Endovascular Management of Intracranial Atherosclerosis-Related Large Vessel Occlusion With the A Direct Aspiration First-Pass Thrombectomy Compared With Solumbra Technique

Abstract

Background: To investigate the effect of the A Direct Aspiration First-Pass Thrombectomy (ADAPT) vs. Solumbra technique in the treatment of acute intracranial atherosclerosis-related large vessel occlusion (LVO). Methods: Patients with acute atherosclerosis-related LVO who had undergone endovascular treatment were retrospectively enrolled into two groups: The Solumbra and ADAPT groups. The clinical data were analyzed. Results: Patients (104) were enrolled with 48 in the Solumbra and 56 in the ADAPT group. The mean time from femoral access to recanalization was significantly (P < 0.05) shorter in the ADAPT than in the Solumbra group. The recanalization time at the first line was significantly shorter in the ADAPT group than in the Solumbra group (17 ± 10.21 vs. 26 ± 15.55 min, P = 0.02). However, the rate of switching to the alternative was significantly higher in the ADAPT group than that in the Solumbra group (46.42 vs. 33.33%, P = 0.01). Eighty-two patients had eventual recanalization, resulting in a final recanalization rate of 78.85%. At 3-month clinical follow-up for all patients, the good prognosis rate reached 51.92% with good prognosis in 24 patients (50%) in the Solumbra and 30 (53.57%) in the ADAPT group. The rate of symptomatic intracranial hemorrhage was 18.75% (n = 9) in the Solumbra and 19.64% (n = 11) in the ADAPT group. The mortality rate was 21.15% (22/104). Among 80 (76.92%) patients who had angiographic follow-up (3-30 months), five (6.25%) patients experienced in-stent stenosis, and two (2.5%) experienced asymptomatic stent occlusion. Conclusion: In patients with acute intracranial atherosclerosis-related LVO, clinical outcomes treated using the ADAPT technique are comparable with those using the Solumbra technique, and more patients need additional remedial measures if treated with the ADAPT technique.

Keywords: ADAPT; Solumbra; endovascular treatment; intracranial atherosclerosis-related; large vessel occlusion.

Figure 1

A 36-year-old man had sudden onset of left limb weakness 17 h ago, and the symptom was relieved after intravenous thrombolysis. However, the symptom was aggravated 4 h later, and he was transferred to our hospital with the NIHSS score of 11. Magnetic resonance imaging demonstrated acute infarction in the right basal ganglia. (A,B) Before aspiration, cerebral angiography revealed occlusion of the right middle cerebral artery. (C) After the thrombus was removed by the aspiration catheter connected to the negative pressure pump, the blood flow forward was resumed. (D) During the procedure, a 2 mm × 12 mm balloon was used to expand the stenotic segment. (E,F) An Enterprise stent (4.5 mm × 22 mm) was deployed at the stenotic location, and the blood flow was restored to the modified Thrombolysis in Cerebral Infarction (mTICI) grade 3.

Figure 2

A male patient in his 60s had paroxysmal dysphasia, left limb weakness for 1 h, and coma for 30 min. The NHISS score was 19. (A) Cerebral digital subtraction angiography showed lateral circulation and basilar artery tip, suggesting intracranial atherosclerotic stenosis-related large vessel occlusion (ICAS-LVO). (B) The right vertebral artery angiography demonstrated occlusion of the initial segment of the basilar artery. (C) A REACT68 suction catheter was navigated to the basilar artery proximal to the occlusion, and after 30 s of negative pressure suction in situ, the retrograde blood flow in the catheter suddenly recovered. (D) Angiography confirmed that the anterior blood flow of the basilar artery returned to normal. (E) The aspiration catheter was withdrawn, and angiography revealed severe stenosis at the middle segment of the basilar artery as ICAS-LVO. (F) After 10 min of observation, the stenosis degree was increased, and the forward blood flow gradually became worse. (G) A stent was implanted after balloon pre-dilation, with the blood flow reaching mTICI grade 3. (H) Computed tomography angiography of the head and neck was performed 3 days after operation, which indicated that the stent was unobstructed, and the basilar artery forward blood flow was stable. Seven days after operation, the patient was discharged, with the NIHSS score of 1.