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In light of a recent publication detailing the safe and effective use of the Solitaire X 3mm (Medtronic) stent retriever in medium- and distal-vessel occlusion (MeVO/DVO) stroke, Marios Psychogios (University Hospital Basel, Basel, Switzerland) discusses the relevance of having a dedicated device for these cases, as well as providing insight on what he feels is the “next frontier” in mechanical thrombectomy.
“We were one of the first clinics that used the device in Europe, and we are happy with it,” Psychogios says, highlighting navigability and radial force as being among key characteristics of the Solitaire X 3mm. “Generally, I like these aspects—the navigability for those superior-trunk M2 and M3 occlusions is really good, and it still has enough radial force to actually be able to capture clots [in those locations].”
He attributes these abilities, at least in part, to the device’s parametric design, which helps it to better accommodate the clot while also providing a strong balance of navigability and radial force, as well as the right level of retrievability and “softness” for use in more distal vessels.
“What [Medtronic] has done nicely here is find the ‘sweet spot’ of combining all these things,” Psychogios adds.
Writing in the Journal of Clinical Medicine, Psychogios et al recently published findings from a retrospective study involving 68 consecutive primary and secondary MeVO/DVO stroke cases treated via thrombectomy across 12 European centres.1 Psychogios is keen to emphasise “really good” reperfusion results reported in the paper—as per the study’s primary endpoint, the Solitaire X 3mm achieved a first-pass rate of complete or near-complete reperfusion (modified treatment in cerebral infarction [mTICI] 2c–3) of 32.3%.
Other key statistics he highlights are a final-pass mTICI 2c–3 rate of 67.6%, a final mTICI 2b–3 rate close to 90%, and—regarding safety endpoints—a 13% rate of intracranial haemorrhage (ICH), with none of these complications being symptomatic or resulting in subsequent neurological deterioration. The researchers also observed no device malfunctions in the study. Psychogios acknowledges that retrospective analyses such as this do inevitably carry limitations and some inherent biases, but that the findings outlined here compare favourably to prior data on other stent-retriever devices.
I strongly believe that, in a few years’ time, we’re going to go after those distal occlusions.
One salient piece of advice Psychogios offers to his neurointerventional peers is to make use of these smaller, specialised stent retrievers like the Solitaire X 3mm when treating ischaemic strokes caused by MeVO/DVOs, if they have access to them at their centres. He advises against the deployment of regular (4–6mm) stent retrievers in said cases, stressing the importance of “dedicated” thrombectomy devices for tackling distal locations where more tortuous vessels are found and a greater risk of bleeding complications—most notably, clinically relevant ICHs—exists.
Psychogios says that, thanks to this newer generation of more specialised devices, his centre has the ability to treat distal occlusions more effectively, but also go after secondary distal occlusions more safely, as they can switch from using a larger stent retriever for an initial large vessel occlusion (LVO) to a smaller device like the Solitaire X 3mm within the same case if necessary.
“It comes back to the safety aspect, and the fact that having a dedicated device for those secondary distal occlusions leads to better safety and then probably better outcomes for the patient,” he states. “This is something that we always do and, if you have the means, I would recommend it—don’t just stay with your LVO setup! It’s good to have a ‘standard’—and we always have that—but, if you [encounter] a new condition in the angio suite, you have to adapt.”
Consistency is key
“Another important thing is that most of the cases [78%] were done with a combined approach, with a dedicated aspiration catheter, and this is something we have been promoting and using in our patients,” Psychogios also says of the study. “With the Quattro technique, we are seeing fewer complications [at our centre], so we promote this combined approach.2 In my opinion, it is not just about the device—you need the whole setup and, usually, we combine [the stent retriever] with an aspiration catheter—but it’s also crucial that the device is correctly chosen and, for those more curved segments, the Solitaire X 3mm is a very good device.”
Psychogios goes on to state that it is often underestimated how vital a standardised setup—like the one he and his colleagues in Basel use consistently—can be in helping to reduce complications, as it gives operators access to the best materials for any given occlusion type. According to Psychogios, while it has been suggested that aspiration alone may be sufficient for more distal occlusions, his own experiences as well as meta-analysis data from some 2,500 thrombectomy cases point towards a higher rate of clinically relevant bleeding, and the fact “you probably don’t open the vessels as [effectively] as with a combined approach”.
While the Solitaire X 3mm is tailormade to fit into this combined setup, one problem Psychogios does encounter when implementing a combined approach is the paucity of dedicated aspiration catheters that are well-suited to the treatment of distal occlusions. He notes that this is something he often emphasises in conversations with industry, adding, “having smaller stent retrievers is a good first step, and we can see in the paper that this leads in the right direction, but I think we can achieve even more if we have the whole setup regarding distal occlusions”.
Distal “truth” moves closer
Psychogios also provides a brief update on the progress of the global DISTAL trial evaluating thrombectomy in primary MeVO/DVO stroke, for which he is the principal investigator: as of early February 2024, the study has enrolled 370 patients out of a targeted 530, with Psychogios anticipating finalised recruitment later in the year and, “hopefully”, initial data presentations at the start of 2025. He goes on to disclose that DISTAL very recently received approval from its data and safety monitoring board (DSMB) to continue, following a planned interim analysis that revealed no safety- or futility-related concerns.
“We will have data from randomised trials showing what is best for these occlusions next year,” he continues. “We also plan to join forces with the other trials—ESCAPE MEVO, DISTALS, DISCOUNT—to pool data. What we have at the moment is just a glimpse of the truth, and I think next year we are going to have a better overview of the whole truth. I strongly believe that, in a few years’ time, we’re going to go after those distal occlusions. We’ve seen this with the LVOs, then ‘late-window’ LVOs, and now the large-core patients, and I think this is going to be the next frontier.”
Psychogios posits that the emergence of thrombectomy for more distal stroke cases is “a process”, as, within his own department, he is observing far fewer complications when treating a MeVO today compared to even 3–4 years ago. He cites improved techniques and training, a greater wealth of experience accrued over time, and the introduction of new devices, as likely drivers of this change.
“That is the beauty of neurointervention,” Psychogios concludes. “We are always improving, and looking at ways of making things safer and making things better—again, I think the Solitaire X 3mm helps a lot in this direction—and, maybe, in the future, we will be able to achieve even better outcomes.”
References:
- Psychogios MN, Ntoulias N, Brehm A et al. Initial Experience with the Solitaire X 3 mm Stent Retriever for the Treatment of Distal Medium Vessel Occlusions. J Clin Med. 2023; 12(23): 7289.
- Psychogios MN, Tsogkas I, Blackham K et al. The Quattro Technique for Medium Distal Vessel Occlusion Stroke. Clin Neuroradiol. 2023. https://doi.org/10.1007/s00062-023-01317-8.
DISCLAIMER: The data and content included in this presentation express only the clinical perspective of the presenter. They are completely independent and do not necessarily reflect the opinions of Medtronic.
