In MT, recanalization after just one pass is associated with better clinical outcomes than procedures that take multiple passes to achieve the same level of recanalization, commonly known as first pass effect (FPE). To achieve this, physicians and engineers are continually investigating new devices and treatment approaches. To distinguish between treatment devices in the pre-clinical setting, test models must also be optimized and expanded become more nuanced and to represent challenging patient cohorts that could be improved through new technology or better techniques. The aim of this paper is to provide a perspective review of the recent advancements in the in-vitro modeling of stroke and to outline how these models need to advance further in future. This review provides an overview of the various in-vitro models used for the modeling of AIS and compares the advantages and limitations of each. In-vitro models remain an extremely useful tool in the evaluation and design of treatment devices, and great strides have been made to improve replication of physiological conditions. However, further advancement is still required to represent the expanding indications for thrombectomy and thrombolysis, and the generation of new thrombectomy devices, to ensure that smaller treatment effects are captured.
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Affiliation(s)
- Sarah Johnson
- Cerenovus (Johnson & Johnson), Galway Neuro Technology Centre, Galway, Ireland
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8
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Pressman E, Sommer KN, Waqas M, Siddiqui AH, Ionita CN, Mokin M. Comparison of stent retriever thrombectomy using 3-dimensional patient-specific models of intracranial circulation with actual middle cerebral artery occlusion thrombectomy cases. J Neuroimaging 2022; 32:436-441. [PMID: 34958701 PMCID: PMC9899120 DOI: 10.1111/jon.12961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 12/05/2021] [Accepted: 12/06/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND PURPOSE Stent retriever (SR) thrombectomy is commonly used for the treatment of emergent large vessel occlusion (ELVO) in acute ischemic stroke. Clot imaging parameters such as clot length, diameter, distance to the internal carotid artery terminus, and vessel angle where the SR is deployed may predict the likelihood of achieving first pass effect (FPE). Most of the proposed factors that seem to affect recanalization success have been studied individually, and conflicting data derived from clinical versus in vitro studies using 3-dimensional printed models of intracranial circulation currently exist. METHODS Using patient-specific 3-dimensional phantoms of the cervical and intracranial circulation, we simulated middle cerebral arteries (MCA) M1 and M2 occlusions treated with SR thrombectomy using Solitaire (Medtronic) or Trevo (Styker). Our primary outcome was FPE, defined as Thrombolysis in Cerebral Infarction score of 2c-3 achieved after a single thrombectomy attempt. We also performed retrospective analysis of same clot imaging characteristics of consecutive cases of MCA occlusion and its association with FPE matching the 3-dimensional in vitro experiments. Analysis was conducted using IBM SPSS Statistics Version 25 (IBM Corp., Armonk, NY). Chi-square tests and bivariate logistic regressions were the main statistical tests used in analysis. A p-value of less than .05 was considered to indicate statistical significance. Ninety-five confidence intervals (95% CI) were generated. RESULTS We compared 41 thrombectomy experiments performed using patient-specific 3-dimensional in vitro models with a retrospective cohort of 41 patients treated with SR thrombectomy. We found that in the in vitro cohort, higher MCA angulation was associated with a lower likelihood of FPE (odds ratio [OR] = 0.967, 95% CI = 0.944-0.991, p = .008). Meanwhile in the in vivo cohort, higher MCA angulation was associated with a higher likelihood of FPE (OR = 1.039, 95% CI = 1.003-1.077, p = .033). Neither clot length nor location of clot (M1 vs. M2) was associated with a difference in FPE rates in either cohort. DISCUSSION Comparison of SR thrombectomy performed during actual MCA occlusion cases versus patient-specific 3-dimensional replicas revealed MCA angulation as an independent predictor of procedure success or failure. However, the opposite direction of effect was observed between the two studied environments, indicating potential limitations of studying SR thrombectomy using 3-dimensional models of LVO.
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Affiliation(s)
- Elliot Pressman
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida 33620
| | - Kelsey N Sommer
- Department of Biomedical Engineering, University at Buffalo NY 14228,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo NY 14208
| | - Mohammad Waqas
- Department of Neurosurgery, University at Buffalo, Buffalo, NY 14208
| | - Adnan H Siddiqui
- Department of Biomedical Engineering, University at Buffalo NY 14228,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo NY 14208,Department of Neurosurgery, University at Buffalo, Buffalo, NY 14208
| | - Ciprian N Ionita
- Department of Biomedical Engineering, University at Buffalo NY 14228,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo NY 14208
| | - Maxim Mokin
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida 33620
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Sommer KN, Bhurwani MMS, Iyer V, Ionita CN. Comparison of fluid dynamics changes due to physical activity in 3D printed patient specific coronary phantoms with the Windkessel equivalent model of coronary flow. 3D Print Med 2022; 8:10. [PMID: 35389117 PMCID: PMC8988414 DOI: 10.1186/s41205-022-00138-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 03/29/2022] [Indexed: 11/11/2022] Open
Abstract
Background 3D printing (3DP) used to replicate the geometry of normal and abnormal vascular pathologies has been demonstrated in many publications; however, reproduction of hemodynamic changes due to physical activities, such as rest versus moderate exercise, need to be investigated. We developed a new design for patient specific coronary phantoms, which allow adjustable physiological variables such as coronary distal resistance and coronary compliance in patients with coronary artery disease. The new design was tested in precise benchtop experiments and compared with a theoretical Windkessel electrical circuit equivalent, that models coronary flow and pressure using arterial resistance and compliance. Methods Five phantoms from patients who underwent clinically indicated elective invasive coronary angiography were built from CCTA scans using multi-material 3D printing. Each phantom was used in a controlled flow system where patient specific flow conditions were simulated by a programmable cardiac pump. To simulate the arteriole and capillary beds flow resistance and the compliance for various physical activities, we designed a three-chamber outlet system which controls the outflow dynamics of each coronary tree. Benchtop pressure measurements were recorded using sensors embedded in each of the main coronary arteries. Using the Windkessel model, patient specific flow equivalent electrical circuit models were designed for each coronary tree branch, and flow in each artery was determined for known inflow conditions. Local flow resistances were calculated through Poiseuille’s Law derived from the radii and lengths of the coronary arteries using CT angiography based multi-planar reconstructions. The coronary stenosis flow rates from the benchtop and the electrical models were compared to the localized flow rates calculated from invasive pressure measurements recorded in the angio-suites. Results The average Pearson correlations of the localized flow rates at the location of the stenosis between each of the models (Benchtop/Electrical, Benchtop/Angio, Electrical/Angio) are 0.970, 0.981, and 0.958 respectively. Conclusions 3D printed coronary phantoms can be used to replicate the human arterial anatomy as well as blood flow conditions. It displays high levels of correlation when compared to hemodynamics calculated in electrically-equivalent coronary Windkessel models as well as invasive angio-suite pressure measurements.
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Affiliation(s)
- Kelsey N Sommer
- Department of Biomedical Engineering, University at Buffalo, Buffalo, NY, USA. .,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA. .,QAS.AI Incorporated, Buffalo, NY, 14203, USA.
| | - Mohammad Mahdi Shiraz Bhurwani
- Department of Biomedical Engineering, University at Buffalo, Buffalo, NY, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA
| | - Vijay Iyer
- University at Buffalo Cardiology, University at Buffalo Jacobs School of Medicine, Buffalo, NY, USA
| | - Ciprian N Ionita
- Department of Biomedical Engineering, University at Buffalo, Buffalo, NY, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA.,QAS.AI Incorporated, Buffalo, NY, 14203, USA
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Wortmann N, Andersek T, Guerreiro H, Kyselyova AA, Frölich AM, Fiehler J, Krause D. Development of synthetic thrombus models to simulate stroke treatment in a physical neurointerventional training model. ALL LIFE 2022. [DOI: 10.1080/26895293.2022.2046181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Nadine Wortmann
- Institute of Product Development and Mechanical Engineering Design, Hamburg University of Technology, Hamburg, Germany
| | - Thomas Andersek
- WEINMANN Emergency Medical Technology GmbH + Co. KG, Hamburg, Germany
| | - Helena Guerreiro
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anna A. Kyselyova
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dieter Krause
- Institute of Product Development and Mechanical Engineering Design, Hamburg University of Technology, Hamburg, Germany
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Freiherr von Seckendorff A, Delvoye F, Levant P, Solo Nomenjanahary M, Ollivier V, Bourrienne MC, Di Meglio L, Piotin M, Escalard S, Maier B, Hebert S, Smajda S, Redjem H, Mazighi M, Blanc R, Ho-Tin-Noé B, Désilles JP. Modeling Large Vessel Occlusion Stroke for the Evaluation of Endovascular Therapy According to Thrombus Composition. Front Neurol 2022; 12:815814. [PMID: 35153990 PMCID: PMC8829452 DOI: 10.3389/fneur.2021.815814] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 12/22/2021] [Indexed: 11/26/2022] Open
Abstract
More than 40% of endovascular therapy (EVT) fail to achieve complete reperfusion of the territory of the occluded artery in patients with acute ischemic stroke (AIS). Understanding factors influencing EVT could help overcome its limitations. Our objective was to study the impact of thrombus cell composition on EVT procedures, using a simulation system for modeling thrombus-induced large vessel occlusion (LVO) in flow conditions. In an open comparative trial, we analyzed the behavior of size-standardized platelet-rich and red blood cells (RBC)-rich thrombi during simulated stent retriever-mediated EVT procedures. Sixteen simulated EVT procedures were performed (8 RBC- vs. 8 platelet-rich thrombi). Platelet-rich thrombi were associated with a higher number of stent retriever passes (p = 0.03) and a longer procedure duration (p = 0.02) compared to RBC-rich thrombi. Conversely, RBC-rich thrombi released more embolic fragments than platelet-rich thrombi (p = 0.004). Both RBC-rich and platelet-rich thrombi underwent drastic compaction after being injected into the in vitro circulation model, and histologic analyses showed that these EVT-retrieved thrombi displayed features comparable to those previously observed in thrombi from patients with AIS patients having LVO, including a marked structural dichotomy between RBC- and platelet-rich areas. Our results show that the injection of in vitro-produced thrombi in artificial cerebrovascular arterial networks is suitable for testing recanalization efficacy and the risk of embolization of EVT devices and strategies in association with thrombus cell composition.
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Affiliation(s)
- Aurélien Freiherr von Seckendorff
- Interventional Neuroradiology Department, Biological Resource Center, Hôpital Fondation Adolphe de Rothschild, Paris, France
- Université de Paris, Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
| | - François Delvoye
- Interventional Neuroradiology Department, Biological Resource Center, Hôpital Fondation Adolphe de Rothschild, Paris, France
| | - Paul Levant
- Interventional Neuroradiology Department, Biological Resource Center, Hôpital Fondation Adolphe de Rothschild, Paris, France
| | - Mialitiana Solo Nomenjanahary
- Université de Paris, Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
| | - Véronique Ollivier
- Université de Paris, Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
| | - Marie-Charlotte Bourrienne
- Université de Paris, Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
| | - Lucas Di Meglio
- Université de Paris, Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
| | - Michel Piotin
- Interventional Neuroradiology Department, Biological Resource Center, Hôpital Fondation Adolphe de Rothschild, Paris, France
- Université de Paris, Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
| | - Simon Escalard
- Interventional Neuroradiology Department, Biological Resource Center, Hôpital Fondation Adolphe de Rothschild, Paris, France
| | - Benjamin Maier
- Interventional Neuroradiology Department, Biological Resource Center, Hôpital Fondation Adolphe de Rothschild, Paris, France
- Université de Paris, Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
| | - Solène Hebert
- Interventional Neuroradiology Department, Biological Resource Center, Hôpital Fondation Adolphe de Rothschild, Paris, France
| | - Stanislas Smajda
- Interventional Neuroradiology Department, Biological Resource Center, Hôpital Fondation Adolphe de Rothschild, Paris, France
| | - Hocine Redjem
- Interventional Neuroradiology Department, Biological Resource Center, Hôpital Fondation Adolphe de Rothschild, Paris, France
| | - Mikael Mazighi
- Interventional Neuroradiology Department, Biological Resource Center, Hôpital Fondation Adolphe de Rothschild, Paris, France
- Université de Paris, Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
| | - Raphael Blanc
- Interventional Neuroradiology Department, Biological Resource Center, Hôpital Fondation Adolphe de Rothschild, Paris, France
- Université de Paris, Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
| | - Benoit Ho-Tin-Noé
- Université de Paris, Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
| | - Jean-Philippe Désilles
- Interventional Neuroradiology Department, Biological Resource Center, Hôpital Fondation Adolphe de Rothschild, Paris, France
- Université de Paris, Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
- *Correspondence: Jean-Philippe Désilles
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Experimental Evaluation of the Effectiveness of Aspiration-Based Techniques to Treat Different Types of Acute Thromboembolic Occlusions in the Femoropopliteal Vascular System Using an In Vitro Flow Model. Cardiovasc Intervent Radiol 2021; 45:228-235. [PMID: 34921347 PMCID: PMC8807461 DOI: 10.1007/s00270-021-03024-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 11/22/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE In this in vitro study, the effectiveness and safety of four aspiration-based techniques for thrombectomy are evaluated for three types of thrombi in a flow model simulating the femoropopliteal segment. MATERIAL AND METHODS Red, white, and mixed thrombi were produced in a standardized manner and used to simulate occlusion of a superficial femoral artery using a pulsatile flow model. Four techniques were compared: aspiration alone, aspiration + stent retriever, exposing thrombus to laser by an excimer laser system and a laser catheter + aspiration, and aspiration + mechanical fragmentation by a separator. Rate of first-pass recanalization, embolic events, and number of embolized fragments > 1 mm were compared. RESULTS Aspiration alone, stent retriever, laser, and separator differed in rates of first-pass recanalization (53.3%; 86.6%; 20%; and 100%) and embolic events (40%; 93.3%; 73.3%; and 60%). Number of embolized fragments was lowest with aspiration and higher with separator, laser, and stent retriever. Rates of first-pass-recanalization (75%; 75%; and 45%) and embolic events (65%; 60%; and 75%) differed for red, white, and mixed thrombi. The mixed thrombus caused the highest number of embolized fragments, which was particularly high using the stent retriever. CONCLUSION Additional use of mechanical techniques significantly enhances the effectiveness of thrombectomy but simultaneously provokes more embolism. Laser seems to negatively alter the structure of a thrombus and thus diminishes the effectiveness, while provoking embolism. All techniques had lowest effectiveness, but highest embolism with the mixed thrombus. This was particularly striking when a stent retriever was used with the mixed thrombus.
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Preclinical modeling of mechanical thrombectomy. J Biomech 2021; 130:110894. [PMID: 34915309 DOI: 10.1016/j.jbiomech.2021.110894] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 11/16/2021] [Accepted: 11/18/2021] [Indexed: 11/21/2022]
Abstract
Mechanical thrombectomy to treat large vessel occlusions (LVO) causing a stroke is one of the most effective treatments in medicine, with a number needed to treat to improve clinical outcomes as low as 2.6. As the name implies, it is a mechanical solution to a blocked artery and modeling these mechanics preclinically for device design, regulatory clearance and high-fidelity physician training made clinical applications possible. In vitro simulation of LVO is extensively used to characterize device performance in representative vascular anatomies with physiologically accurate hemodynamics. Embolus analogues, validated against clots extracted from patients, provide a realistic simulated use experience. In vitro experimentation produces quantitative results such as particle analysis of distal emboli generated during the procedure, as well as pressure and flow throughout the experiment. Animal modeling, used mostly for regulatory review, allows estimation of device safety. Other than one recent development, nearly all animal modeling does not incorporate the desired target organ, the brain, but rather is performed in the extracranial circulation. Computational modeling of the procedure remains at the earliest stages but represents an enormous opportunity to rapidly characterize and iterate new thrombectomy concepts as well as optimize procedure workflow. No preclinical model is a perfect surrogate; however, models available can answer important questions during device development and have to date been successful in delivering efficacious and safe devices producing excellent clinical outcomes. This review reflects on the developments of preclinical modeling of mechanical thrombectomy with particular focus on clinical translation, as well as articulate existing gaps requiring additional research.
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Salem MM, Kvint S, Choudhri OA, Burkhardt JK. Endovascular Transcarotid Artery Revascularization Using the Walrus Balloon Guide Catheter: Preliminary Experience. World Neurosurg 2021; 156:e175-e182. [PMID: 34534717 DOI: 10.1016/j.wneu.2021.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/04/2021] [Accepted: 09/06/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND The Walrus Balloon Guided System Catheter is a new generation of balloon guide catheter (BGC) designed to bypass some technical limitations of conventional BGC devices. Their utility in cervical carotid disease treatment has not been reported. We report our preliminary experience in cervical carotid treatment using the Walrus BGC to perform a modified endovascular transcarotid artery revascularization technique. METHODS Patients with cervical carotid disease undergoing endovascular treatment using the Walrus BGC at our institution were identified. The pertinent baseline demographics and procedural outcomes were collected and analyzed. RESULTS Twelve patients were included (median age, 70; 58.3% females). All patients had an imaging-confirmed cervical carotid disease that indicated intervention: 6 with high-grade cervical arteriosclerotic carotid stenosis, 2 with intraluminal thrombi, 1 with traumatic carotid dissection, and 3 patients with cervical carotid tandem occlusion along with acute ischemic stroke secondary to large vessel occlusion that required mechanical thrombectomy. Carotid artery stenting was performed in all cases, except 2 of the 3 mechanical thrombectomy cases (angioplasty only). All patients had at least periprocedural follow-up of 30 days, with no stroke, myocardial infarction, or death encountered. CONCLUSIONS We describe a modified endovascular transcarotid artery revascularization technique. We used a standard femoral access to navigate the Walrus catheter in the common carotid artery, followed by balloon inflation for proximal flow arrest or flow reversal (when connected to the aspiration pump) to deploy the carotid stent across the stenosis, while avoiding distal external carotid artery balloon occlusion. Successful treatment was achieved in all cases, with no periprocedural complications encountered.
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Affiliation(s)
- Mohamed M Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Svetlana Kvint
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Omar A Choudhri
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA.
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Luraghi G, Cahalane RME, van de Ven E, Overschie SCM, Gijsen FJH, Akyildiz AC. In vitro and in silico modeling of endovascular stroke treatments for acute ischemic stroke. J Biomech 2021; 127:110693. [PMID: 34450517 DOI: 10.1016/j.jbiomech.2021.110693] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 07/06/2021] [Accepted: 08/09/2021] [Indexed: 12/25/2022]
Abstract
Acute ischemic stroke occurs when a thrombus obstructs a cerebral artery, leading to sub-optimal blood perfusion to brain tissue. A recently developed, preventive treatment is the endovascular stroke treatment (EVT), which is a minimally invasive procedure, involving the use of stent-retrievers and/or aspiration catheters. Despite its increasing use, many critical factors of EVT are not well understood. In this respect, in vitro, and in silico studies have the great potential to help us deepen our understanding of the procedure, perform further device and procedural optimization, and help in clinical training. This review paper provides an overview of the previous in vitro and in silico evaluations of EVT treatments, with a special emphasis on the four main aspects of the adopted experimental and numerical set-ups: vessel, thrombus, device, and procedural settings.
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Affiliation(s)
- Giulia Luraghi
- Department of Biomechanical Engineering, Delft University of Technology, Delft, the Netherlands; Department of Chemistry, Materials and Chemical Engineering "Giulio Natta", Politecnico di Milano, Milan, Italy.
| | - Rachel M E Cahalane
- Department of Biomedical Engineering, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Emma van de Ven
- Department of Biomechanical Engineering, Delft University of Technology, Delft, the Netherlands
| | - Serena C M Overschie
- Department of Biomechanical Engineering, Delft University of Technology, Delft, the Netherlands
| | - Frank J H Gijsen
- Department of Biomechanical Engineering, Delft University of Technology, Delft, the Netherlands; Department of Biomedical Engineering, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Ali C Akyildiz
- Department of Biomechanical Engineering, Delft University of Technology, Delft, the Netherlands; Department of Biomedical Engineering, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands
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16
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Sommer KN, Bhurwani MMS, Tutino V, Siddiqui A, Davies J, Snyder K, Levy E, Mokin M, Ionita CN. Use of patient specific 3D printed neurovascular phantoms to simulate mechanical thrombectomy. 3D Print Med 2021; 7:32. [PMID: 34568987 PMCID: PMC8474770 DOI: 10.1186/s41205-021-00122-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 09/11/2021] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The ability of the patient specific 3D printed neurovascular phantoms to accurately replicate the anatomy and hemodynamics of the chronic neurovascular diseases has been demonstrated by many studies. Acute occurrences, however, may still require further development and investigation and therefore we studied acute ischemic stroke (AIS). The efficacy of endovascular procedures such as mechanical thrombectomy (MT) for the treatment of large vessel occlusion (LVO), can be improved by testing the performance of thrombectomy devices and techniques using patient specific 3D printed neurovascular models. METHODS 3D printed phantoms were connected to a flow loop with physiologically relevant flow conditions, including input flow rate and fluid temperature. A simulated blood clot was introduced into the model and placed in the proximal Middle Cerebral Artery (MCA) region. Clot location, composition, length, and arterial angulation were varied and MTs were simulated using stent retrievers. Device placement relative to the clot and the outcome of the thrombectomy were recorded for each situation. Digital subtraction angiograms (DSA) were captured before and after LVO simulation. Recanalization outcome was evaluated using DSA as either 'no recanalization' or 'recanalization'. Forty-two 3DP neurovascular phantom benchtop experiments were performed. RESULTS Clot angulation within the MCA region had the most significant impact on the MT outcome, with a p-value of 0.016. Other factors such as clot location, clot composition, and clot length correlated weakly with the MT outcome. CONCLUSIONS This project allowed us to gain knowledge of how such characteristics influence thrombectomy success and can be used in making clinical decisions when planning the procedure and selecting specific thrombectomy tools and approaches.
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Affiliation(s)
- Kelsey N. Sommer
- grid.273335.30000 0004 1936 9887Department of Biomedical Engineering, University at Buffalo, Buffalo, NY 14228 USA ,grid.273335.30000 0004 1936 9887Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY 14208 USA
| | - Mohammad Mahdi Shiraz Bhurwani
- grid.273335.30000 0004 1936 9887Department of Biomedical Engineering, University at Buffalo, Buffalo, NY 14228 USA ,grid.273335.30000 0004 1936 9887Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY 14208 USA
| | - Vincent Tutino
- grid.273335.30000 0004 1936 9887Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY 14208 USA ,grid.273335.30000 0004 1936 9887Department of Neurosurgery, University at Buffalo, Buffalo, NY 14208 USA ,grid.273335.30000 0004 1936 9887Department of Pathology and Anatomical Sciences, University at Buffalo, Buffalo, 14208 USA
| | - Adnan Siddiqui
- grid.273335.30000 0004 1936 9887Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY 14208 USA ,grid.273335.30000 0004 1936 9887Department of Neurosurgery, University at Buffalo, Buffalo, NY 14208 USA
| | - Jason Davies
- grid.273335.30000 0004 1936 9887Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY 14208 USA ,grid.273335.30000 0004 1936 9887Department of Neurosurgery, University at Buffalo, Buffalo, NY 14208 USA ,grid.273335.30000 0004 1936 9887Department of Biomedical Informatics, University at Buffalo, Buffalo, 14208 USA
| | - Kenneth Snyder
- grid.273335.30000 0004 1936 9887Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY 14208 USA ,grid.273335.30000 0004 1936 9887Department of Neurosurgery, University at Buffalo, Buffalo, NY 14208 USA
| | - Elad Levy
- grid.273335.30000 0004 1936 9887Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY 14208 USA ,grid.273335.30000 0004 1936 9887Department of Neurosurgery, University at Buffalo, Buffalo, NY 14208 USA
| | - Maxim Mokin
- grid.170693.a0000 0001 2353 285XDepartment of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL 33620 USA
| | - Ciprian N. Ionita
- grid.273335.30000 0004 1936 9887Department of Biomedical Engineering, University at Buffalo, Buffalo, NY 14228 USA ,grid.273335.30000 0004 1936 9887Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY 14208 USA ,grid.273335.30000 0004 1936 9887Department of Neurosurgery, University at Buffalo, Buffalo, NY 14208 USA
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Liu Y, Abbasi M, Arturo Larco JL, Kadirvel R, Kallmes DF, Brinjikji W, Savastano L. Preclinical testing platforms for mechanical thrombectomy in stroke: a review on phantoms, in-vivo animal, and cadaveric models. J Neurointerv Surg 2021; 13:816-822. [PMID: 33722966 PMCID: PMC8364863 DOI: 10.1136/neurintsurg-2020-017133] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 02/18/2021] [Accepted: 02/19/2021] [Indexed: 11/03/2022]
Abstract
Preclinical testing platforms have been instrumental in the research and development of thrombectomy devices. However, there is no single model which fully captures the complexity of cerebrovascular anatomy, physiology, and the dynamic artery-clot-device interaction. This article provides a critical review of phantoms, in-vivo animal, and human cadaveric models used for thrombectomy testing and provides insights into the strengths and limitations of each platform. Articles published in the past 10 years that reported thrombectomy testing platforms were identified. Characteristics of each test platform, such as intracranial anatomy, artery tortuosity, vessel friction, flow conditions, device-vessel interaction, and visualization, were captured and benchmarked against human cerebral vessels involved in large-vessel occlusion stroke. Thrombectomy phantoms have been constructed from silicone, direct 3D-printed polymers, and glass. These phantoms represent oversimplified patient-specific cerebrovascular geometry but enable adequate visualization of devices and clots under appropriate flow conditions. They do not realistically mimic the artery-clot interaction. For the animal models, arteries from swine, canines, and rabbits have been reported. These models can reasonably replicate the artery-clot-device interaction and have the unique value of evaluating the safety of thrombectomy devices. However, the vasculature geometries are substantially less complex and flow conditions are different from human cerebral arteries. Cadaveric models are the most accurate vascular representations but with limited access and challenges in reproducibility of testing conditions. Multiple test platforms should be likely used for comprehensive evaluation of thrombectomy devices. Interpretation of the testing results should take into consideration platform-specific limitations.
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Affiliation(s)
- Yang Liu
- Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mehdi Abbasi
- Radiology, Mayo Clinic, Rochester, Minnesota, USA
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Baek SH, Kim S, Kang M, Choi JH, Kwon HJ, Kim DW. Effect of distal access catheter tip position on angiographic and clinical outcomes following thrombectomy using the combined stent-retriever and aspiration approach. PLoS One 2021; 16:e0252641. [PMID: 34111176 PMCID: PMC8192018 DOI: 10.1371/journal.pone.0252641] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 05/19/2021] [Indexed: 11/19/2022] Open
Abstract
Purpose Mechanical thrombectomy using the stent-retriever in conjunction with the distal access catheter may improve the rates of successful revascularization and clinical outcomes in patients with acute stroke. We aimed to compare two different thrombectomy techniques, according to the position of the distal access catheter tip in the combined stent-retriever and aspiration approach. Methods In this retrospective study, patients with middle cerebral artery occlusion treated with the combined technique were divided into two groups based on the tip position of the distal access catheter: distal group (catheter placed adjacent to the thrombus) and proximal group (catheter placed in the cavernous segment of the internal carotid artery below the ophthalmic artery). Baseline characteristics, angiographic results, and clinical outcomes were compared. Results Eighty-three patients (distal group, n = 45; proximal group, n = 38) were included. Higher complete reperfusion was observed in the distal group (unweighted analysis: 66.7% vs. 42.1%, p = 0.025; weighted analysis: 74.0% vs. 28.8%; p = 0.002). In the multivariate analysis, the distal tip position was independently associated with complete reperfusion (unweighted analysis: aOR, 4.10; 95% CI, 1.40–11.98; p = 0.01; weighted analysis: aOR, 5.20; 95% CI, 1.72–15.78; p = 0.004). The distal group also showed more favorable clinical outcomes and early neurological improvement (unweighted analysis: 62.2% vs. 55.3%; p = 0.521, 60% vs. 50%; p = 0.361, respectively; weighted analysis: 62.7% vs. 61.1%; p = 0.877, 66% vs. 45.7%; p = 0.062, respectively). However, more arterial dissections were observed in the distal group (8.9%, n = 4 vs. 2.6%, n = 1; p = 0.36). In the distal group, one patient with vascular injury died due to complications. No cases of emboli in new territory were observed. Conclusions Distal tip position of the distal access catheter has a significant impact on reperfusion in patients with acute ischemic stroke. However, there was also a higher rate of vascular injury as the catheter was advanced further. If advancement to the target lesion is too difficult, placing it in the cavernous internal carotid artery may be a viable method without complications.
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Affiliation(s)
- Sang Hun Baek
- Department of Radiology, Busan Regional Cardio-Cerebrovascular Disease Center, Dong-A University Hospital, Busan, Republic of Korea
| | - Sanghyeon Kim
- Department of Radiology, Busan Regional Cardio-Cerebrovascular Disease Center, Dong-A University Hospital, Busan, Republic of Korea
- * E-mail:
| | - Myongjin Kang
- Department of Radiology, Busan Regional Cardio-Cerebrovascular Disease Center, Dong-A University Hospital, Busan, Republic of Korea
| | - Jae-Hyung Choi
- Department of Neurosurgery, Busan Regional Cardio-Cerebrovascular Disease Center, Dong-A University Hospital, Busan, Republic of Korea
| | - Hee Jin Kwon
- Department of Radiology, Busan Regional Cardio-Cerebrovascular Disease Center, Dong-A University Hospital, Busan, Republic of Korea
| | - Dong Won Kim
- Department of Radiology, Busan Regional Cardio-Cerebrovascular Disease Center, Dong-A University Hospital, Busan, Republic of Korea
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Dmytriw AA, Ha W, Bickford S, Bhatia K, Shroff M, Dirks P, Muthusami P. Long Vascular Sheaths for Transfemoral Neuroendovascular Procedures in Children. Neurointervention 2021; 16:149-157. [PMID: 34078026 PMCID: PMC8261116 DOI: 10.5469/neuroint.2021.00192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 05/21/2021] [Indexed: 11/24/2022] Open
Abstract
PURPOSE To evaluate the safety and efficacy of long vascular sheaths for transfemoral neuroendovascular procedures in children. MATERIALS AND METHODS A retrospective evaluation of transfemoral neuroendovascular procedures in children <18 years, using long sheaths was undertaken analyzing procedure type, fluoroscopic times, technical success, access site and systemic complications. Twenty-seven consecutive procedures were included over a 2-year period. Mean age was 8.4 years (standard deviation [SD] 6.3) (range 17.0 months-16.3 years). RESULTS Patients were 44% female and mean weight was 35.0 kg (SD 22.8) (range 9.8-72.2 kg). A third of the procedures were performed in ≤15 kg children. The most common procedure was for embolization (n=13, 48.1%) and the most common indication was dual microcatheter technique (52%). The most common device used was the 5 Fr Cook Shuttle sheath. Mean fluoroscopy time was 61.9 minutes (SD 43.1). Of these procedures, 93% were technically successful. Femoral vasospasm, when present, was self-limiting. Complications (3/27, 11.1%) included groin hematoma (n=1), neck vessel spasm that resolved with verapamil (n=1), and intracranial thromboembolism (n=1), with no significant difference between the ≤15 kg and >15 kg subcohorts. There were no aorto-femoro-iliac or limb-ischemic complications. CONCLUSION Long vascular sheaths without short femoral sheaths can be safely used for pediatric neuroendovascular procedures as they effectively increase inner diameter access without increasing the outer sheath diameter. This property increases the range of devices used and intracranial techniques that can be safely performed without arterial compromise, thus increasing the repertoire of the neurointerventionist.
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Affiliation(s)
- Adam A Dmytriw
- Neuroradiology and Image Guided Therapy, Hospital for Sick Children, Toronto, ON, Canada
| | - Winston Ha
- Neuroradiology and Image Guided Therapy, Hospital for Sick Children, Toronto, ON, Canada
| | - Suzanne Bickford
- Neuroradiology and Image Guided Therapy, Hospital for Sick Children, Toronto, ON, Canada
| | - Kartik Bhatia
- Neuroradiology and Image Guided Therapy, Hospital for Sick Children, Toronto, ON, Canada
| | - Manohar Shroff
- Neuroradiology and Image Guided Therapy, Hospital for Sick Children, Toronto, ON, Canada
| | - Peter Dirks
- Department of Neurosurgery, Hospital for Sick Children, Toronto, ON, Canada
| | - Prakash Muthusami
- Neuroradiology and Image Guided Therapy, Hospital for Sick Children, Toronto, ON, Canada
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Paccione E, Ionita CN. Challenges in hemodynamics assessment in complex neurovascular geometries using computational fluid dynamics and benchtop flow simulation in 3D printed patient specific phantoms. PROCEEDINGS OF SPIE--THE INTERNATIONAL SOCIETY FOR OPTICAL ENGINEERING 2021; 11600. [PMID: 33814673 DOI: 10.1117/12.2582169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Purpose Complex hemodynamics assessments, as those related to carotid stenosis, are not always easily straightforward due to multifaceted challenges presented by the collateral flow in the Circle of Willis (CoW) and brain flow autoregulation. Advanced computational and benchtop methods to investigate hemodynamics aspects related to such complex flows are often used, however both have limitations and could lead to results which may diverge. In this study we investigated these aspects by performing correlated computational fluid dynamics (CFD) simulations and benchtop experiments in patient specific 3D printed phantoms. Materials and Methods To investigate the flow in patients with carotid stenosis, we built two patient specific phantoms which contained the arterial lesion of interest, all main arteries leading to the brain, the CoW and main arteries branching from it. Each phantom was connected to a generic aortic arch. A programmable pump was connected and flow parameters were measured proximal and distal to the lesion and the contralateral arteries. The patient 3D geometry was used to perform a set of CFD simulations where inflow boundary conditions matched the experimental ones. Flow conditions were recorded at the same locations as the experimental setup. Further exploration into the translation from experimental to CFD was also performed by customizing vascular segmentation and physically manipulating arterial compliance properties. Results We initially observed significant differences between the CFD recordings and the experimental setup. Most of the differences were due to changes in phantom geometry when subjected to physiological pressures and simplistic outflow boundary conditions in the CFD simulations which do not account for pulsatility and nonlinear phenomena. Further work confirms the need for dynamic mesh behavior within CFD simulations attempting to computationally mimic 3D-printed benchtop experiments. Additionally, CFD simulation may benefit from considering geometry specific to a 3D-printed vascular phantom.
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Affiliation(s)
- Eric Paccione
- University Dept. of Biomedical Engineering, University at Buffalo, Buffalo, NY
| | - Ciprian N Ionita
- University Dept. of Biomedical Engineering, University at Buffalo, Buffalo, NY.,Canon Stroke and Vascular Research Center, Buffalo, NY
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Reddy AS, Liu Y, Cockrum J, Gebrezgiabhier D, Davis E, Zheng Y, Pandey AS, Shih AJ, Savastano LE. Construction of a comprehensive endovascular test bed for research and device development in mechanical thrombectomy in stroke. J Neurosurg 2021; 134:1190-1197. [PMID: 32244204 DOI: 10.3171/2020.1.jns192732] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 01/28/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The development of new endovascular technologies and techniques for mechanical thrombectomy in stroke has greatly relied on benchtop simulators. This paper presents an affordable, versatile, and realistic benchtop simulation model for stroke. METHODS A test bed for embolic occlusion of cerebrovascular arteries and mechanical thrombectomy was developed with 3D-printed and commercially available cerebrovascular phantoms, a customized hydraulic system to generate physiological flow rate and pressure, and 2 types of embolus analogs (elastic and fragment-prone) capable of causing embolic occlusions under physiological flow. RESULTS The test bed was highly versatile and allowed realistic, radiation-free mechanical thrombectomy for stroke due to large-vessel occlusion with rapid exchange of geometries and phantom types. Of the transparent cerebrovascular phantoms tested, the 3D-printed phantom was the easiest to manufacture, the glass model offered the best visibility of the interaction between embolus and thrombectomy device, and the flexible model most accurately mimicked the endovascular system during device navigation. None of the phantoms modeled branches smaller than 1 mm or perforating arteries, and none underwent realistic deformation or luminal collapse from device manipulation or vacuum. The hydraulic system created physiological flow rate and pressure leading to iatrogenic embolization during thrombectomy in all phantoms. Embolus analogs with known fabrication technique, structure, and tensile strength were introduced and consistently occluded the middle cerebral artery bifurcation under physiological flow, and their interaction with the device was accurately visualized. CONCLUSIONS The test bed presented in this study is a low-cost, comprehensive, realistic, and versatile platform that enabled high-quality analysis of embolus-device interaction in multiple cerebrovascular phantoms and embolus analogs.
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Affiliation(s)
| | - Yang Liu
- 2Mechanical Engineering, University of Michigan, Ann Arbor, Michigan
| | | | | | - Evan Davis
- 2Mechanical Engineering, University of Michigan, Ann Arbor, Michigan
| | - Yihao Zheng
- 3Department of Mechanical Engineering, Worcester Polytechnic Institute, Worcester, Massachusetts; and
| | | | - Albert J Shih
- 2Mechanical Engineering, University of Michigan, Ann Arbor, Michigan
| | - Luis E Savastano
- Departments of1Neurosurgery and
- 4Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
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Sommer KN, Bhurwani MMS, Mokin M, Ionita CN. Evaluation of challenges and limitations of mechanical thrombectomy using 3D printed neurovascular phantoms. PROCEEDINGS OF SPIE--THE INTERNATIONAL SOCIETY FOR OPTICAL ENGINEERING 2021; 11601:116010B. [PMID: 34334874 PMCID: PMC8323489 DOI: 10.1117/12.2580962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The mechanical thrombectomy (MT) efficacy, for large vessel occlusion (LVO) treatment in patients with stroke, could be improved if better teaching and practicing surgical tools were available. We propose a novel approach that uses 3D printing (3DP) to generate patient anatomical vascular variants for simulation of diverse clinical scenarios of LVO treated with MT. 3DP phantoms were connected to a flow loop with physiologically relevant flow conditions, including input flow rate and fluid temperature. A simulated blood clot was introduced into the model and placed in the Middle Cerebral Artery region. Clot location, composition (hard or soft clot), length, and arterial angulation were varied and MTs were simulated using stent retrievers. Device placement relative to the clot and the outcome of the thrombectomy were recorded for each situation. Angiograms were captured before and after LVO simulation and after the MT. Recanalization outcome was evaluated using the Thrombolysis in Cerebral Infarction (TICI) scale. Forty-two 3DP neurovascular phantom benchtop experiments were performed. Clot mechanical properties, hard versus soft, had the highest impact on the MT outcome, with 18/42 proving to be successful with full or partial clot retrieval. Other factors such as device manufacturer and the tortuosity of the 3DP model correlated weakly with the MT outcome. We demonstrated that 3DP can become a comprehensive tool for teaching and practicing various surgical procedures for MT in LVO patients. This platform can help vascular surgeons understand the endovascular devices limitations and patient vascular geometry challenges, to allow surgical approach optimization.
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Affiliation(s)
- Kelsey N Sommer
- Department of Biomedical Engineering, University at Buffalo NY 14228,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo NY 14208
| | - Mohammad Mahdi Shiraz Bhurwani
- Department of Biomedical Engineering, University at Buffalo NY 14228,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo NY 14208
| | - Maxim Mokin
- Department of Neurosurgery, University of South Florida, Tampa, Florida 33620
| | - Ciprian N Ionita
- Department of Biomedical Engineering, University at Buffalo NY 14228,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo NY 14208
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23
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Waqas M, Mokin M, Lim J, Vakharia K, Springer ME, Meess KM, Ducharme RW, Ionita CN, Nagesh SVS, Gutierrez LC, Snyder KV, Davies JM, Levy EI, Siddiqui AH. Design and Physical Properties of 3-Dimensional Printed Models Used for Neurointervention: A Systematic Review of the Literature. Neurosurgery 2021; 87:E445-E453. [PMID: 32392300 DOI: 10.1093/neuros/nyaa134] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 03/11/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Three-dimensional (3D) printing has revolutionized training, education, and device testing. Understanding the design and physical properties of 3D-printed models is important. OBJECTIVE To systematically review the design, physical properties, accuracy, and experimental outcomes of 3D-printed vascular models used in neurointervention. METHODS We conducted a systematic review of the literature between January 1, 2000 and September 30, 2018. Public/Publisher MEDLINE (PubMed), Web of Science, Compendex, Cochrane, and Inspec databases were searched using Medical Subject Heading terms for design and physical attributes of 3D-printed models for neurointervention. Information on design and physical properties like compliance, lubricity, flow system, accuracy, and outcome measures were collected. RESULTS A total of 23 articles were included. Nine studies described 3D-printed models for stroke intervention. Tango Plus (Stratasys) was the most common material used to develop these models. Four studies described a population-representative geometry model. All other studies reported patient-specific vascular geometry. Eight studies reported complete reconstruction of the circle of Willis, anterior, and posterior circulation. Four studies reported a model with extracranial vasculature. One prototype study reported compliance and lubricity. Reported circulation systems included manual flushing, programmable pistons, peristaltic, and pulsatile pumps. Outcomes included thrombolysis in cerebral infarction, post-thrombectomy flow restoration, surgical performance, and qualitative feedback. CONCLUSION Variations exist in the material, design, and extent of reconstruction of vasculature of 3D-printed models. There is a need for objective characterization of 3D-printed vascular models. We propose the development of population representative 3D-printed models for skill improvement or device testing.
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Affiliation(s)
- Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Maxim Mokin
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida
| | - Jaims Lim
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Kunal Vakharia
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | | | | | | | - Ciprian N Ionita
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York
| | - Swetadri Vasan Setlur Nagesh
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York
| | - Liza C Gutierrez
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York
| | - Kenneth V Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Jason M Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Jacobs Institute, Buffalo, New York.,Department of Bioinformatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Jacobs Institute, Buffalo, New York.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Jacobs Institute, Buffalo, New York.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
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24
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Scullen T, Nerva JD, Amenta PS, Dumont AS. Commentary: Design and Physical Properties of 3-Dimensional Printed Models Used for Neurointervention: A Systematic Review of the Literature. Neurosurgery 2020; 87:E454-E455. [PMID: 32453826 DOI: 10.1093/neuros/nyaa217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 03/28/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Tyler Scullen
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
| | - John D Nerva
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
| | - Peter S Amenta
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
| | - Aaron S Dumont
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
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25
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Boisseau W, Escalard S, Fahed R, Lapergue B, Smajda S, Maier B, Desilles JP, Delvoye F, Ciccio G, Redjem H, Hebert S, Ben Maacha M, Walker G, Gory B, Richard S, Mazighi M, Piotin M, Blanc R. Direct aspiration stroke thrombectomy: a comprehensive review. J Neurointerv Surg 2020; 12:1099-1106. [PMID: 32532857 DOI: 10.1136/neurintsurg-2019-015508] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/22/2020] [Accepted: 04/29/2020] [Indexed: 01/22/2023]
Abstract
Mechanical thrombectomy is now the standard of care for acute ischemic stroke patients with large vessel occlusions, and can be performed with several devices and techniques. One of these techniques, direct aspiration (DA), consists of navigating a large-bore catheter up to the face of the clot and initiating forceful suction. This comprehensive review has three objectives: (1) to describe the direct aspiration technique; (2) to present the available evidence regarding predictive factors of DA success and performance compared with other techniques; and (3) to discuss the forthcoming improvements in distal aspiration.
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Affiliation(s)
- William Boisseau
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France
| | - Simon Escalard
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France
| | - Robert Fahed
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France.,Department of Medicine - Division of Neurology, Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - Stanislas Smajda
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France
| | - Benjamin Maier
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France.,Université de Paris, Paris, Île-de-France, France
| | - Jean Philippe Desilles
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France.,Université de Paris, Paris, Île-de-France, France
| | - François Delvoye
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France
| | - Gabriele Ciccio
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France
| | - Hocine Redjem
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France
| | - Solène Hebert
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France
| | - Malek Ben Maacha
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France
| | - Gregory Walker
- Department of Medicine - Division of Neurology, Ottawa Hospital, Ottawa, Ontario, Canada.,Department of Medicine - Division of Neurology, Royal Columbian Hospital, New Westminster, British Columbia, Canada
| | - Benjamin Gory
- Diagnostic and Interventional Neuroradiology, Centre Hospitalier Universitaire de Nancy, Nancy, France
| | - Sébastien Richard
- Neurology Stroke Unit, University Hospital Centre Nancy, Nancy, France
| | - Mikael Mazighi
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France.,Université de Paris, Paris, Île-de-France, France
| | - Michel Piotin
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France.,Université de Paris, Paris, Île-de-France, France
| | - Raphaël Blanc
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France .,Université de Paris, Paris, Île-de-France, France
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26
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Soize S, Pierot L, Mirza M, Gunning G, Gilvarry M, Gawlitza M, Vivien D, Zuber M, Touzé E. Fast Stent Retrieval Improves Recanalization Rates of Thrombectomy: Experimental Study on Different Thrombi. AJNR Am J Neuroradiol 2020; 41:1049-1053. [PMID: 32409312 DOI: 10.3174/ajnr.a6559] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 03/02/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE About 20% of patients with acute ischemic stroke due to large-artery occlusion do not achieve recanalization with mechanical thrombectomy. We aimed to determine whether the speed of retrieval of the stent retriever influences the efficacy in removing different clot types. MATERIALS AND METHODS Sixty mechanical thrombectomies were performed using an in vitro pulsatile cerebrovascular circulation model with controlled pressure and flow rate. Experiments were dichotomized into fast and slow retrieval using a wedging technique, in which the stent retriever and distal catheter are retrieved together. We used 3 different clot types: erythrocyte-rich, fibrin-rich, and friable clots. Primary end points were complete (TICI 3) and successful (TICI 2b-3) recanalizations. Secondary measures were distal and new territory embolizations. RESULTS Fast retrieval was more frequently associated with complete (RR = 1.83; 95% CI, 1.12-2.99) and successful recanalization (RR = 1.50; 95% CI, 1.03-2.19) than slow retrieval, without a difference in distal embolization (RR = 0.75; 95% CI, 0.29-1.90). There were no emboli in a new territory. The advantage of fast retrieval over slow retrieval differed according to the clot composition, with a stronger effect with fibrin-rich clots with regard to complete (RR = 4.00; 95% CI, 1.11-14.35; Pint = .04) and successful (Pint = .10) recanalization. CONCLUSIONS In our experimental model, a fast removal improved recanalization rates of mechanical thrombectomy, especially in the case of fibrin-rich clots. An in vivo confirmation is warranted to see whether our findings can have an impact in clinical practice.
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Affiliation(s)
- S Soize
- From the Department of Neuroradiology (S.S., L.P., M. Gawlitza), Hôpital Maison Blanche, Champagne-Ardenne University, Reims, France .,Unité Mixte de Recherche (UMR)-S 1237 Physiopathology and Imaging of Neurological Disorders (S.S., D.V., E.T.), National Institute for Health and Medical Research, Normandie University, Université Caen Normandie, Cyceron, Caen, France
| | - L Pierot
- From the Department of Neuroradiology (S.S., L.P., M. Gawlitza), Hôpital Maison Blanche, Champagne-Ardenne University, Reims, France
| | - M Mirza
- Neuravi/Cerenovus (M.M., G.G., M. Gilvarry), Galway, Ireland
| | - G Gunning
- Neuravi/Cerenovus (M.M., G.G., M. Gilvarry), Galway, Ireland
| | - M Gilvarry
- Neuravi/Cerenovus (M.M., G.G., M. Gilvarry), Galway, Ireland
| | - M Gawlitza
- From the Department of Neuroradiology (S.S., L.P., M. Gawlitza), Hôpital Maison Blanche, Champagne-Ardenne University, Reims, France
| | - D Vivien
- Unité Mixte de Recherche (UMR)-S 1237 Physiopathology and Imaging of Neurological Disorders (S.S., D.V., E.T.), National Institute for Health and Medical Research, Normandie University, Université Caen Normandie, Cyceron, Caen, France
| | - M Zuber
- Department of Neurology (M.Z.), Hôpital Saint-Joseph, Paris Descartes University, Paris, France
| | - E Touzé
- Unité Mixte de Recherche (UMR)-S 1237 Physiopathology and Imaging of Neurological Disorders (S.S., D.V., E.T.), National Institute for Health and Medical Research, Normandie University, Université Caen Normandie, Cyceron, Caen, France
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27
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Chueh JY, Kang DH, Kim BM, Gounis MJ. Role of Balloon Guide Catheter in Modern Endovascular Thrombectomy. J Korean Neurosurg Soc 2019; 63:14-25. [PMID: 31591997 PMCID: PMC6952736 DOI: 10.3340/jkns.2019.0114] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 06/21/2019] [Indexed: 01/09/2023] Open
Abstract
Proximal flow control achieved with a balloon guide catheter (BGC) during endovascular treatment of acute ischemic stroke is reviewed in this article. In clinical practice, BGCs offer a multi-faceted approach for clot retrieval by creating proximal flow arrest, reducing embolic burden, and shortening procedure time. Evaluation of frontline thrombectomy procedures with BGCs revealed advantages of combined use over the conventional guide catheter (CGC), notably in the significant reduction of distal emboli to both the affected and previously unaffected territories. Recently, new measures of early and complete reperfusion at first thrombectomy pass have been identified as independent predictors of improved outcomes, which were consistently demonstrated with use of BGC as a safe and effective option to minimize number of passes during intervention. Prior randomized controlled trials reported the positive correlation between BGC-treated patients and a lower risk of mortality as well as shortened procedure time. While BGC use is more common in stent retriever-mediated mechanical thrombectomy, preliminary data has shown the potential benefit of device application during contact aspiration thrombectomy to achieve successful recanalization. However, the question of which major endovascular strategy reigns superior as a frontline remains to be answered. Along with clinical case assessments, BGC performance during in-vitro simulation was analyzed to further understand mechanisms for optimization of thrombectomy technique.
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Affiliation(s)
- Ju-Yu Chueh
- Department of Radiology, New England Center for Stroke Research, University of Massachusetts Medical School, Worcester, MA, USA
| | - Dong-Hun Kang
- Department of Neurosurgery and Radiology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Byung Moon Kim
- Department of Radiology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Matthew J Gounis
- Department of Radiology, New England Center for Stroke Research, University of Massachusetts Medical School, Worcester, MA, USA
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28
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Bernava G, Rosi A, Boto J, Brina O, Kulcsar Z, Czarnetzki C, Carrera E, Schaller K, Lovblad KO, Machi P. Direct thromboaspiration efficacy for mechanical thrombectomy is related to the angle of interaction between the aspiration catheter and the clot. J Neurointerv Surg 2019; 12:396-400. [PMID: 31548213 PMCID: PMC7146918 DOI: 10.1136/neurintsurg-2019-015113] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 08/23/2019] [Accepted: 08/27/2019] [Indexed: 12/13/2022]
Abstract
Background Direct thromboaspiration has been reported as an effective mechanical treatment for acute ischemic stroke. We aimed to determine whether the angle of interaction between the aspiration catheter and the clot affects the success of clot removal in ischemic stroke patients with large vessel occlusion in the anterior and posterior circulation. Methods All patients treated at our institution by direct thromboaspiration as a firstline technique between January 2016 and December 2017 were enrolled in the study. We retrospectively reviewed baseline and procedural characteristics, the angle of interaction formed between the aspiration catheter and the clot, the modified Thrombolysis in Cerebral Infarction score, and the 3 month modified Rankin Scale score. Results 85 patients underwent direct thromboaspiration as the firstline treatment during the study period. 100 direct thromboaspiration passes were performed. An angle of interaction of ≥125.5° significantly influenced the success of clot removal (P<0.001) with good sensitivity and specificity, in particular for occlusion of the middle cerebral and basilar artery. The combination of aspiration with a stent retriever based thrombectomy was a valid rescue treatment in cases of standalone direct thromboaspiration failure. Conclusions In our series, an angle of interaction between the aspiration catheter and the clot of ≥125.5° was significantly associated with successful clot removal. The prediction of the angle of interaction on pretreatment imaging may help operators to select the most adequate mechanical thrombectomy technique on a case by case basis.
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Affiliation(s)
| | - Andrea Rosi
- Neuroradiology, University Hospitals of Geneva, Geneva, Switzerland
| | - José Boto
- Neuroradiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Olivier Brina
- Neuroradiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Zsolt Kulcsar
- Neuroradiology, University Hospitals of Zurich, Zurich, Switzerland
| | | | | | - Karl Schaller
- Neurosurgery, University Hospitals of Geneva, Geneva, Switzerland
| | | | - Paolo Machi
- Neuroradiology, University Hospitals of Geneva, Geneva, Switzerland
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29
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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; 28:2574-2579. [PMID: 31239220 DOI: 10.1016/j.jstrokecerebrovasdis.2019.05.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 04/14/2019] [Accepted: 05/14/2019] [Indexed: 11/24/2022] Open
Abstract
GOALS While mechanical thrombectomy (MT) has been shown to be effective in the treatment of acute large vessel occlusions, adjunctive measures, such as balloon guide catheters (BGC) and aspiration techniques, are utilized heterogeneously. Clarifying the effects of aspiration applied to the anterior cerebral circulation with proximal flow arrest can shed light on embolic protection during MT. MATERIALS AND METHODS Manual and pump aspiration were applied through a BGC in a synthetic cerebrovascular model with a 60 ml syringe and a Penumbra pump, respectively. Flow direction was observed during the procedure with fluorescent particles and ultraviolet light. Flow rates were monitored at the simulated internal carotid artery and middle cerebral artery (MCA). FINDINGS Both aspiration methods produced retrograde flow in all the modeled cerebrovascular segments. In the syringe aspiration methods, an interval phase occurred during the experimental trial in which suction forces paused and MCA flow became anterograde through posterior communication artery collateral circulation. CONCLUSION Flow patterns vary with different methods of aspiration. With proximal flow arrest, continuous aspiration methods induce constant retrograde flow in all vessels, whereas manual aspiration demonstrates various flow changes, including periods of anterograde flow during the procedure, which may be less effective at distal re-embolization prevention.
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Affiliation(s)
- Hideo Okada
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois; Department of Neurosurgery, Wakayama Rosai Hospital, Wakayama City, Japan.
| | - Yoshikazu Matsuda
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois; Department of Neurosurgery, Wakayama Rosai Hospital, Wakayama City, Japan.
| | - Alex Malisch
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois.
| | - Joonho Chung
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois; Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; Severance Institute for Vascular and Metabolic Research, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Daniel M Heiferman
- Department of Neurological Surgery, Loyola University Stritch School of Medicine, Maywood, Illinois.
| | - Demetrius K Lopes
- Department of Neurological Surgery, Advocate Health, Park Ridge, Illinois.
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30
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Girdhar G, Epstein E, Nguyen K, Gregg C, Kumar T, Wainwright J, Liu AY, Linfante I. Longer 6-mm Diameter Stent Retrievers Are Effective for Achieving Higher First Pass Success with Fibrin-Rich Clots. INTERVENTIONAL NEUROLOGY 2019; 8:187-195. [PMID: 32508901 DOI: 10.1159/000499974] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 03/28/2019] [Indexed: 11/19/2022]
Abstract
First pass success (FPS) can be defined as in vitro retrieval of clot in a single pass during mechanical thrombectomy (MT) for acute large vessel occlusion (LVO). Despite advancements in MT technology, retrieval of fibrin-rich clots remains a challenge. Therefore, the effect of stent retriever length on FPS for fibrin-rich clots was investigated by using SolitaireTM 6 × 40 versus 6 × 30 mm devices with a balloon guide catheter (BGC) or distal access catheter (DAC) and sheath, in an in vitro model of anterior circulation neurovascular anatomy. Additionally, vascular safety of the SolitaireTM 6 × 40 versus 6 × 30 mm devices was evaluated in a porcine model for differences in: luminal thrombus, inflammation, endothelial coverage, fibrin deposits, smooth muscle cell loss, elastic lamina and adventitia disruption, intimal hyperplasia, and lumen reduction, at 0, 30, and 90 days post-treatment. In vitro overall FPS was measured as: SolitaireTM 6 × 40 (95%) and SolitaireTM 6 × 30 (67%). FPS for clot location in middle cerebral artery was: (a) BGC (6 × 40 mm: 100%; 6 × 30 mm: 100%; n = 8); (b) DAC with 088 sheath (6 × 40 mm: 83%; 6 × 30 mm: 33%; n = 12). FPS for clot location in internal carotid artery was: (a) BGC (6 × 40 mm: 100%; 6 × 30 mm: 80%; n = 11); (b) DAC with 088 sheath (6 × 40 mm: 100%; 6 × 30 mm: 67%; n = 10). Stent length had a significant effect (Fisher's exact test; p < 0.05) on FPS. In vivo evaluation in the porcine model showed no difference in vascular safety parameters between the SolitaireTM 6 × 40 and 6 × 30 mm devices (p > 0.05) at all time points in the study. Longer stent retrievers may be safe and effective in improving FPS for fibrin-rich clots in in vitro and in vivo models of LVO.
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Affiliation(s)
- Gaurav Girdhar
- Department of R&D, Neurovascular, Medtronic, Irvine, California, USA
| | - Evan Epstein
- Department of R&D, Neurovascular, Medtronic, Irvine, California, USA
| | - Kevin Nguyen
- Department of R&D, Neurovascular, Medtronic, Irvine, California, USA
| | - Chelsea Gregg
- Department of R&D, Neurovascular, Medtronic, Irvine, California, USA
| | - Tejashri Kumar
- Department of R&D, Neurovascular, Medtronic, Irvine, California, USA
| | - John Wainwright
- Department of R&D, Neurovascular, Medtronic, Irvine, California, USA
| | - Amon Y Liu
- AYL Consulting LLC, Redwood City, California, USA
| | - Italo Linfante
- Interventional Neuroradiology and Endovascular Neurosurgery, Miami Cardiac and Vascular Institute, Baptist Hospital, Miami, Florida, USA
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31
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Jeong DE, Kim JW, Kim BM, Hwang W, Kim DJ. Impact of Balloon-Guiding Catheter Location on Recanalization in Patients with Acute Stroke Treated by Mechanical Thrombectomy. AJNR Am J Neuroradiol 2019; 40:840-844. [PMID: 30948374 DOI: 10.3174/ajnr.a6031] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 03/07/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Mechanical thrombectomy with proximal flow control and forced aspiration may improve the outcome of endovascular revascularization therapy for patients with acute stroke. The purpose of this study was to compare the impact of balloon-guiding catheter locations in patients treated for anterior circulation acute ischemic stroke using mechanical thrombectomy. MATERIALS AND METHODS The influence of the balloon-guiding catheter location (proximal, balloon-guiding catheter tip proximal to C1 vertebral body; distal, between the skull base and the C1 vertebral body) was analyzed in patients with acute anterior circulation stroke treated with stent-retriever thrombectomy. The baseline angiographic/clinical characteristics, time intervals, recanalization rates, and clinical outcomes were compared. RESULTS The clinical analysis included 102 patients (mean age, 69.5 ± 12.8 years; male/female ratio = 52:50). The balloon-guiding catheter was located distally in 49 patients and proximally in 53 patients for flow control and forced aspiration during stent retrieval. The puncture-to-recanalization time was shorter in the distal group than in the proximal group (40 versus 56 minutes, P = .02). Successful and complete recanalizations were more frequently achieved in the distal group compared with the proximal group (98.0% versus 75.5%. P = .003; 67.3% versus 45.3%, P = .04, respectively). Multivariate analysis showed that the distal catheterization location was independently associated with successful recanalization (adjusted OR, 13.4; 95% CI, 2.4-254.8; P = .02). CONCLUSIONS Location of the balloon-guiding catheter has a significant impact on recanalization in patients with acute stroke. The balloon-guiding catheter should be positioned as distally as safely possible in the cervical ICA for maximally effective thrombectomy.
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Affiliation(s)
- D E Jeong
- From the Department of Radiology (D.E.J., J.W.K., B.M.K., D.J.K.), Yonsei University College of Medicine, Severance Hospital, Seoul, South Korea
- Department of Neurology (D.E.J.), YeongNam University College of Medicine, Daegu, South Korea
| | - J W Kim
- From the Department of Radiology (D.E.J., J.W.K., B.M.K., D.J.K.), Yonsei University College of Medicine, Severance Hospital, Seoul, South Korea
| | - B M Kim
- From the Department of Radiology (D.E.J., J.W.K., B.M.K., D.J.K.), Yonsei University College of Medicine, Severance Hospital, Seoul, South Korea
| | - W Hwang
- Department of Mechanical and Aerospace Engineering (W.H.), Seoul National University, Seoul, South Korea
| | - D J Kim
- From the Department of Radiology (D.E.J., J.W.K., B.M.K., D.J.K.), Yonsei University College of Medicine, Severance Hospital, Seoul, South Korea
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Zaidat OO, Mueller-Kronast NH, Hassan AE, Haussen DC, Jadhav AP, Froehler MT, Jahan R, Ali Aziz-Sultan M, Klucznik RP, Saver JL, Hellinger FR, Yavagal DR, Yao TL, Gupta R, Martin CO, Bozorgchami H, Kaushal R, Nogueira RG, Gandhi RH, Peterson EC, Dashti S, Given CA, Mehta BP, Deshmukh V, Starkman S, Linfante I, McPherson SH, Kvamme P, Grobelny TJ, Hussain MS, Thacker I, Vora N, Chen PR, Monteith SJ, Ecker RD, Schirmer CM, Sauvageau E, Chebl AB, Derdeyn CP, Maidan L, Badruddin A, Siddiqui AH, Dumont TM, Alhajeri A, Taqi MA, Asi K, Carpenter J, Boulos A, Jindal G, Puri AS, Chitale R, Deshaies EM, Robinson D, Kallmes DF, Baxter BW, Jumaa M, Sunenshine P, Majjhoo A, English JD, Suzuki S, Fessler RD, Delgado-Almandoz J, Martin JC, Liebeskind DS. Impact of Balloon Guide Catheter Use on Clinical and Angiographic Outcomes in the STRATIS Stroke Thrombectomy Registry. Stroke 2019; 50:697-704. [DOI: 10.1161/strokeaha.118.021126] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Osama O. Zaidat
- From the Mercy Health St. Vincent Mercy Hospital, Toledo, OH (O.O.Z.)
| | | | | | - Diogo C. Haussen
- Emory University School of Medicine, Atlanta, GA (D.C.H.)
- Grady Memorial Hospital, Atlanta, GA (D.C.H., R.G.N.)
| | | | | | - Reza Jahan
- University of California, Los Angeles, CA (R.J., J.L.S., S.S., D.S.L.)
| | | | | | - Jeffrey L. Saver
- University of California, Los Angeles, CA (R.J., J.L.S., S.S., D.S.L.)
| | | | - Dileep R. Yavagal
- University of Miami Miller School of Medicine/Jackson Memorial Hospital, FL (D.R.Y., E.C.P.)
| | - Tom L. Yao
- Norton Neuroscience Institute, Norton Healthcare, Louisville, KY (T.L.Y., S.D.)
| | - Rishi Gupta
- WellStar Neurosciences Network, WellStar Kennestone Regional Medical Center, Marietta, GA (R.G.)
| | | | | | - Ritesh Kaushal
- Advanced Neuroscience Network/Tenet South Florida, Coral Springs (N.H.M.-K., R.K.)
| | | | - Ravi H. Gandhi
- Florida Hospital Neuroscience Institute, Winter Park (F.R.H., R.H.G.)
| | - Eric C. Peterson
- University of Miami Miller School of Medicine/Jackson Memorial Hospital, FL (D.R.Y., E.C.P.)
| | - Shervin Dashti
- Norton Neuroscience Institute, Norton Healthcare, Louisville, KY (T.L.Y., S.D.)
| | | | | | - Vivek Deshmukh
- Providence St. Vincent Medical Center, Portland, OR (V.D.)
| | - Sidney Starkman
- University of California, Los Angeles, CA (R.J., J.L.S., S.S., D.S.L.)
| | | | | | - Peter Kvamme
- University of Tennessee Medical Center, Knoxville (P.K.)
| | | | | | - Ike Thacker
- Baylor University Medical Center, Dallas, TX (I.T.)
| | - Nirav Vora
- OhioHealth Riverside Methodist Hospital, Columbus (N.V.)
| | - Peng Roc Chen
- Memorial Hermann Texas Medical Center, Houston (P.R.C.)
| | | | | | | | | | | | | | - Lucian Maidan
- Mercy San Juan Medical Center and Mercy General, Carmichael, CA (L.M.)
| | | | | | | | | | | | | | | | | | - Gaurav Jindal
- University of Maryland Medical Center, Baltimore (G.J.)
| | - Ajit S. Puri
- University of Massachusetts Memorial Medical Center, Worcester (A.S.P.)
| | - Rohan Chitale
- Vanderbilt University Medical Center, Nashville, TN (M.T.F., R.C.)
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Mokin M, Waqas M, Setlur Nagesh SV, Karkhanis NV, Levy EI, Ionita CN, Siddiqui AH. Assessment of distal access catheter performance during neuroendovascular procedures: measuring force in three-dimensional patient specific phantoms. J Neurointerv Surg 2018; 11:619-622. [PMID: 30514736 DOI: 10.1136/neurintsurg-2018-014468] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 11/09/2018] [Accepted: 11/14/2018] [Indexed: 01/03/2023]
Abstract
BACKGROUND The amount of force applied on a device is an important measure to evaluate the endovascular and surgical device manipulations. The measure has not been evaluated for neuroenodvascular procedures. PURPOSE We aimed to study the use of force measure as a novel approach to test distal access catheter (DAC) performance during catheterization of cervical and intracranial vessels using patient specific 3-dimentional (3D) phantoms. METHODS Using patient specific 3D phantoms of the cervical and intracranial circulation, we recorded measure of force required to deliver three types of DACs beyond the ophthalmic segment of the internal carotid artery. Six different combinations of DAC-microcatheter-guidewire were tested. We intentionally included what we considered suboptimal combinations of DACs, microcatheters, and guidewires during our experiments to test the feasibility of measuring force under different conditions. A six axis force sensor was secured to the DAC with an adjustable torque used to track axially directed push and pull forces required to navigate the DAC to the target site. RESULTS In a total of 55 experiments, we found a significant difference in the amount of force used between different DACs (mean force for DAC A, 1.887±0.531N; for DAC B, 2.153±1.280 N; and for DAC C, 1.194±0.521 N, P=0.007). There was also a significant difference in force measures among the six different catheter systems (P=0.035). CONCLUSIONS Significant difference in the amount of force used between different DACs and catheter systems were recorded. Use of force measure in neuroendovascular procedures on 3D printed phantoms is feasible.
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Affiliation(s)
- Maxim Mokin
- Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Swetadri Vasan Setlur Nagesh
- Canon Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Nitant Vivek Karkhanis
- Canon Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York, USA.,Department of Biomedical Engineering, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Ciprian N Ionita
- Canon Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York, USA.,Department of Biomedical Engineering, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA
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Qin C, Shang K, Xu SB, Wang W, Zhang Q, Tian DS. Efficacy and safety of direct aspiration versus stent-retriever for recanalization in acute cerebral infarction: A PRISMA-compliant systematic review and meta-analysis. Medicine (Baltimore) 2018; 97:e12770. [PMID: 30313091 PMCID: PMC6203566 DOI: 10.1097/md.0000000000012770] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 09/15/2018] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND AND PURPOSE Whether the direct aspiration approach of thrombectomy for recanalization in patients with acute ischemic stroke has a similar efficacy and safety compared to the stent-retriever remains uncertain. METHODS We conducted a meta-analysis of 9 studies obtained through PubMed and Embase database searches to determine whether successful recanalization rate, good functional outcome at 3 months (modified Rankin score, mRS≤2), procedure time from groin puncture to maximal revascularization and procedure-related adverse events differed between patients who underwent the direct aspiration and those receiving stent-retriever for recanalization in acute cerebral infarction. RESULTS There was no significant difference between the direct aspiration group and the stent-retriever group in rate of successful recanalization (summary odds ratio [OR], 0.86 [95% confidence interval (CI), 0.45-1.52]; P = .60), but a better functional outcomes in the direct aspiration group at 3 months defined as a mRS score of 0 to 2 (OR, 0.77; 95% CI, 0.66-0.97; P = .03). Furthermore, the direct aspiration patients compared with the stent-retriever patients had a tendency of shorter procedural time (Mean difference [MD], -8.77 [95% CI, from-18.90 to 1.37]; P = .09). Finally, there were less adverse events especially in symptomatic intracerebral hemorrhage (sICH) (OR, 0.56; 95% CI, 0.33-0.98; P = .04) and embolization to a new territory (ENT) (OR, 0.49; 95% CI, 0.28-0.84; P = .01) in the direct aspiration group when compared with the stent-retriever group, although no difference between them in the rate of any ICH (OR, 0.81; 95% CI, 0.41-1.60; P = .54). CONCLUSIONS The results support that the direct aspiration technique for those acute ischemic stroke patients may have better functional outcomes, less procedure related-adverse events and a tendency of faster revascularization time as compared to the stent-retriever thrombectomy, with a similar successful recanalization rate. However, major limitations of current evidence (mainly from retrospective and observational studies and a small number of patients population) indicate a need for adequately powered, multicenter randomized controlled trials (RCT) to answer this question.
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Teleb MS. Endovascular Acute Ischemic Stroke Treatment with FlowGate Balloon Guide Catheter: A Single-Center Observational Study of FlowGate Balloon Guide Catheter Use. INTERVENTIONAL NEUROLOGY 2018; 7:327-333. [PMID: 30410509 DOI: 10.1159/000488601] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Accepted: 03/19/2018] [Indexed: 11/19/2022]
Abstract
Background Treatment of large vessel occlusion acute ischemic stroke with mechanical thrombectomy has become the standard of care after recent clinical trials. However, the degree of recanalization with stent retrievers remains very important in overall outcomes. We sought to review the utility of a new balloon guide catheter (BGC) in improving the degree of recanalization in conjunction with mechanical thrombectomy. Methods The medical records of a prospectively collected endovascular ischemic stroke database were reviewed. All consecutive strokes when a FlowGate BGC was used with a thrombectomy stent retriever were identified. Use of a FlowGate BGC, number of passes, final Thrombolysis in Cerebral Infarction (TICI) score, trackability, and use of adjunct devices were all collected and analyzed. Results Use of a FlowGate BGC resulted in 64% (33/52) first-pass effect (FPE) of TICI 2b/3, and specifically 46% (24/52) TICI 3 FPE (true FPE). A total of 52/62 (84%) of thrombectomy cases were treated with BGCs. In the remaining 10, the BGC was not inflated or used due to the clot not being visualized or the lesions being distal and BGC use thus not deemed appropriate. Adjunct use of an aspiration catheter was seen in 12% (6/52) of cases. The overall success with FlowGate BGCs with one or more passes of TICI 2b/3 was 94% (49/52). Trackability was achieved in 92% (57/62) of cases. Conclusions Use of the FlowGate BGC as an adjunct to mechanical thrombectomy was associated with good FPE and an overall recanalization of TICI 2b/3 of 94%.
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Affiliation(s)
- Mohamed S Teleb
- Neurointerventional Surgery, Stroke, and Neurocritical Care, Banner Health, Mesa, Arizona, USA
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Sonig A, Setlur Nagesh SV, Fennell VS, Gandhi S, Rangel-Castilla L, Ionita CN, Snyder KV, Hopkins LN, Bednarek DR, Rudin S, Siddiqui AH, Levy EI. A Patient Dose-Reduction Technique for Neuroendovascular Image-Guided Interventions: Image-Quality Comparison Study. AJNR Am J Neuroradiol 2018; 39:734-741. [PMID: 29449282 DOI: 10.3174/ajnr.a5552] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 12/06/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The ROI-dose-reduced intervention technique represents an extension of ROI fluoroscopy combining x-ray entrance skin dose reduction with spatially different recursive temporal filtering to reduce excessive image noise in the dose-reduced periphery in real-time. The aim of our study was to compare the image quality of simulated neurointerventions with regular and reduced radiation doses using a standard flat panel detector system. MATERIALS AND METHODS Ten 3D-printed intracranial aneurysm models were generated on the basis of a single patient vasculature derived from intracranial DSA and CTA. The incident dose to each model was reduced using a 0.7-mm-thick copper attenuator with a circular ROI hole (10-mm diameter) in the middle mounted inside the Infinix C-arm. Each model was treated twice with a primary coiling intervention using ROI-dose-reduced intervention and regular-dose intervention protocols. Eighty images acquired at various intervention stages were shown twice to 2 neurointerventionalists who independently scored imaging qualities (visibility of aneurysm-parent vessel morphology, associated vessels, and/or devices used). Dose-reduction measurements were performed using an ionization chamber. RESULTS A total integral dose reduction of 62% per frame was achieved. The mean scores for regular-dose intervention and ROI dose-reduced intervention images did not differ significantly, suggesting similar image quality. Overall intrarater agreement for all scored criteria was substantial (Kendall τ = 0.62887; P < .001). Overall interrater agreement for all criteria was fair (κ = 0.2816; 95% CI, 0.2060-0.3571). CONCLUSIONS Substantial dose reduction (62%) with a live peripheral image was achieved without compromising feature visibility during neuroendovascular interventions.
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Affiliation(s)
- A Sonig
- From the Departments of Neurosurgery (A.S., V.S.F., L.R.-C., C.N.I., K.V.S., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Department of Neurosurgery (A.S., V.S.F., S.G., L.R.-C., K.V.S., L.N.H., S.R., A.H.S., E.I.L.), Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - S V Setlur Nagesh
- Toshiba Stroke and Vascular Research Center (S.V.S.N., C.N.I., L.N.H., D.R.B., S.R., A.H.S., E.I.L.)
| | - V S Fennell
- From the Departments of Neurosurgery (A.S., V.S.F., L.R.-C., C.N.I., K.V.S., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Department of Neurosurgery (A.S., V.S.F., S.G., L.R.-C., K.V.S., L.N.H., S.R., A.H.S., E.I.L.), Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - S Gandhi
- Neurology (S.G., K.V.S.), Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurosurgery (A.S., V.S.F., S.G., L.R.-C., K.V.S., L.N.H., S.R., A.H.S., E.I.L.), Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Buffalo Neuroimaging Analysis Center (S.G.), Buffalo, New York
| | - L Rangel-Castilla
- From the Departments of Neurosurgery (A.S., V.S.F., L.R.-C., C.N.I., K.V.S., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Department of Neurosurgery (A.S., V.S.F., S.G., L.R.-C., K.V.S., L.N.H., S.R., A.H.S., E.I.L.), Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - C N Ionita
- From the Departments of Neurosurgery (A.S., V.S.F., L.R.-C., C.N.I., K.V.S., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Toshiba Stroke and Vascular Research Center (S.V.S.N., C.N.I., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Department of Biomedical Engineering (C.N.I., S.R.)
| | - K V Snyder
- From the Departments of Neurosurgery (A.S., V.S.F., L.R.-C., C.N.I., K.V.S., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Radiology (K.V.S., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Neurology (S.G., K.V.S.), Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurosurgery (A.S., V.S.F., S.G., L.R.-C., K.V.S., L.N.H., S.R., A.H.S., E.I.L.), Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - L N Hopkins
- From the Departments of Neurosurgery (A.S., V.S.F., L.R.-C., C.N.I., K.V.S., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Radiology (K.V.S., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Department of Neurosurgery (A.S., V.S.F., S.G., L.R.-C., K.V.S., L.N.H., S.R., A.H.S., E.I.L.), Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Toshiba Stroke and Vascular Research Center (S.V.S.N., C.N.I., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Jacobs Institute (L.N.H., A.H.S.), Buffalo, New York
| | - D R Bednarek
- From the Departments of Neurosurgery (A.S., V.S.F., L.R.-C., C.N.I., K.V.S., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Radiology (K.V.S., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Toshiba Stroke and Vascular Research Center (S.V.S.N., C.N.I., L.N.H., D.R.B., S.R., A.H.S., E.I.L.)
| | - S Rudin
- From the Departments of Neurosurgery (A.S., V.S.F., L.R.-C., C.N.I., K.V.S., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Radiology (K.V.S., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Department of Neurosurgery (A.S., V.S.F., S.G., L.R.-C., K.V.S., L.N.H., S.R., A.H.S., E.I.L.), Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Toshiba Stroke and Vascular Research Center (S.V.S.N., C.N.I., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Department of Biomedical Engineering (C.N.I., S.R.).,Department of Mechanical and Aerospace Engineering (S.R.).,Department of Electrical Engineering (S.R.), University at Buffalo, State University of New York, Buffalo, New York
| | - A H Siddiqui
- From the Departments of Neurosurgery (A.S., V.S.F., L.R.-C., C.N.I., K.V.S., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Radiology (K.V.S., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Department of Neurosurgery (A.S., V.S.F., S.G., L.R.-C., K.V.S., L.N.H., S.R., A.H.S., E.I.L.), Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Toshiba Stroke and Vascular Research Center (S.V.S.N., C.N.I., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Jacobs Institute (L.N.H., A.H.S.), Buffalo, New York
| | - E I Levy
- From the Departments of Neurosurgery (A.S., V.S.F., L.R.-C., C.N.I., K.V.S., L.N.H., D.R.B., S.R., A.H.S., E.I.L.) .,Radiology (K.V.S., L.N.H., D.R.B., S.R., A.H.S., E.I.L.).,Department of Neurosurgery (A.S., V.S.F., S.G., L.R.-C., K.V.S., L.N.H., S.R., A.H.S., E.I.L.), Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Toshiba Stroke and Vascular Research Center (S.V.S.N., C.N.I., L.N.H., D.R.B., S.R., A.H.S., E.I.L.)
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Fennell VS, Setlur Nagesh SV, Meess KM, Gutierrez L, James RH, Springer ME, Siddiqui AH. What to do about fibrin rich ‘tough clots’? Comparing the Solitaire stent retriever with a novel geometric clot extractor in an in vitro stroke model. J Neurointerv Surg 2018; 10:907-910. [DOI: 10.1136/neurintsurg-2017-013507] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 12/07/2017] [Accepted: 12/07/2017] [Indexed: 11/03/2022]
Abstract
BackgroundDespite advances in revascularization tools for large vessel occlusion presenting as acute ischemic stroke, a significant subset of clots remain recalcitrant to current strategies. We assessed the effectiveness of a novel thrombectomy device that was specifically designed to retrieve resistant fibrin rich clots, the geometric clot extractor (GCE; Neuravi, Galway, Ireland), in an in vitro cerebrovascular occlusion stroke model.MethodsAfter introducing fibrin rich clot analogues into the middle cerebral artery of the model, we compared the rates of recanalization between GCE and Solitaire flow restoration stent retriever (SR; Medtronic, Minneapolis, Minnesota, USA; control group) cases. A maximum of three passes of each device was allowed. If the SR failed to recanalize the vessel after three passes, one pass of the GCE was allowed (rescue cases).ResultsIn a total of 26 thrombectomy cases (13 GCE, 13 SR), successful recanalization (Thrombolysis in Cerebral Infarction score of 2b or 3) was achieved 100% of the time in the GCE cases with an average of 2.13 passes per case. This rate was significantly higher compared with the Solitaire recanalization rate (7.7%, P<0.0001) with an average of three passes per case. After SR failure (in 92% of cases), successful one pass GCE rescue recanalization was achieved 66% of the time (P<0.005).ConclusionApplication of the GCE in this experimental stroke model to retrieve typically recalcitrant fibrin rich clots resulted in higher successful recanalization rates than the SR.
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Meng SW, Kuo RC, Yang HJ, Lai CL, Wu CC, Hsieh MY. Recruiting an Acute Coronary Team to Perform Emergent Mechanical Thrombectomy in Acute Ischemic Stroke Patients: A Successful Case and Team Model in a Local Hospital. ACTA CARDIOLOGICA SINICA 2018; 34:99-103. [PMID: 29375231 PMCID: PMC5777950 DOI: 10.6515/acs.201801_34(1).20170730a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Stroke treatment has entered a new era after the publication of multiple randomized trials involving the use of a stent retriever since 2015. In Taiwan, the demand for interventional neuroradiologists to perform mechanical thrombectomy is high. For this reason, providing this standard care requires reshaping of the care model. Here, we report our experience in recruiting an acute coronary care team to perform emergent mechanical thrombectomy, which is essential in a patient with acute ischemic stroke.
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Affiliation(s)
- Shih-Wei Meng
- Cardiovascular Center, National Taiwan University Hospital, Hsinchu Branch, Hsinchu
| | - Ruei-Cheng Kuo
- Cardiovascular Center, National Taiwan University Hospital, Hsinchu Branch, Hsinchu
| | - Hui-Jen Yang
- Cardiovascular Center, National Taiwan University Hospital, Hsinchu Branch, Hsinchu
| | - Chao-Lun Lai
- Cardiovascular Center, National Taiwan University Hospital, Hsinchu Branch, Hsinchu;
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College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chih-Cheng Wu
- Cardiovascular Center, National Taiwan University Hospital, Hsinchu Branch, Hsinchu
| | - Mu-Yang Hsieh
- Cardiovascular Center, National Taiwan University Hospital, Hsinchu Branch, Hsinchu
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39
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Lapergue B, Blanc R, Gory B, Labreuche J, Duhamel A, Marnat G, Saleme S, Costalat V, Bracard S, Desal H, Mazighi M, Consoli A, Piotin M. Effect of Endovascular Contact Aspiration vs Stent Retriever on Revascularization in Patients With Acute Ischemic Stroke and Large Vessel Occlusion: The ASTER Randomized Clinical Trial. JAMA 2017; 318:443-452. [PMID: 28763550 PMCID: PMC5817613 DOI: 10.1001/jama.2017.9644] [Citation(s) in RCA: 524] [Impact Index Per Article: 74.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 06/30/2017] [Indexed: 12/20/2022]
Abstract
Importance The benefits of endovascular revascularization using the contact aspiration technique vs the stent retriever technique in patients with acute ischemic stroke remain uncertain because of lack of evidence from randomized trials. Objective To compare efficacy and adverse events using the contact aspiration technique vs the standard stent retriever technique as a first-line endovascular treatment for successful revascularization among patients with acute ischemic stroke and large vessel occlusion. Design, Setting, and Participants The Contact Aspiration vs Stent Retriever for Successful Revascularization (ASTER) study was a randomized, open-label, blinded end-point clinical trial conducted in 8 comprehensive stroke centers in France (October 2015-October 2016). Patients who presented with acute ischemic stroke and a large vessel occlusion in the anterior circulation within 6 hours of symptom onset were included. Interventions Patients were randomly assigned to first-line contact aspiration (n = 192) or first-line stent retriever (n = 189) immediately prior to mechanical thrombectomy. Main Outcomes and Measures The primary outcome was the proportion of patients with successful revascularization defined as a modified Thrombolysis in Cerebral Infarction score of 2b or 3 at the end of all endovascular procedures. Secondary outcomes included degree of disability assessed by overall distribution of the modified Rankin Scale (mRS) score at 90 days, change in National Institutes of Health Stroke Scale (NIHSS) score at 24 hours, all-cause mortality at 90 days, and procedure-related serious adverse events. Results Among 381 patients randomized (mean age, 69.9 years; 174 women [45.7%]), 363 (95.3%) completed the trial. Median time from symptom onset to arterial puncture was 227 minutes (interquartile range, 180-280 minutes). For the primary outcome, the proportion of patients with successful revascularization was 85.4% (n = 164) in the contact aspiration group vs 83.1% (n = 157) in the stent retriever group (odds ratio, 1.20 [95% CI, 0.68-2.10]; P = .53; difference, 2.4% [95% CI, -5.4% to 9.7%]). For the clinical efficacy outcomes (change in NIHSS score at 24 hours, mRS score at 90 days) and adverse events, there were no significant differences between groups. Conclusions and Relevance Among patients with ischemic stroke in the anterior circulation undergoing thrombectomy, first-line thrombectomy with contact aspiration compared with stent retriever did not result in an increased successful revascularization rate at the end of the procedure. Trial Registration clinicaltrials.gov Identifier: NCT02523261.
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Affiliation(s)
- Bertrand Lapergue
- Department of Stroke Center and Diagnostic and Interventional Neuroradiology, University of Versailles and Saint Quentin en Yvelines, Foch Hospital, Suresnes, France
| | - Raphael Blanc
- Department of Diagnostic and Interventional Neuroradiology, Rothschild Foundation, Paris, France
| | - Benjamin Gory
- Department of Diagnostic and Interventional Neuroradiology, Hospices Civils de Lyon, Bron, France
| | - Julien Labreuche
- University Lille, CHU Lille, Department of Biostatistics, EA 2694–Santé Publique: Epidémiologie et Qualité des Soins, Lille, France
| | - Alain Duhamel
- University Lille, CHU Lille, Department of Biostatistics, EA 2694–Santé Publique: Epidémiologie et Qualité des Soins, Lille, France
| | - Gautier Marnat
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Bordeaux, Bordeaux, France
| | - Suzana Saleme
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Limoges, Limoges, France
| | - Vincent Costalat
- Department of Diagnostic and Interventional Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France
| | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nancy, Nancy, France
| | - Hubert Desal
- Department of Diagnostic and Interventional Neuroradiology, Guillaume et René Laennec University Hospital, Nantes, France
| | - Mikael Mazighi
- Department of Diagnostic and Interventional Neuroradiology, Rothschild Foundation, Paris, France
| | - Arturo Consoli
- Department of Stroke Center and Diagnostic and Interventional Neuroradiology, University of Versailles and Saint Quentin en Yvelines, Foch Hospital, Suresnes, France
| | - Michel Piotin
- Department of Diagnostic and Interventional Neuroradiology, Rothschild Foundation, Paris, France
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Lapergue B, Labreuche J, Blanc R, Barreau X, Berge J, Consoli A, Rodesch G, Saleme S, Costalat V, Bracard S, Desal H, Duhamel A, Baffert S, Mazighi M, Gory B, Turjman F, Piotin M. First-line use of contact aspiration for thrombectomy versus a stent retriever for recanalization in acute cerebral infarction: The randomized ASTER study protocol. Int J Stroke 2017; 13:87-95. [PMID: 28592218 DOI: 10.1177/1747493017711948] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Rationale Mechanical thrombectomy with a stent retriever is now the standard of care in anterior circulation ischemic stroke caused by large vessel occlusion. New techniques for mechanical thrombectomy, such as contact aspiration, appear promising to increase reperfusion status and improve clinical outcome. Aim We aim at ascertaining whether contact aspiration is more efficient than the stent retriever as a first-line endovascular procedure. Sample size estimates With a two-sided test (alpha = 5%, power = 90%) and an anticipated rate of spontaneous recanalization and catheterization failures of 15%, we estimate that a sample size of 380 patients will be necessary to detect an absolute difference of 15% in primary outcome (superiority design). Methods and design The ASTER trial is a prospective, randomized, multicenter, controlled, open-label, blinded end-point clinical trial. Patients admitted with suspected ischemic anterior circulation stroke secondary to large vessel occlusion, with onset of symptoms <6 h, will be randomly assigned to contact aspiration or stent retriever in a 1:1 ratio; stratified by center and prior IV thrombolysis. If the assigned treatment technique is not successful after three attempts, another technique will be applied, at the operator's discretion. Study outcomes The primary outcome will be successful recanalization (modified Thrombolysis in Cerebral Infarction score 2b-3) at the end of the endovascular procedures. Secondary outcome will include successful recanalization after the assigned first-line treatment technique alone, procedural times, the need for a rescue technique, complications and modified Rankin Scale at three months. Discussion No previous head to head randomized trials have directly compared contact aspiration versus stent retriever reperfusion techniques. This prospective trial aims to provide further evidence of benefit of contact aspiration versus stent retriever techniques among patients with ischemic stroke.
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Affiliation(s)
- Bertrand Lapergue
- 1 Hôpital Foch, University Versailles Saint Quentin en Yvelynes; Department of Stroke Center, Diagnostic and Interventional Neuroradiology, Suresnes, France
| | - Julien Labreuche
- 2 Department of Biostatistics, University of Lille, Lille, France
| | - Raphael Blanc
- 3 Department of Diagnostic and Interventional Neuroradiology, Fondation Rothschild, Paris, France
| | - Xavier Barreau
- 4 Department of Diagnostic and Interventional Neuroradiology, CHU Pellegrin, Bordeaux, France
| | - Jérome Berge
- 4 Department of Diagnostic and Interventional Neuroradiology, CHU Pellegrin, Bordeaux, France
| | - Arturo Consoli
- 1 Hôpital Foch, University Versailles Saint Quentin en Yvelynes; Department of Stroke Center, Diagnostic and Interventional Neuroradiology, Suresnes, France
| | - Georges Rodesch
- 1 Hôpital Foch, University Versailles Saint Quentin en Yvelynes; Department of Stroke Center, Diagnostic and Interventional Neuroradiology, Suresnes, France
| | - Susanna Saleme
- 5 Department of Diagnostic and Interventional Neuroradiology, CHU Dupuytren, Limoges, France
| | - Vincent Costalat
- 6 Department of Diagnostic and Interventional Neuroradiology, CHU Hôpital Gui de Chaulac, Montpellier, France
| | - Serge Bracard
- 7 Department of Diagnostic and Interventional Neuroradiology, Hôpital Neurologique, Nancy, France
| | - Hubert Desal
- 8 Department of Diagnostic and Interventional Neuroradiology, Hôpital Guillaume et René Laennec, Nantes, France
| | - Alain Duhamel
- 3 Department of Diagnostic and Interventional Neuroradiology, Fondation Rothschild, Paris, France
| | - Sandrine Baffert
- 3 Department of Diagnostic and Interventional Neuroradiology, Fondation Rothschild, Paris, France
| | - Mikael Mazighi
- 3 Department of Diagnostic and Interventional Neuroradiology, Fondation Rothschild, Paris, France
| | - Benjamin Gory
- 9 Department of Diagnostic and Interventional Neuroradiology, Hospices Civils de Lyon, Bron, France
| | - Francis Turjman
- 5 Department of Diagnostic and Interventional Neuroradiology, CHU Dupuytren, Limoges, France
| | - Michel Piotin
- 3 Department of Diagnostic and Interventional Neuroradiology, Fondation Rothschild, Paris, France
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Chartrain AG, Awad AJ, Mascitelli JR, Shoirah H, Oxley TJ, Feng R, Gallitto M, De Leacy R, Fifi JT, Kellner CP. Novel and emerging technologies for endovascular thrombectomy. Neurosurg Focus 2017; 42:E12. [PMID: 28366058 DOI: 10.3171/2017.1.focus16518] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Endovascular thrombectomy device improvements in recent years have served a pivotal role in improving the success and safety of the thrombectomy procedure. As the intervention gains widespread use, developers have focused on maximizing the reperfusion rates and reducing procedural complications associated with these devices. This has led to a boom in device development. This review will cover novel and emerging technologies developed for endovascular thrombectomy.
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Affiliation(s)
- Alexander G Chartrain
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ahmed J Awad
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Justin R Mascitelli
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Hazem Shoirah
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Thomas J Oxley
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Rui Feng
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Matthew Gallitto
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Reade De Leacy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Johanna T Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Christopher P Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
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Shepard L, Sommer K, Izzo R, Podgorsak A, Wilson M, Said Z, Rybicki FJ, Mitsouras D, Rudin S, Angel E, Ionita CN. Initial Simulated FFR Investigation Using Flow Measurements in Patient-specific 3D Printed Coronary Phantoms. PROCEEDINGS OF SPIE--THE INTERNATIONAL SOCIETY FOR OPTICAL ENGINEERING 2017. [PMID: 28649159 DOI: 10.1117/12.2253889] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE Accurate patient-specific phantoms for device testing or endovascular treatment planning can be 3D printed. We expand the applicability of this approach for cardiovascular disease, in particular, for CT-geometry derived benchtop measurements of Fractional Flow Reserve, the reference standard for determination of significant individual coronary artery atherosclerotic lesions. MATERIALS AND METHODS Coronary CT Angiography (CTA) images during a single heartbeat were acquired with a 320×0.5mm detector row scanner (Toshiba Aquilion ONE). These coronary CTA images were used to create 4 patient-specific cardiovascular models with various grades of stenosis: severe, <75% (n=1); moderate, 50-70% (n=1); and mild, <50% (n=2). DICOM volumetric images were segmented using a 3D workstation (Vitrea, Vital Images); the output was used to generate STL files (using AutoDesk Meshmixer), and further processed to create 3D printable geometries for flow experiments. Multi-material printed models (Stratasys Connex3) were connected to a programmable pulsatile pump, and the pressure was measured proximal and distal to the stenosis using pressure transducers. Compliance chambers were used before and after the model to modulate the pressure wave. A flow sensor was used to ensure flow rates within physiological reported values. RESULTS 3D model based FFR measurements correlated well with stenosis severity. FFR measurements for each stenosis grade were: 0.8 severe, 0.7 moderate and 0.88 mild. CONCLUSIONS 3D printed models of patient-specific coronary arteries allows for accurate benchtop diagnosis of FFR. This approach can be used as a future diagnostic tool or for testing CT image-based FFR methods.
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Affiliation(s)
- Lauren Shepard
- University Dept. of Biomedical Engineering, University at Buffalo, Buffalo, NY.,Toshiba Stroke and Vascular Research Center, Buffalo, NY
| | - Kelsey Sommer
- University Dept. of Biomedical Engineering, University at Buffalo, Buffalo, NY.,Toshiba Stroke and Vascular Research Center, Buffalo, NY
| | - Richard Izzo
- University Dept. of Biomedical Engineering, University at Buffalo, Buffalo, NY.,Toshiba Stroke and Vascular Research Center, Buffalo, NY.,The Jacobs Institute, Buffalo, NY
| | - Alexander Podgorsak
- University Dept. of Biomedical Engineering, University at Buffalo, Buffalo, NY.,Toshiba Stroke and Vascular Research Center, Buffalo, NY
| | - Michael Wilson
- Interventional Cardiology, University at Buffalo Medicine, UBMD, Buffalo, NY
| | - Zaid Said
- Interventional Cardiology, University at Buffalo Medicine, UBMD, Buffalo, NY
| | - Frank J Rybicki
- The Ottawa Hospital Research Institute and the Department of Radiology, University of Ottawa, Ottawa, ON, CA
| | | | - Stephen Rudin
- University Dept. of Biomedical Engineering, University at Buffalo, Buffalo, NY.,Toshiba Stroke and Vascular Research Center, Buffalo, NY
| | - Erin Angel
- Toshiba American Medical Systems, Tustin, CA
| | - Ciprian N Ionita
- University Dept. of Biomedical Engineering, University at Buffalo, Buffalo, NY.,Toshiba Stroke and Vascular Research Center, Buffalo, NY
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Meess KM, Izzo RL, Dryjski ML, Curl RE, Harris LM, Springer M, Siddiqui AH, Rudin S, Ionita CN. 3D Printed Abdominal Aortic Aneurysm Phantom for Image Guided Surgical Planning with a Patient Specific Fenestrated Endovascular Graft System. PROCEEDINGS OF SPIE--THE INTERNATIONAL SOCIETY FOR OPTICAL ENGINEERING 2017. [PMID: 28638171 DOI: 10.1117/12.2253902] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Following new trends in precision medicine, Juxatarenal Abdominal Aortic Aneurysm (JAAA) treatment has been enabled by using patient-specific fenestrated endovascular grafts. The X-ray guided procedure requires precise orientation of multiple modular endografts within the arteries confirmed via radiopaque markers. Patient-specific 3D printed phantoms could familiarize physicians with complex procedures and new devices in a risk-free simulation environment to avoid periprocedural complications and improve training. Using the Vascular Modeling Toolkit (VMTK), 3D Data from a CTA imaging of a patient scheduled for Fenestrated EndoVascular Aortic Repair (FEVAR) was segmented to isolate the aortic lumen, thrombus, and calcifications. A stereolithographic mesh (STL) was generated and then modified in Autodesk MeshMixer for fabrication via a Stratasys Eden 260 printer in a flexible photopolymer to simulate arterial compliance. Fluoroscopic guided simulation of the patient-specific FEVAR procedure was performed by interventionists using all demonstration endografts and accessory devices. Analysis compared treatment strategy between the planned procedure, the simulation procedure, and the patient procedure using a derived scoring scheme. RESULTS With training on the patient-specific 3D printed AAA phantom, the clinical team optimized their procedural strategy. Anatomical landmarks and all devices were visible under x-ray during the simulation mimicking the clinical environment. The actual patient procedure went without complications. CONCLUSIONS With advances in 3D printing, fabrication of patient specific AAA phantoms is possible. Simulation with 3D printed phantoms shows potential to inform clinical interventional procedures in addition to CTA diagnostic imaging.
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Affiliation(s)
- Karen M Meess
- The Jacobs Institute, Buffalo, NY 14203.,CUBRC Inc., Buffalo, NY 14225.,Department of Biomedical Engineering, University at Buffalo, Buffalo, NY 14228.,Toshiba Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY 14203
| | - Richard L Izzo
- The Jacobs Institute, Buffalo, NY 14203.,Department of Biomedical Engineering, University at Buffalo, Buffalo, NY 14228.,Toshiba Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY 14203
| | - Maciej L Dryjski
- Department of Vascular Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY 14203
| | - Richard E Curl
- Department of Vascular Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY 14203
| | - Linda M Harris
- Department of Vascular Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY 14203
| | | | - Adnan H Siddiqui
- The Jacobs Institute, Buffalo, NY 14203.,Toshiba Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY 14203.,Department of Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY 14203
| | - Stephen Rudin
- Department of Biomedical Engineering, University at Buffalo, Buffalo, NY 14228.,Toshiba Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY 14203.,Department of Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY 14203.,Department of Radiology, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY 14203
| | - Ciprian N Ionita
- Department of Biomedical Engineering, University at Buffalo, Buffalo, NY 14228.,Toshiba Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY 14203
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Intraprocedural Thrombus Fragmentation During Interventional Stroke Treatment: A Comparison of Direct Thrombus Aspiration and Stent Retriever Thrombectomy. Cardiovasc Intervent Radiol 2017; 40:987-993. [DOI: 10.1007/s00270-017-1614-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 02/26/2017] [Indexed: 11/26/2022]
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45
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Efficacy and safety of direct aspiration first pass technique versus stent-retriever thrombectomy in acute basilar artery occlusion—a retrospective single center experience. Neuroradiology 2017; 59:297-304. [DOI: 10.1007/s00234-017-1802-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Accepted: 02/03/2017] [Indexed: 10/20/2022]
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Shakir HJ, Shallwani H, Levy EI. Editorial: See One, Do One, Teach One? Paradigm Shift with Three-Dimensional Printing. Neurosurgery 2017; 80:3-5. [PMID: 28362896 DOI: 10.1093/neuros/nyw001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 10/18/2016] [Indexed: 11/15/2022] Open
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Matsumoto H, Nishiyama H, Tetsuo Y, Takemoto H, Nakao N. Initial clinical experience using the two-stage aspiration technique (TSAT) with proximal flow arrest by a balloon guiding catheter for acute ischemic stroke of the anterior circulation. J Neurointerv Surg 2016; 9:1160-1165. [DOI: 10.1136/neurintsurg-2016-012787] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Revised: 11/10/2016] [Accepted: 11/11/2016] [Indexed: 11/04/2022]
Abstract
BackgroundOur initial experience using the two-stage aspiration technique (TSAT) with proximal flow arrest by a balloon guiding catheter is presented. In TSAT, aspiration is applied with the 5MAX ACE and also with the 3MAX catheter with a Penumbra aspiration pump, while arresting proximal flow by balloon inflation.MethodsIn patients treated with TSAT, clinical data including National Institutes of Health Stroke Scale (NIHSS) score at admission and the modified Rankin Scale (mRS) score at discharge, as well as procedural data including the Thrombolysis in Cerebral Infarction (TICI) score, procedural time, and complications were analyzed.ResultsThirty-four consecutive patients (19 men (56%); mean age 73 years) were treated with TSAT using a balloon guiding catheter. The patients presented with a mean NIHSS score of 17.4 and 23 (68%) patients received IV tissue plasminogen activator. Median time from groin puncture to successful recanalization was 41 min (range 15–160 min). All patients were successfully revascularized; TICI 2b or better recanalization was achieved in 30 (88%) patients. No patient required an additional procedure such as use of a stent retriever. Procedure-related complications occurred in two (5.9%) patients (vessel injury and guidewire perforation). Symptomatic intracranial hemorrhage occurred in one patient and asymptomatic hemorrhagic infarction occurred in two patients. There were no cases of embolization to new territory (ENT). The mean NIHSS score at discharge improved to 6.1. Sixteen patients (47%) achieved a good outcome with an mRS score of 0–2 at discharge (mean hospitalization period 20 days).ConclusionsTSAT with proximal flow arrest by a balloon guiding catheter is an effective and safe method to achieve good clinical and angiographic outcomes. This method may reduce ENT in the direct aspiration first-pass thrombectomy (ADAPT) technique.
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Kim YW, Kang DH, Hwang YH, Park J, Kim YS. Efficacy of Proximal Aspiration Thrombectomy for Using Balloon-Tipped Guide Catheter in Acute Intracranial Internal Carotid Artery Occlusion. J Korean Neurosurg Soc 2016; 59:379-84. [PMID: 27446520 PMCID: PMC4954887 DOI: 10.3340/jkns.2016.59.4.379] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 02/25/2016] [Accepted: 03/20/2016] [Indexed: 11/27/2022] Open
Abstract
Objective Mechanical thrombectomy (MT) for acute intracranial internal carotid artery (ICA) occlusion is often complicated by difficult revascularization and non-involved territory embolization possibly related with larger clot-burden. This study aims to evaluate the efficacy of proximal aspiration thrombectomy (PAT) using a balloon-tipped guide catheter for clot-burden reduction in such cases with period-to-period analysis (period 1 : standard MT without PAT; period 2 : PAT first, then standard MT for the remaining occlusion). Methods Eighty-six patients who underwent MT for acute intracranial ICA occlusion were included in this analysis from the prospectively maintained stroke registry (33 patients in period 1 and 53 in period 2). In period 2, 'responder' was defined as a case where some amount of clot was retrieved by PAT and the following angiography showed partial or full recanalization. Results Fifteen of fifty-three patients in period 2 (28.3%) were 'responders' to PAT. There was a significantly higher incidence of atrial fibrillation in the 'responder' subgroup. Period 2 showed a significantly shorter puncture-to-reperfusion time (94.5 minutes vs. 56.0 minutes; p=0.002), a significantly higher Thrombolysis in Cerebral Infarction of 2b-3 reperfusion (45.5% vs. 73.6%; p=0.009), but only a trend for better 3-month favorable outcome (mRS 0–2; 36.4% vs. 54.7%; p=0.097). There was no increase in the incidence of procedure-related complications or intracranial hemorrhage in period 2. Conclusion A strategy of PAT before standard MT may result in shorter puncture-to-reperfusion time and better angiographic outcome than a strategy of standard MT for acute intracranial ICA occlusion.
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Affiliation(s)
- Yong-Won Kim
- Department of Radiology, Cerebrovascular Center, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea.; Department of Neurology, Cerebrovascular Center, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Dong-Hun Kang
- Department of Radiology, Cerebrovascular Center, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea.; Department of Neurosurgery, Cerebrovascular Center, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yang-Ha Hwang
- Department of Neurology, Cerebrovascular Center, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jaechan Park
- Department of Neurosurgery, Cerebrovascular Center, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yong-Sun Kim
- Department of Radiology, Cerebrovascular Center, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
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Izzo RL, O'Hara RP, Iyer V, Hansen R, Meess KM, Nagesh SVS, Rudin S, Siddiqui AH, Springer M, Ionita CN. 3D Printed Cardiac Phantom for Procedural Planning of a Transcatheter Native Mitral Valve Replacement. PROCEEDINGS OF SPIE--THE INTERNATIONAL SOCIETY FOR OPTICAL ENGINEERING 2016; 9789. [PMID: 28615797 DOI: 10.1117/12.2216952] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
3D printing an anatomically accurate, functional flow loop phantom of a patient's cardiac vasculature was used to assist in the surgical planning of one of the first native transcatheter mitral valve replacement (TMVR) procedures. CTA scans were acquired from a patient about to undergo the first minimally-invasive native TMVR procedure at the Gates Vascular Institute in Buffalo, NY. A python scripting library, the Vascular Modeling Toolkit (VMTK), was used to segment the 3D geometry of the patient's cardiac chambers and mitral valve with severe stenosis, calcific in nature. A stereolithographic (STL) mesh was generated and AutoDesk Meshmixer was used to transform the vascular surface into a functioning closed flow loop. A Stratasys Objet 500 Connex3 multi-material printer was used to fabricate the phantom with distinguishable material features of the vasculature and calcified valve. The interventional team performed a mock procedure on the phantom, embedding valve cages in the model and imaging the phantom with a Toshiba Infinix INFX-8000V 5-axis C-arm bi-Plane angiography system. RESULTS After performing the mock-procedure on the cardiac phantom, the cardiologists optimized their transapical surgical approach. The mitral valve stenosis and calcification were clearly visible. The phantom was used to inform the sizing of the valve to be implanted. CONCLUSION With advances in image processing and 3D printing technology, it is possible to create realistic patient-specific phantoms which can act as a guide for the interventional team. Using 3D printed phantoms as a valve sizing method shows potential as a more informative technique than typical CTA reconstruction alone.
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Affiliation(s)
- Richard L Izzo
- The Jacobs Institute, 875 Ellicott Street, 5 Floor, Buffalo, NY.,Biomedical Engineering, University at Buffalo, 332 Bonner Hall, Buffalo, NY
| | - Ryan P O'Hara
- The Jacobs Institute, 875 Ellicott Street, 5 Floor, Buffalo, NY.,Biomedical Engineering, University at Buffalo, 332 Bonner Hall, Buffalo, NY
| | - Vijay Iyer
- The Jacobs Institute, 875 Ellicott Street, 5 Floor, Buffalo, NY.,Interventional Cardiology, University at Buffalo, 875 Ellicott Street, Suite 7030, Buffalo, NY
| | - Rose Hansen
- Interventional Cardiology, University at Buffalo, 875 Ellicott Street, Suite 7030, Buffalo, NY
| | - Karen M Meess
- The Jacobs Institute, 875 Ellicott Street, 5 Floor, Buffalo, NY.,Biomedical Engineering, University at Buffalo, 332 Bonner Hall, Buffalo, NY
| | - S V Setlur Nagesh
- Toshiba Stroke and Vascular Research Center, 875 Ellicott Street, 8 Floor, Buffalo, NY
| | - Stephen Rudin
- Toshiba Stroke and Vascular Research Center, 875 Ellicott Street, 8 Floor, Buffalo, NY
| | - Adnan H Siddiqui
- The Jacobs Institute, 875 Ellicott Street, 5 Floor, Buffalo, NY.,University at Buffalo Neurosurgery, 100 High Street, Section B4, Buffalo, NY
| | | | - Ciprian N Ionita
- Biomedical Engineering, University at Buffalo, 332 Bonner Hall, Buffalo, NY.,Toshiba Stroke and Vascular Research Center, 875 Ellicott Street, 8 Floor, Buffalo, NY
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Neidlin M, Büsen M, Brockmann C, Wiesmann M, Sonntag SJ, Steinseifer U, Kaufmann TAS. A numerical framework to investigate hemodynamics during endovascular mechanical recanalization in acute stroke. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2016; 32:e02748. [PMID: 26420012 DOI: 10.1002/cnm.2748] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 09/11/2015] [Accepted: 09/23/2015] [Indexed: 06/05/2023]
Abstract
Ischemic stroke, caused by embolism of cerebral vessels, inflicts high morbidity and mortality. Endovascular aspiration of the blood clot is an interventional technique for the recanalization of the occluded arteries. However, the hemodynamics in the Circle of Willis (CoW) are not completely understood, which results in medical misjudgment and complications during surgeries. In this study we establish a multiscale description of cerebral hemodynamics during aspiration thrombectomy. First, the CoW is modeled as a 1D pipe network on the basis of computed tomography angiography (CTA) scans. Afterwards, a vascular occlusion is placed in the middle cerebral artery and the relevant section of the CoW is transferred to a 3D computational fluid dynamic (CFD) domain. A suction catheter in different positions is included in the CFD simulations. The boundary conditions of the 3D domain are taken from the 1D domain to ensure system coupling. A Eulerian-Eulerian multiphase simulation describes the process of thrombus aspiration. The physiological blood flow in the 1D and 3D domains is validated with literature data. Further on, it is proved that domain reduction and pressure coupling at the boundaries are an appropriate method to reduce computational costs. Future work will apply the developed framework to various clinical questions.
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Affiliation(s)
- Michael Neidlin
- Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany
| | - Martin Büsen
- Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany
| | - Carolin Brockmann
- Clinic for Diagnostic and Interventional Neuroradiology, RWTH Aachen University Clinic, Aachen, Germany
| | - Martin Wiesmann
- Clinic for Diagnostic and Interventional Neuroradiology, RWTH Aachen University Clinic, Aachen, Germany
| | - Simon J Sonntag
- Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany
| | - Ulrich Steinseifer
- Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany
| | - Tim A S Kaufmann
- Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany
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