Advancing Mechanical Thrombectomy: The Impact of Cyclic Aspiration on First-Pass Success and Distal Emboli Reduction

Introduction

Mechanical thrombectomy has emerged as a groundbreaking intervention for patients with emergent large vessel occlusion, showing promising outcomes when complete recanalization is achieved in the initial pass. A recent study sheds light on a crucial aspect of this process - the role of non-static (cyclical) aspiration in enhancing first-pass success rates and reducing distal emboli.

The Study:

This study utilized a patient-specific cerebrovascular replica connected to a flow loop, simulating the conditions of a middle cerebral artery occlusion with clot analogs. Two key independent variables were explored: the diameter of the aspiration catheter (ranging from 0.054 to 0.088 inches) and the aspiration pattern (static versus cyclical).

Key Findings:

1. Complete Clot Ingestion and First-Pass Success:

   • Results revealed that achieving complete clot ingestion during aspiration thrombectomy consistently led to first-pass complete recanalization.

   • Notably, first-pass complete recanalization was achieved in every experiment with complete clot ingestion, as opposed to only 21% of experiments with partial ingestion (P<0.0001).

2. Impact of Aspiration Catheter Diameter:

   • The study found that the use of a large bore 0.088-inch aspiration catheter resulted in the highest rates of complete clot ingestion, reaching an impressive 90%.

3. Cyclic Aspiration Enhancement:

   • Cyclic aspiration, characterized by pressure cycles of 18-29 inHg at a frequency of 0.5 Hz, significantly increased the rate of complete clot ingestion (OR 21 [1.6, 266]; P=0.04).

4. Distal Emboli Reduction:

   • Across all experiments, complete clot ingestion consistently led to fewer and smaller distal emboli, indicating a positive correlation between achieving first-pass success and minimizing the risk of embolic events.

Conclusion:

In the realm of mechanical thrombectomy, this study highlights the critical impact of complete clot ingestion on achieving first-pass complete recanalization and reducing distal emboli. Furthermore, the study underscores the importance of considering both the inner diameter of the aspiration catheter and the application of cyclic aspiration as influential factors in optimizing outcomes.

As we delve into these findings, the implications for clinical practice become evident. Cyclic aspiration, in particular, emerges as a potential game-changer, offering a quantitative reduction in distal emboli and a higher likelihood of first-pass success during mechanical thrombectomy procedures. This research paves the way for continued exploration and refinement of techniques, bringing us one step closer to more effective and precise interventions in the challenging landscape of stroke thrombectomy.

Citation: Arslanian RA, Marosfoi M, Caroff J, et al. Complete clot ingestion with cyclical ADAPT increases first-pass recanalization and reduces distal embolization Journal of NeuroInterventional Surgery 2019;11:931-936.