Striving for more distal guide-catheter placement is a “no-brainer” in stroke thrombectomy


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Violiza Inoa

“Going distally with guide catheters is more routine nowadays,” says Violiza Inoa (Memphis, USA), discussing what she sees as a relatively recent shift in the way many physicians choose to prepare for a mechanical thrombectomy procedure to treat stroke patients.

“During mechanical thrombectomy, distal base catheter placement makes more sense because you have to [achieve] shorter distances from the base catheter to the intracranial space where the clot is located,” she continues.

Inoa says that, compared to previous years, the distal placement of guide or ‘base’ catheters has grown in popularity, and is now more accepted than ever before among the neurointerventional community. She believes there are “a multitude of factors” that have brought about this change.

“When mechanical thrombectomy became the standard of care [in acute ischaemic stroke], and the number of thrombectomies increased, neurointerventionists started to feel more skilled to perform the procedure,” she states.

“But, also, a major [factor] is that the newer generations of devices have made it possible. Previous devices were stiff, less trackable and harder to navigate—now, from the wires to the guide catheters, to the intermediate and aspiration catheters, everything has [evolved] to the point where the technical aspects of mechanical thrombectomy are much less challenging.”

Benefits of ‘going distal’

“You have more control over your devices,” Inoa goes on, outlining the key advantages of ‘going distal’i when it comes to guide-catheter placement. “And, one other thing that I believe is important here is that— when you need to perform more passes—you are right there, and you can get to the clot. If you do not get full revascularisation at the first pass, you can go extremely quickly with the second pass [and subsequent passes].”

Expanding on this, Inoa notes that tangible benefits to more distal guide-catheter placement include the fact there is less tension when withdrawing the treatment catheters following clot retrieval, in addition to a lower possibility of the clot fragmenting or migrating to other vessels, owing to the shorter distances at play.

“It works two ways,” she goes on. “You get to the clot faster—[meaning] shorter times to potential revascularisationii—and, also, on the way out, you have a lot more support with a catheter that is placed distally in the cervical/ petrous ICA [internal carotid artery], for example.”

While she admits it is difficult to say with absolute certainty that improved procedural outcomes can be achieved as a result of placing guide catheters more distally, Inoa cites a retrospective, single-institution experience that has been presented by the Ochsner group (New Orleans, USA), and concluded better reperfusion results and first-pass effect rates were associated with intracranial guide-catheter placement.1

She further avers that it is likely wider research would reinforce these positive findings, as she has observed the same trend in her own clinical practice to date.

Device progression

Inoa also highlights “very good” experiences using two Cerenovus products in mechanical thrombectomy procedures: the CEREBASETM Long Guide Sheath and the EMBOGUARDTM Balloon Guide Catheter. She reports choosing to deploy the latter “a lot more” recently, owing to the growing evidence base that balloon guide catheters (BGCs) can increase the likelihood of achieving first-pass revascularisation—and becoming “very comfortable” with the device as a result.

In addition, she asserts that, while physicians may have doubted the utility of BGCs in the past, these devices have also seen a “significant improvement”, and now boast reliable trackability as well as being able to accommodate larger aspiration catheters.

“I have even considered using it [EMBOGUARD] in more tortuous anatomies, over just a regular guide catheter,” Inoa says. “This may be counterintuitive, in a way, but the reason why I have done it is that I have been using the anchor technique more and more for steep arches—you can actually inflate your balloon at the origin of the common carotid artery, and then use that support to drag your [intermediate] and diagnostic catheters to the distal vasculature. Then, you deflate your balloon, and it tracks pretty nicely.”

Discussing current BGC products, Inoa notes that she would “set the EMBOGUARD Balloon Guide Catheter apart” from prior generations of balloons, due in part to its favourable trackability and the fact it is specifically designed to ‘go distal’. Inoa relays that this ultra-compliant, atraumatic balloon performs “really well” when inflated distally and, as such, she is deploying it “more and more” in her thrombectomy practice.

Figure 1: Left M1 occlusion, NIHSS 15
Figure 2: EMBOGUARD placed proximally to left petrous ICA in distal left cervical ICA
Figure 3: Ultra-compliant EMBOGUARD balloon inflated in distal ICA
Figure 4: First-pass TICI 3 with stent retriever, aspiration catheter and distal flow arrest

Here, Inoa highlights her use of these devices in a recent case where she was treating a 60-year-old patient with multiple vascular risk factors. The patient presented with right hemiparesis and dysarthria, with a National Institutes of Health stroke scale (NIHSS) score of 15 (figure 1). The computed tomography angiography (CTA) demonstrated a left middle cerebral artery (MCA) M1 occlusion with no early ischaemic changes on head CT.

The patient received a mechanical thrombectomy, with right femoral access being obtained, and an EMBOGUARD Balloon Guide Catheter and diagnostic catheter being placed in the distal cervical/proximal petrous ICA (figures 2 and 3). The arteriogram of the left ICA confirmed the left M1 occlusion. Successful thrombolysis in cerebral infarction (TICI) 3 reperfusion was obtained after one pass with combination therapy using a stent retriever, continuous aspiration, and distal flow arrest with the EMBOGUARD Balloon Guide Catheter (figure 4).

Advice for operators

Inoa also says that, “for the most part”, while she favours the cervical/petrous junction of the ICA—describing it as a “safe spot” that gives the operator “a lot of support”, owing to the bony anatomy found there—she tends not to go any further into the intracranial vasculature when placing a guide catheter, and “would advise against it”.

“One other thing I would advise to physicians that want to embark on getting their guide catheters more distally is that, besides [vessel] spasm, which I have seen, the other thing I could foresee happening is—as you withdraw your intracranial devices—your guide catheter may migrate forward and inadvertently dissect [the vessel],” she continues. “So, I would advise watching on [imaging] as you come back with your treatment devices so you can actually hold the catheter in place. That is a trick that I use in order to avoid dissections.”

Delivering a final, take-home message to her neurointerventional colleagues, Inoa reiterates of distal guide-catheter placement that “it is efficacious, it is supportive, and it is safe”.

“To me, getting the most distal access that is safe for the patient and will enhance the efficacy of your thrombectomy technique is a no-brainer,” she adds. “It is a technique that is being used a lot more and, again, with the comfort level [with stroke thrombectomy] that we now have, it would surprise me if physicians did not want to place their guide catheters more distally. But, I would say to anyone who is not feeling comfortable [enough to do this] that they should start with straighter anatomies, using simpler cases to get comfortable with the technique to the point where—when they have more challenging cases—they feel more confident doing it.”



  1. Milburn J, Vidal G, Gulotta P, et al. E-240 Intracranial large bore guide catheter placement is associated with excellent reperfusion: a single institution experience. J Neurointerv Surg. 2022; 14: A210.

i. Better trackability and more support than NeuronMax™, Infinity™, Shuttle™ and Fubuki™. More support than Ballast™. The third-party trademarks used herein are the properties of their respective owners.

ii. Studies demonstrate that balloon guide catheters increase first-pass rate and lower puncture-to-revascularisation time.

Violiza Inoa is an interventional neurologist at the Semmes Murphey Clinic and an associate professor in the Departments of Neurology and Neurosurgery at the University of Tennessee Health Science Center’s College of Medicine in Memphis, USA. She is also a paid consultant of CERENOVUS, part of Johnson & Johnson MedTech.



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