VIPUL GUPTANEUROINTERVENTION SURGERY, MEDANTA THE MEDICITY

Objective:

Describe technique to achieve first pass reperfusion and relevant literature.

Case study of a patient with terminal ICA occlusion

Single center experience with relevant technical pearls

PUSH AND PUFF TECHNIQUE FOR MECHANICAL THROMBECTOMY – OUR EXPERIENCE

Significantly better first pass reperfusion and higher modified TICI 3 reperfusion with Trevo device

Stent opens better and cell size larger (shown in image)

Standard unsheathing technique with TREVO stent

Push and fluff technique- Note better expansion of stent and larger cell size to allow for better clot entrapment

Solitaire (Medtronic, MN) stent has been the most common device used in the randomized trials The parametric design of the Solitaire device (Medtronic, MN) allows for maintaining cell size regardless of the vessel size. In addition, the folding design provides greater device - clot interaction, particularly in the stage of delivery of stent. One may wonder if the parameteric design and consequent unfurling of stent may offer greater possibility of engaging the clot if push and fluff techniques is employed. Therefore, we utilized the ‘push and fluff’ technique with Solitaire (Medtronic, MN) device

Case study:

65 year old female with a history of ST elevation MI a week ago presented with left sided weakness that started 2.5 hours ago. She had gaze deviation to the right, left hemispatial neglect, left hemifield loss and left hemiplegia (NIHSS – 18).

Patient underwent multimodal imaging that revealed right terminal ICA occlusion, good collaterals and a large penumbra.

In view of recent MI intravenous thrombolysis was contraindicated and patient was shifted to angio suite for mechanical thrombectomy

A B

C D

A, B – Noncontrast CT brain – ASPECTS of 10, no early ischemia noted; C – CBV map, no infarct core; D – MTT, prolonged MTT suggestive of a large area of penumbra.

A B C D

E F G H

A – CT angio demonstrating right L – type terminal ICA occlusion; B – tapered R ICA due to terminal ICA occlusion; C, D – Initial run demonstrating occlusion beyond the origin of the ophthalmic; E- microcatheter run after crossing the occlusion; F- well expanded Solitaire stent; G, H – TICI 3 reperfusion in the occluded territory.Post procedure, patient made near complete recovery

with a NIHSS of 4.

Our experience of PUSH and FLUFF technique with Solitaire device:

7 consecutive patients (2016) 3 terminal ICA occlusion; 4 M1 MCA occlusionFirst pass reperfusion – 7/ 7 (100%)

Modified TICI 3 reperfusion – (6/7)85%Modified TICI 2b reperfusion – (1/7) 15%

Picture to Puncture time : 58 minutes (median)Puncture to reperfusion: 18 minutes (median)

Clinical – mRS 0-2 in 6/7 (85%), one patient had heparin induced bleeding

Commonly encountered problems post stent retrieval – •Spasm in M1 MCA (spontaneously resolves in most; otherwise resolves with a small dose of Nimodipine )•Thrombus at site of stent delivery – resolved with adequate heparinization

Conclusion

•Push and Puff technique appears to be a very promising method to improve results of mechanical thrombectomy

•Our early experience with Solitaire stent-retriever are extremely encouraging

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Dr Vipul Gupta

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