Double solitaire mechanical thrombectomy in acute stroke: effective rescue strategy for refractory artery occlusions?

Abstract

Background and purpose: Mechanical thrombectomy by using a single stent retriever system has demonstrated high efficacy for recanalization of large-artery occlusions in acute stroke. We aimed to evaluate the feasibility, safety, and efficacy of a novel double Solitaire stent retriever technique as an escalating treatment for occlusions that are refractory to first-line single stent retriever mechanical thrombectomy.

Materials and methods: All patients treated with the double stent retriever technique by using the Solitaire system were retrospectively selected from 2 large neurointerventional centers. Time to recanalization, angiographic (TICI) and clinical outcomes (mRS), and complications were assessed.

Results: Ten patients (median NIHSS score, 16; mean age, 70 years) with MCA M1 segment (n = 5) and terminal ICA (n = 5 including 2 ICA tandem) occlusions were included. Prior single stent retriever mechanical thrombectomy had been performed in 9 patients (median number of passes, 3). Median time to recanalization was 60 minutes (interquartile range, 45-87 minutes). Procedure-related complications occurred in 1 patient; overall mortality was 20%. Recanalization of the target vessel (TICI 2b/3) was achieved in 80%. Good clinical outcome (mRS 0-2) was 50%.

Conclusions: In this preliminary feasibility study, the double Solitaire stent retriever technique proved to be an effective method for recanalization of anterior circulation large-artery occlusions refractory to standard stent retriever mechanical thrombectomy.

Fig 1.

Double Solitaire SR maneuver in patient 1 with a left ICAT occlusion. Large M1 thrombus (arrow in A, gradient recalled-echo image) and proximal ICA contrast media stasis (arrows in B) are shown. Two Solitaire SRs are placed parallel (arrow in C, proximal markers) with 1 extending to the MCA bifurcation (black arrowhead, 6 × 30 mm) and 1 into the mid-M1 segment (white arrowhead, 4 × 20 mm). Three consecutive fluoroscopic images (D–F) depict simultaneous retrieval of both SRs; during this maneuver, the distal tip markers of the longer SR device (black arrowheads) follow the shorter one (white arrowheads), with retrieval of a large thrombus inside the tip of the inflated balloon-guide catheter (arrows). After double Solitaire SR MT, complete recanalization is demonstrated (G).

Fig 2.

Double Solitaire SR maneuver with SRs in a Y-type configuration in patient 2 with MCA M1 occlusion. Following 3 single SR passes, there is refractory M1 occlusion (A). Simultaneous injection of 2 microcatheters being placed in the superior (white arrowhead) and inferior (black arrowhead) MCA divisions is shown in B. C, ICA injection after unfolding of 2 Solitaire devices (4 × 20 mm), which extend from both M2 segments (distal markers in the superior and inferior divisions, white and black arrowheads, respectively) to the terminal ICA (attachment zones, white arrow), demonstrates re-establishment of flow within both MCA trunks. D, After simultaneous retrieval of both SRs by using proximal occlusion and aspiration through a balloon-guide catheter, both MCA trunks are recanalized. Mild vasospasm of ICA and MCA vessels is depicted.