Mechanical thrombectomy using the retrograde semi-retrieval technique for patients with underlying intracranial atherosclerotic stenosis

Abstract

Background: The retrograde semi-retrieval technique (RESET) has been described as a modified technique for endovascular thrombectomy (EVT) whose safety and efficacy for intracranial atherosclerosis stenosis (ICAS) patients remain uncertain. This article presents our single-center experience, comparing RESET vs. non-RESET in ICAS patients.

Materials and methods: We analyzed 327 consecutive ICAS patients who underwent EVT at Tianjin Huanhu Hospital from January 2018 and December 2022. Patients were categorized into two groups: RESET and non-RESET. The primary outcome was the first-pass effect (FPE). Secondary outcomes included successful reperfusion, functional independence at 90 days, mortality, and symptomatic intracranial hemorrhage (sICH).

Results: RESET was significantly associated with FPE [adjusted odds ratio (aOR) 2.00, 95% confidence interval (CI) 1.03-3.87, p = 0.040]. RESET was not significantly associated with successful reperfusion (aOR 1.5, CI 0.55-4.06, p = 0.425), an mRS of 0-2 at 90 days (aOR 1.36, CI 0.83-2.21, p = 0.223), sICH (aOR 0.39, CI 0.12-1.23, p = 0.108), and mortality (aOR 0.49, CI 0.16-1.44, p = 0.193). After propensity score matching, the results were consistent with the primary analysis.

Conclusion: Compared to non-RESET, patients treated with RESET showed increased FPE incidence and significantly decreased puncture-to-reperfusion time. RESET was proven to be safe and effective in enhancing reperfusion for LVO patients receiving EVT with underlying ICAS.

Keywords: acute ischemic stroke; large vessel occlusion; retrograde semi-retrieval technique; stent retriever; thrombectomy.

Figure 1

Hand-drawn illustration of the retrograde semi-retrieval technique in patients with ICAS. (A) Stent-retriever was fully deployed across the thrombus, with the DIC advanced until its tip was over the ACA's orifice. (B) Microcatheter was maintained in position to re-sheath the stent retriever in case of failure of re-sheath process by DIC. The DIC was advanced to attain proximity to the thrombus and held in place to generate maximum negative pressure during stent retriever withdrawal. (C) Rescue therapy, such as stent-retriever implantation or balloon dilation, was carried out on residual stenosis as required through the DIC. (D) In cases where compromised blood flow persisted, or vascular dissection occurred post-balloon dilation, a Solitaire stent was implanted. ACA, anterior cerebral artery.

Figure 2

A case presentation showcasing the application of the retrograde semi-retrieval technique in a real-world clinical setting for a patient with ICAS. A 67-year-old male with a medical history of hypertension and diabetes, and no indication of atrial fibrillation, presented to the emergency room with sudden right limb numbness and hemiplegia, which had started 10 h before admission. His NIHSS score upon admission was 9, clinically suggestive of AIS due to LVO with underlying ICAS. (A) Preoperative angiography revealed occlusion in the left MCA. The bilateral tissue regions supplied by the ACA were sustained by one dominant ACA, and the ICA was tortuous. (B) DIC was advanced to the petrous portion of the ICA and a Solitaire FR stent was deployed. Severe stenosis observed in the MCA on angiography further substantiated the ICAS diagnosis. (C) DIC was advanced beyond the ophthalmic artery (OA) origin, up to the C7 segment of the ICA. However, it was unable to progress further into the MCA. The stent was semi-retrieved using the microcatheter, following which the microcatheter and Solitaire FR stent were withdrawn as a single unit. (D) Angiography postretrieval of the Solitaire FR demonstrated unrecanalized MCA. (E) Rescue balloon angioplasty was initiated via the unwithdrawn DIC. (F) Although the MCA recanalized following angioplasty, potential indicators of vascular dissection were discerned. (G) The Solitaire FR stent was redeployed, and subsequent angiography revealed no signs of dissection. (H) The removal of the Solitaire FR stent resulted in good vascular patency, as per the angiography. NIHSS, National Institute of Health Stroke Scale; AIS, acute ischemic stroke; LVO, large vessel occlusion; ICAS, intracranial atherosclerotic stenosis; ACA, anterior cerebral artery; MCA, middle cerebral artery; ICA, internal carotid artery.

Figure 3

Study flow chart. AIS, acute ischemic stroke; BMM, best medical management; EVT, endovascular thrombectomy; ICAS, intracranial atherosclerotic stenosis; LVO, large vessel occlusion; NIHSS, National Institute of Health stroke scale; RESET, Retrograde Semi-Retrieval Technique.