SAN DIEGO – Manual, endoscopic clot aspiration restored cerebral blood flow in 66 (58.9%) of 112 acute ischemic stroke patients at the University of Pittsburgh Medical Center, according to a retrospective review.
When it failed, trying again with a stentriever ultimately restored flow on the thrombolysis in cerebral infarction scale (TICI 2b/3) in 97 (86.6%) patients, about the same rate of success as if a stentriever had been used in the first place. Patients needed a median of two passes.
Dr. Ashutosh Jadhav
Stentrievers are "the new technology that everyone is using, and they work very well, but they’re expensive," in the range of $5,000-$7,000, said investigator and interventional neurologist Dr. Ashutosh P. Jadhav.
"Our local practice is to use manual aspiration thrombectomy as our first pass. We are [often] able to do the procedure with just the catheter alone, which is a fifth of the price. We like it because it’s cost effective, and we are comfortable doing it. If the clot is refractory, then we move onto stentrievers," he said at the International Stroke Conference, sponsored by the American Heart Association (Tech. Vasc. Interv. Radiol. 2012;15:68-77).
The median time from symptom onset to groin puncture was 267 minutes. When manual aspiration was used alone, the mean procedural time was 63 minutes. When the team had to try again with a stentriever, the mean procedural time was 97 minutes (P less than .0001).
"Maybe if we did a trial against stentriever" on first pass, "we might find" trying manual aspiration first "takes a little bit longer, but we don’t have evidence of that right now," Dr. Jadhav of the UMPC Stroke Institute said.
Large-bore catheters – 0.07 inches and above – were used in about a quarter of the cases, and medium-bore catheters – 0.054-0.058 inches – in the rest. "Primary manual aspiration thrombectomy was carried out with a preference for the largest catheter considered to be trackable into the target lesion." Catheter make and size were not associated with higher or faster recanalization rates, Dr. Jadhav and his team noted.
"When we get the catheter into the clot, we pull back [on the attached 20 cc syringe] in one movement, so we don’t see a high rate of embolism. We did get a 9.8% risk of parenchymal hematoma, and a 6.2% risk of symptomatic hemorrhage," but the rates are "comparable to what people have seen with other therapies," he said. Four patients (3.6%) had intracranial distal wire perforations.
The median age in the series was 67 years, and median NIH stroke scale score was 17. Seventy patients (62.5%) were occluded in the first branch of the middle cerebral artery, and nine (8.0%) were occluded in the second branch. Twenty-one (18.8%) were occluded in the terminus of the internal carotid artery, and 12 (10.7%) had vertebrobasilar occlusions.
Almost half of the patients had 90-day modified Rankin Scale scores of 2 or less, but 35 (31.3%) had died at 3 months. Manual aspiration alone was not associated with better outcomes.
The investigators did not report outside funding. Dr. Jadhav said he has no disclosures.