While the treatment paradigm for stroke continues to evolve, even a quick review of the current literature will point to how complete reperfusion after a single thrombectomy pass is a predictor for favourable outcomes. During the Society of NeuroInterventional Surgery’s (SNIS) annual meeting (22–25 July, Miami, USA), NeuroNews caught up with some of the field’s key leaders, Raul Nogueira (Grady Memorial Hospital, Atlanta, USA), Ajit Puri (UMass Memorial Medical Center, Worcester, USA) and Demetrius Lopes (AdvocateAurora Health, Chicago, USA) about why stent retriever choice matters, how flow control can improve outcomes, and maximising the TRAP technique.
Trevo Stentriever allows for full-length visibility combined with 360 degrees of consistently large cells, providing real-time visual feedback for additional control. “I use the full-length visibility of the Trevo device to help me through several steps of the thrombectomy procedure. Having full visibility of the device gives you real-time feedback; not only tactile, but visual feedback on the degree of opening you achieve for every step of the deployment technique,” noted Nogueira.
“Often, you will see that the device is pinched. If the device is pinched, it means that you are dealing with one of two situations; either a high fibrin content clot, or intracranial atherosclerotic carotid disease.” If the latter is the reason for the occlusion, Nogueira proposed that he would immediately give the patient intravenous or intra-arterial tirofiban to prevent reocclusion and observe the lesion to decide whether or not to stent it. “In these cases, having the visual picture where I can see the Trevo device and the entire lesion, really helps me pick the right size and length for my angioplasty balloon or stent.”
He further explained, “Let us say if my device is stretching—it is not fully opposing the vessel wall—I know I have to push the wire a little more as opposed to letting the microcatheter relax. Good wall opposition means a more complete opening of the device. This is where the data shows the active deployment technique is very important. Having full visibility is very helpful in making all of this possible.”
In terms of optimising flow control, Puri posited, “There is overwhelming evidence for the use of a balloon guide catheter for anterior circulation thrombectomy. [For example] preclinical studies which were published in Stroke in 2013, the NASA, STRATIS, and TRACK registries, and meta-analyses that all say that the use of a balloon guide catheter is an independent predictor of good clinical outcomes.”
He added, “That being said, it comes down to what we really care about; we want a good modified Rankin score at 90-days for our patients. And, over and over again, these studies have shown that you can achieve a better modified first-pass efficacy, shorter times to recanalisation, and eventually, better clinical outcomes with balloon guide catheters.”
Providing a balance of trackability and support, the FlowGate² balloon guide catheter offers proximal flow control and a stable platform to facilitate the insertion and guidance of intravascular catheters. Speaking on the Trevo aspiration proximal flow control technique—coined TRAP—Lopes told NeuroNews, “I believe TRAP is the optimal approach for thrombectomy, mainly because of clot control. We never know what kind of clot we are going to be dealing with, so having a technique that addresses the majority of cases and allows for a first-pass success; it achieves the goal we all want.”
“My set-up for TRAP is a short 8F sheath, followed usually by the FlowGate2 with a VTK catheter. The inner catheter that comes with the FlowGate2 has improved and is very capable of getting to vertebral arteries and the right carotid artery. I have to say, I am very excited about the possibility of exchanging, for example, deploying the Trevo, removing the microcatheter and going up with a CAT 6 or 7, depending on the anatomy.”
Lastly, Lopes said, “I challenge operators to keep trying to incorporate TRAP into their workflow and practice it, because once you get the hang of it, it becomes extremely intuitive. Once you build the set-up for TRAP, you are ready for anything. You can do a carotid or intracranial stent, and distal clots as well as proximal clots, probably with the highest first-pass recanalisation that you can achieve with any technique.”
Raul Nogueira, Ajit Puri, and Demetrius Lopes are paid consultants of Stryker.
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