Comparison of Efficacy, Embolism Rate and Safety of Thrombectomy with Stent Retrievers in an Anterior Circulation Stroke Model

Abstract

Purpose Various stent retrievers differing in stent design and mechanical properties are currently available for the treatment of ischemic stroke. We conducted this in vitro study to compare the efficacy, embolism rate, and safety of commercially available stent retrievers and prototypes.

Materials and Methods Whole blood thrombi were produced in a Chandler loop. The thrombi were inserted into the curved M1 segment of a silicone model of the anterior cerebral circulation. Thrombectomy maneuvers were performed with six commercially available stent retrievers and 2 prototypes with different strut thickness. Wall-stent apposition, first pass recanalization rate, retraction force, and embolism rate were compared.

Results Devices with complete wall-stent apposition had the highest first pass recanalization rate and lowest embolism rate, but showed the highest retraction force. The prototype with thinner struts had a comparable recanalization and embolism rate, while a lower retraction force had to be applied compared to the prototype with thicker struts.

Conclusion Complete wall-stent apposition facilitates a higher recanalization rate and lower embolism rate but also correlates to a higher necessary retraction force and thus possibly higher risk of endothelium damage. Stent modifications leading to a reduced retraction force do not compromise efficacy and embolism rate.

Key Points: 

• Complete wall-stent apposition facilitates an effective thrombectomy

• Complete wall-stent apposition leads to higher retraction force and possibly greater endothelium damage

• Modifications of strut thickness do not compromise recanalization and embolism rate

• Thinner struts correlate with a lower retraction force

Citation Format

• Larsen N, Oberbeck K, Lima de Miranda R et al. Comparison of Efficacy, Embolism Rate and Safety of Thrombectomy with Stent Retrievers in an Anterior Circulation Stroke Model. Fortschr Röntgenstr 2018; 190: 1053 – 1058

Zusammenfassung

Ziel In der Therapie des ischämischen Schlaganfalles kommen verschiedene Stentretriever zum Einsatz, die sich in Stentdesign und mechanischen Eigenschaften unterscheiden. Wir führten diese in vitro-Studie durch, um Effektivität, Embolisationsrate und notwendige Retraktionskraft von kommerziell erhältlichen Stentretrievern und zwei Prototypen zu vergleichen.

Material und Methoden In einem Chandler loop generierte Vollblutthromben wurden in das bogig verlaufende M1-Segment eines Silikonmodells der vorderen intrakraniellen Zirkulation eingebracht. Thrombektomiemanöver wurden mit 6 kommerziell erhältlichen Stentretrievern und 2 Prototypen, die sich in der Stärke der Stentstreben unterschieden, durchgeführt. Die Adaptation des Stentretrievers an die Gefäßwand, first pass-Rekanalisierungsrate, Retraktionskraft und Embolisationsrate wurden verglichen.

Ergebnisse Die Stentretriever, die eine vollständige Adaptation an die Gefäßwand zeigten, wiesen eine höhere first pass-Rekanalisierungsrate und geringere Embolisationsrate auf als Stentretriever, die sich nicht in voller Länge an die Gefäßwand anlegten. Andererseits war bei ersteren eine höhere Retraktionskraft notwendig. Der Prototyp mit dünneren Stentstreben erreichte eine vergleichbare Rekanalisations- und Embolierate bei geringerer aufzuwendender Retraktionskraft im Vergleich zum Prototypen mit stärkeren Stentstreben.

Schlussfolgerung Eine vollständige Adaptation des Stentretrievers an die Gefäßwand ermöglicht eine effektive Thrombektomie mit geringer Embolierate, ist jedoch mit einer höheren notwendigen Retraktionskraft und damit potentiell höheren Gefahr einer Endothelverletzung verbunden. Veränderungen des Stentdesigns in den Prototypen mit Verminderung der Stärke der Stentstreben führen zu einer geringeren Retraktionskraft, beeinträchtigten jedoch nicht die Rekanalisierungs- und Embolierate.

Kernaussagen: 

• Die vollständige Adaptation des Stentretrievers an die Gefäßwand ermöglicht eine effektive Thrombektomie

• Diese ist mit einer höheren Retraktionskraft und möglicherweise Gefahr der Endothelverletzung verbunden

• Durch Verringerung der Strebendicke wird die Rekanalisations- und Embolierate nicht beeinträchtigt

• Die Retraktionskraft kann hierdurch vermindert werden

Key words

thrombectomy - stroke - stent retriever

• References

• 1 Berkhemer OA, Fransen PSS, Beumer D. et al. A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke. N Engl J Med 2015; 372: 11-20 . doi:10.1056/NEJMoa1411587
• 2 Campbell BCV, Mitchell PJ, Kleinig TJ. et al. Endovascular Therapy for Ischemic Stroke with Perfusion-Imaging Selection. N Engl J Med 2015; 372: 1009-1018 . doi:10.1056/NEJMoa1414792
• 3 Gralla J, Schroth G, Remonda L. et al. Mechanical Thrombectomy for Acute Ischemic Stroke. Stroke 2006; 37: 3019-3024 . doi:10.1161/01.STR.0000248457.55493.85
• 4 Saver JL, Goyal M, Bonafe A. et al. Stent-Retriever Thrombectomy after Intravenous t-PA vs. t-PA Alone in Stroke. N Engl J Med 2015; 372: 2285-2295 . doi:10.1056/NEJMoa1415061
• 5 Jovin TG, Chamorro A, Cobo E. et al. Thrombectomy within 8 Hours after Symptom Onset in Ischemic Stroke. N Engl J Med 2015; 372: 2296-2306 . doi:10.1056/NEJMoa1503780
• 6 Roth C, Junk D, Papanagiotou P. et al. A Comparison of 2 Stroke Devices: The New Aperio Clot-Removal Device and the Solitaire AB/FR. Am J Neuroradiol 2012; 33: 1317-1320 . doi:10.3174/ajnr.A2962
• 7 Saleh M, Spence JN, Nayak S. et al. Safety and efficacy of the Aperio thrombectomy device when compared to the Solitaire AB/FR and the Revive devices in a pulsatile flow system. Am J Cardiovasc Dis 2012; 2: 301-308
• 8 Jansen O, Macho JM, Killer-Oberpfalzer M. et al. Neurothrombectomy for the treatment of acute ischemic stroke: results from the TREVO study. Cerebrovasc Dis Basel Switz 2013; 36: 218-225 . doi:10.1159/000353990
• 9 Mordasini P, Brekenfeld C, Byrne JV. et al. Experimental evaluation of immediate recanalization effect and recanalization efficacy of a new thrombus retriever for acute stroke treatment in vivo. AJNR Am J Neuroradiol 2013; 34: 153-158 . doi:10.3174/ajnr.A3275
• 10 Pereira VM, Gralla J, Davalos A. et al. Prospective, multicenter, single-arm study of mechanical thrombectomy using Solitaire Flow Restoration in acute ischemic stroke. Stroke 2013; 44: 2802-2807 . doi:10.1161/STROKEAHA.113.001232
• 11 Kurre W, Aguilar-Pérez M, Schmid E. et al. Clinical experience with the pREset stent retriever for the treatment of acute ischemic stroke – a review of 271 consecutive cases. Neuroradiology 2014; 56: 397-403 . doi:10.1007/s00234-014-1346-y
• 12 Mendonça N, Flores A, Pagola J. et al. Trevo versus solitaire a head-to-head comparison between two heavy weights of clot retrieval. J Neuroimaging Off J Am Soc Neuroimaging 2014; 24: 167-170 . doi:10.1111/j.1552-6569.2012.00730.x
• 13 Mpotsaris A, Bussmeyer M, Weber W. Mechanical thrombectomy with the penumbra 3D separator and lesional aspiration: technical feasibility and clinical outcome. Clin Neuroradiol 2014; 24: 245-250 . doi:10.1007/s00062-013-0242-x
• 14 Haussen DC, Rebello LC, Nogueira RG. Optimizating Clot Retrieval in Acute Stroke: The Push and Fluff Technique for Closed-Cell Stentrievers. Stroke 2015; 46: 2838-2842 . doi:10.1161/STROKEAHA.115.010044
• 15 Ishikawa K, Ohshima T, Nishihori M. et al. Treatment protocol based on assessment of clot quality during endovascular thrombectomy for acute ischemic stroke using the Trevo stent retriever. Nagoya J Med Sci 2016; 78: 255-265
• 16 Tsumoto T, Tsurusaki Y, Tokunaga S. Interaction between the stent strut and thrombus characterized by contrast-enhanced high-resolution cone beam CT during deployment of the Solitaire stent retriever. J Neurointerventional Surg 2016; DOI: 10.1136/neurintsurg-2016-012492.
• 17 van der Marel K, Chueh JY, Brooks OW. et al. Quantitative assessment of device-clot interaction for stent retriever thrombectomy. J Neurointerventional Surg 2016; DOI: 10.1136/neurintsurg-2015-012209.
• 18 Saposnik G, Black SE, Hakim A. et al. Age Disparities in Stroke Quality of Care and Delivery of Health Services. Stroke 2009; 40: 3328-3335 . doi:10.1161/STROKEAHA.109.558759
• 19 Heidrich J, Heuschmann PU, Kolominsky-Rabas P. et al. Variations in the use of diagnostic procedures after acute stroke in Europe: results from the BIOMED II study of stroke care. Eur J Neurol 2007; 14: 255-261 . doi:10.1111/j.1468-1331.2006.01573.x
• 20 Robbie LA, Young SP, Bennett B. et al. Thrombi formed in a Chandler loop mimic human arterial thrombi in structure and RAI-1 content and distribution. Thromb Haemost 1997; 77: 510-515
• 21 Stringer HA, van Swieten P, Heijnen HF. et al. Plasminogen activator inhibitor-1 released from activated platelets plays a key role in thrombolysis resistance. Studies with thrombi generated in the Chandler loop. Arterioscler Thromb J Vasc Biol 1994; 14: 1452-1458
• 22 Lima de Miranda R, Zamponi C, Quandt E. Micropatterned Freestanding Superelastic TiNi Films. Adv Eng Mater 2013; 15: 66-69 . doi:10.1002/adem.201200197
• 23 Wenger KJ, Berkefeld J, Wagner M. Flat panel detector computed tomography for the interaction between contrast-enhanced thrombi and stent retrievers in stroke therapy: a pilot study. Clin Neuroradiol 2014; 24: 251-254 . doi:10.1007/s00062-013-0246-6
• 24 Madjidyar J, Hermes J, Freitag-Wolf S. et al. Stent-thrombus interaction and the influence of aspiration on mechanical thrombectomy: evaluation of different stent retrievers in a circulation model. Neuroradiology 2015; 57: 791-797 . doi:10.1007/s00234-015-1526-4
• 25 Machi P, Jourdan F, Ambard D. et al. Experimental evaluation of stent retrievers’ mechanical properties and effectiveness. J NeuroInterventional Surg 2017; 9: 257-263 . doi:10.1136/neurintsurg-2015-012213
• 26 Arai D, Ishii A, Chihara H. et al. Histological examination of vascular damage caused by stent retriever thrombectomy devices. J Neurointerventional Surg 2016; 8: 992-995 . doi:10.1136/neurintsurg-2015-011968
• 27 Eugène F, Gauvrit JY, Ferré JC. et al. One-year MR angiographic and clinical follow-up after intracranial mechanical thrombectomy using a stent retriever device. AJNR Am J Neuroradiol 2015; 36: 126-132 . doi:10.3174/ajnr.A4071
• 28 Misaki K, Uchiyama N, Mohri M. et al. Pseudoaneurysm formation caused by the withdrawal of a Trevo ProVue stent at a tortuous cerebral vessel: a case report. Acta Neurochir (Wien) 2016; 158: 2085-2088 . doi:10.1007/s00701-016-2952-8
• 29 Peschillo S, Diana F, Berge J. et al. A comparison of acute vascular damage caused by ADAPT versus a stent retriever device after thrombectomy in acute ischemic stroke: a histological and ultrastructural study in an animal model. J Neurointerventional Surg 2016; DOI: 10.1136/neurintsurg-2016-012533.
• 30 Power S, Matouk C, Casaubon LK. et al. Vessel wall magnetic resonance imaging in acute ischemic stroke: effects of embolism and mechanical thrombectomy on the arterial wall. Stroke 2014; 45: 2330-2334 . doi:10.1161/STROKEAHA.114.005618
• 31 Singh P, Doostkam S, Reinhard M. et al. Immunohistochemical Analysis of Thrombi Retrieved During Treatment of Acute Ischemic Stroke. Stroke 2013; 44: 1720-1722 . doi:10.1161/STROKEAHA.113.000964
• 32 Hsieh K, Verma RK, Schroth G. et al. Multimodal 3 Tesla MRI confirms intact arterial wall in acute stroke patients after stent-retriever thrombectomy. Stroke 2014; 45: 3430-3432 . doi:10.1161/STROKEAHA.114.006665
• 33 Kurre W, Pérez MA, Horvath D. et al. Does Mechanical Thrombectomy in Acute Embolic Stroke Have Long-term Side Effects on Intracranial Vessels? An Angiographic Follow-up Study. Cardiovasc Intervent Radiol 2013; 36: 629-636 . doi:10.1007/s00270-012-0496-8
• 34 Humphries W, Hoit D, Doss VT. et al. Distal aspiration with retrievable stent assisted thrombectomy for the treatment of acute ischemic stroke. J NeuroInterventional Surg 2015; 7: 90-94 . doi:10.1136/neurintsurg-2013-010986