Balloon Gliding Technique: A novel use of balloon guiding catheters in accessing challenging circulations when treating acute ischemic stroke

Abstract

Background: Challenging arterial anatomy delays, or prevents timely endovascular treatment (EVT) of acute ischemic stroke (AIS). We introduce a new technique called 'Balloon Gliding Technique (BGT)' to overcome difficult arterial anatomy during EVT of AIS, utilizing flow-assistance to access challenging circulations.

Methods: Retrospective review of a prospectively collected database of all patients presenting to a single institution with AIS who underwent EVT was performed from January 2021 to June 2021. Patients in whom BGT was performed were assessed. BGT consists of advancing the balloon guide catheter in the cervical carotid artery while its balloon is inflated, and therefore carried by downstream flow.

Results: Of 51 patients presenting with AIS secondary to large vessel occlusion during the study period, five patients underwent BGT. All five patients had anterior circulation large vessel occlusions. Mean age of the BGT patients was 92.2 years, and all patients were females. A type 3 arch was present in all patients. BGT was performed in all cases following initial failure of conventional techniques to cannulate the target circulation. BGT was successful in achieving distal cervical carotid access in 4 out of the 5 patients in whom BGT was attempted. Successful recanalization (modified treatment in cerebral ischemia 2b-3) was obtained in all cases with no complications.

Conclusions: Balloon Gliding Technique (BGT) is a safe technique that can safely overcome challenging anatomy during endovascular treatment of acute ischemic stroke. Further studies can assist in demonstrating both its safety and effectiveness.

Keywords: Acute stroke; Balloon guide catheter; reperfusion.

Figure 1.

A 93 year old woman who presented with an acute stroke due to a right M2 occlusion. (a) Coronal CT angiogram of the aortic arch showing type III arch with the vertical distance between the origin of brachiocephalic artery (white arrow head) and the origin of the left subclavian artery (black arrow head) is greater than two times the diameter of the common carotid artery. (b) Initial attempt to catheterize the right carotid arteries using a Simmons 2 catheter failed because of the type three arch and the tandem severe tortuosity of the right internal carotid artery (Black Arrow). (c-f) Demonstration of the Balloon Gliding Technique. The brachiocephalic artery is catheterized using a Sim2 catheter followed by placement of the guidewire in the internal carotid artery. The BGC is next inflated to stabilize the system and the diagnostic/intermediate catheter is advanced into the cervical ICA. The inflated BGC is then incrementally co-axially advanced over the guidewire and diagnostic or intermediate catheter (white arrows).