Treatment of vertebrobasilar occlusion by using a coronary waterjet thrombectomy device: a pilot study

Abstract

Background and purpose: Despite improved patient outcomes because of intraarterial fibrinolysis, vertebrobasilar thromboembolism remains a fatal disease with a death rate of more than 50%. The outcome depends on the success of recanalization. Fibrinolysis achieves recanalization in only 50%-70% of the cases. Therefore, we investigated the feasibility of using a coronary mechanical device to increase the recanalization rate.

Methods: Twelve patients with acute vertebrobasilar occlusion were included in the pilot study. The older 5F and the new 4F versions of the Possis Angiojet catheter, which use a waterjet to attract, fragment, and extract the thrombus, were used. Inclusion depended on the presence of acute multisegmental intracranial or any extracranial vertebrobasilar occlusion. Exclusion criteria included coma lasting >8 hours and age >80. The Angiojet treatment did not exclude other therapeutic options.

Results: The Angiojet catheter accessed the thrombosed site in 10 of 12 patients. Combined treatment with the Angiojet and additional fibrinolysis or angioplasty resulted in a recanalization rate of 100%. Of 37 occluded vertebrobasilar segments, 30 were primarily recanalized with the Angiojet. Three symptomatic and two asymptomatic hemorrhages were detected by CT. Five of the 12 patients died. Fifty percent of all patients obtained a moderate to excellent outcome (Modified Rankin Scale 0-3).

Conclusions: Use of the coronary Angiojet in the vertebrobasilar system is feasible. The device has the potential to increase the recanalization rate, especially in cases of extensive thrombosis, and, thus, improve patient outcomes.

Fig 1.

Patient 7, a 43-year-old male, with hemiplegia right, anarthria, and dysphagia for 7.5 hours. Occlusion of the extra- and intracranial left VA and the entire BA is shown.

Fig 2.

Collateralization of the tip of the BA.

Fig 3.

The Choice-PT microwire (black) with its tip in the posterior cerebral artery (white vessels) straightened the atlas loop (white line in the roadmap) and the Angiojet reached the basilar tip.

Fig 4.

Complete thrombus extraction was achieved, but a high-grade stenosis of the VA remained.

Fig 5.

The stenosis worsened due to rethrombosis despite heparinization (ACT >250).

Fig 6.

Therefore, tirofiban was infused, and a 4-mm Medtronic stent was implanted. Complete recanalization was achieved. Shortly after the procedure, the patient improved significantly and returned to work.