Mechanical Thrombectomy of Large Vessel Occlusions Using Stent Retriever Devices

Transcription

1 Mechanical Thrombectomy of Large Vessel Occlusions Using Stent Retriever Devices Joey English MD, PhD Medical Director, Neurointerventional Services California Pacific Medical Center Hospitals, San Francisco, CA Stroke Medical Director, Mills-Peninsula Health Services, Burlingame, CA

2 Disclosures Consultant Work Stryker Neurovascular. Covidien. Silk Road Medical.

3 Endovascular Approaches to Large Vessel Occlusions Intra-Arterial Thrombolytic Mechanical Thrombectomy Merci Retriever Penumbra Aspiration Successful Revascularization (TICI 2b/3) IMS III Carotid Terminus 38% M1 or M2 44% MR Rescue TICI 2a/2b/3 67% TICI 2b/3 27%

4 Endovascular Approaches to Large Vessel Occlusions Intra-Arterial Thrombolytic Mechanical Thrombectomy Merci Retriever Penumbra Aspiration Stent Retrievers Solitaire (Covidien) Trevo (Stryker)

5 Randomized Trials of Stent Retrievers versus Merci SWIFT TREVO2 TIMI 2/3 TICI 2B/3 2A/2B/3 Solitaire 69% Merci 30% Trevo 68% 90% Merci 44% 64%

6 Retrospective Registries of Real World Stent Retriever Use NASA Registry 354 patients treated with Solitaire RF device at 24 centers. Center-reported TICI 2B/3 in 73%, TICI 2A/2B/3 in 88%. TRACK Registry

7 Prospective Registries of Real World Stent Retriever Use 100 th Patient Recently Enrolled STRATIS Solitaire Registry

8 Randomized Trials of Stent Retrievers and Clinical Benefit SWIFT PRIME, REVASCAT, ESCAPE, EXTEND IA, PISTE, POSITIVE, DAWN MR CLEAN Randomized trial from the Netherlands 500 Patients, Carotid T (30%) or MCA (70%) Occlusions 90% Treated with IV tpa 97% of Endovascular Interventions were Stent Retrievers TICI 2B/3: 59%

9 Still in Early Days of Stent Retriever Optimization 1. Guide Catheter 6F - 9F Guide: support, aspiration 7F - 9F Balloon Guide: support, proximal flow arrest, aspiration 2. Intracranial Catheter System Single Microcatheter for Stent Delivery Intermediate Catheter + Stent Delivery Micro Local aspiration with stent retrieval 3. Stent Retriever Evolving Families of Devices 3, 4, 6 mm diame Novel lengths Visibility, Tracking

10 Still in Early Days of Stent Retriever Optimization 1. Guide Catheter 6F - 9F Guide: support, aspiration 7F - 9F Balloon Guide: support, proximal flow arrest, aspiration 2. Intracranial Catheter System Single Microcatheter for Stent Delivery Intermediate Catheter + Stent Delivery Micro Local aspiration with stent retrieval 3. Stent Retriever Evolving Families of Devices 3, 4, 6 mm diame Novel lengths Visibility, Tracking

11 Stryker Neurovascular Family of TREVO Stent Retriever Devices 4 mm x 20 mm 3 mm x 20 mm

12 Stryker Neurovascular Family of TREVO Stent Retriever Devices 4 mm x 20 mm 3 mm x 20 mm

13 Covidien Family of SOLITAIRE Stent Retriever Devices 4 mm x 15 mm 4 mm x 20 mm 4 mm x 40 mm 6 mm x 20 mm 6 mm x 30 mm

14 Potential Advantages of Stent Retrievers: Coverage of Extensive Thrombus 138 pts, acute MCA stroke All treated with IV tpa Successful Recanalization ~40% recanalization Persistent Occlusion

15 Potential Advantages of Stent Retrievers: Coverage of Extensive Thrombus Successful Recanalization Persistent Occlusion

16 Potential Advantages of Stent Retrievers: Coverage of Extensive Thrombus Successful Recanalization Persistent Occlusion Successful TICI 2B and 3 Revascularization versus Thrombus Burden

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18 Potential Advantages of Stent Retrievers: Immediate Perfusion Channel Initial Angiogram Stent Retriever Deployed Post-Thrombectomy

19 Somatosensory Evoked Potentials Left UE Right UE Left LE Right LE

20 Take Away Points, Things to Study Stent retrievers have proven to be a major advance for endovascular AIS rx. 1. Superior results compared with Merci in randomized trials. 2. Retrospective registry data shows similar efficacy in real world use. 3. Multiple ongoing randomized trials to show clinical benefit. Still in early days of optimizing stent retriever mechanical thrombectomy. 1. Utility of proximal and/or local aspiration during stent retrieval. BGC and/or large diameter intermediate catheter. 2. Devices continue to evolve (diameters, length, visibility, etc). Stent retrievers may provide unique benefits. 1. Coverage of extensive (long) thrombus burden. 2. Immediate perfusion channel with device deployment.

21 Mechanical Thrombectomy of Large Vessel Occlusions Using Stent Retriever Devices THANK YOU. Joey English MD, PhD Medical Director, Neurointerventional Services California Pacific Medical Center Hospitals, San Francisco, CA Stroke Medical Director, Mills-Peninsula Health Services, Burlingame, CA

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24 Endovascular Rx of AIS -> My Anterior Circulation Approach General anesthesia, with neuromonitoring of tcmeps and sseps. Goal systolic blood pressure 150s-170s. 10 F short vascular sheath in common femoral artery. (close at end with 8F Angioseal) 5 F catheter for diagnostic cerebral angiogram. This presentation contains many case studies. Results from case studies are not predictive of results in other cases. Results in other cases may vary.

25 Endovascular Rx of AIS -> My Anterior Circulation Approach 9 F Concentric/Stryker Balloon Guide Catheter (now 8F Flowgate Balloon Guide Catheter) via exchange length 035 wire (STORQ). Trevo Pro Microcatheter/Transend EX Platinum Guidewire This presentation contains many case studies. Results from case studies are not predictive of results in other cases. Results in other cases may vary.

26 Endovascular Rx of AIS -> My Anterior Circulation Approach Dual angiogram (guide catheter and microcatheter) to map proximal and distal borders of occlusion, as well as landing zone for Retrieval System. This presentation contains many case studies. Results from case studies are not predictive of results in other cases. Results in other cases may vary.

27 Endovascular Rx of AIS -> My Anterior Circulation Approach Dual angiogram (guide catheter and microcatheter) to map proximal and distal borders of occlusion, as well as landing zone for Retrieval System. Dual road map (guide catheter and microcatheter) to guide Trevo ProVue positioning and deployment. Angiogram 2 minutes after device placement. This presentation contains many case studies. Results from case studies are not predictive of results in other cases. Results in other cases may vary.

28 Endovascular Rx of AIS -> My Anterior Circulation Approach Administration of IA vasodilator (e.g., verapamil). Retrieval at five minutes using proximal flow arrest with balloon guide catheter and manual aspiration via guide catheter. Visualization of the Trevo ProVue during retrieval. This presentation contains many case studies. Results from case studies are not predictive of results in other cases. Results in other cases may vary.

29 Endovascular Rx of AIS -> My Anterior Circulation Approach This presentation contains many case studies. Results from case studies are not predictive of results in other cases. Results in other cases may vary.

30 81 year old woman with atrial fibrillation and a right MCA syndrome, NIHSS 15, treated with IV tpa at 3 hours. This presentation contains many case studies. Results from case studies are not predictive of results in other cases. Results in other cases may vary.

31 81 year old woman with afib and R MCA syndrome, NIHSS 15, treated with IV tpa at 3 hours. This presentation contains many case studies. Results from case studies are not predictive of results in other cases. Results in other cases may vary.

32 81 year old woman with afib and R MCA syndrome, NIHSS 15, treated with IV tpa at 3 hours. This presentation contains many case studies. Results from case studies are not predictive of results in other cases. Results in other cases may vary.

33 This presentation contains many case studies. Results from case studies are not predictive of results in other cases. Results in other cases may vary.

34 This presentation contains many case studies. Results from case studies are not predictive of results in other cases. Results in other cases may vary.

35 CPMC Acute Stroke Treatment May 2012 August endovascular acute stroke treatments. 73 patients treated with a stent retriever: Trevo (53), Solitaire (20). Transfer patients: 88% (64/73). All selected with CT angiography and CT perfusion studies.

36 TREVO2 Trial (n=88) CPMC (n=73) Age 67.4 (13.9) 67.3 (13.9) Male 45% 56% Hypertension 76% 86% Atrial Fibrillation 48% 63% Diabetes 38% 28% Hyperlipidemia 63% 64% Mean NIHSS 18.3 (5.3) 14.6 (6.9) IV tpa Failure 58% 67% Vertebrobasilar 8% 18% Supraclinoid ICA 16% 14% M1 60% 58% M2 16% 10%

37 TREVO2 Trial (n=88) CPMC (n=73) Mean Time from Onset 4.6 hours (1.5) 7.0 hours (2.5) To Arterial Puncture

38 Procedural Data and Outcomes Balloon Guide Catheter Utilized in 100% of Anterior Circulation Strokes 60/73 Cases Number of Passes: Mean 2.2 (1.4) Reperfusion: TICI 2B or 3 in 85% TICI 2A/2B/3 in 92% Outcomes (90 day, n=65): mrs 0-2: 61.5%; mrs %

39 Safety Data sich (any ICH associated with increase in NIHSS >4): 2.7% (2/73). Procedural Complications: No device related complications. 1 microwire perforation during attempted microcatheter placement. Embolization to previously uninvolved territory: 5.4% (4/73). Groin complication requiring transfusion or surgical repair: 0/73.

40 Clinical Management of Acute Ischemic Stroke & Patient Case Experiences THANK YOU. Joey English MD, PhD Medical Director, Neurointerventional Services California Pacific Medical Center Hospitals, San Francisco, CA Stroke Medical Director, Mills-Peninsula Health Services, Burlingame, CA

41 Stent-retriever : Self-Expanding Non-Detachable Stent

42 Stent-retriever : Self-Expanding Non-Detachable Stent