Manual Aspiration

Techniques in Acute

Ischemic Stroke

Ashutosh P. Jadhav, MD PhD

Department of Neurology

University of Pittsburgh

Approaches to

revascularization

1. Local lytic delivery

2. Snare/retrieval device

3. Balloon plasty/stent detachment

4. Stentriever

5. Aspiration thrombectomy

1. Separator device with pump

2. ADAPT

3. Manual aspiration thrombectomy (MAT)

4. Stentriever mediated manual aspiration thrombectomy (SMAT)

Benefits of manual aspiration

1.Safe

2.Simple

3.High rates of recanalization

4.Fast rates of recanalization

5.Lower costs

Aspiration through

7F Cordis catheter

with 60-mL syringe

Toolbox

1. Microwire: 0.014” Synchro 2; 0.016” Fathom

2. Microcatheter: 18L; Marksman; Velocity

3. Support catheter: 6Fr Neuron Max; 6Fr Cook Shuttle

4. Mid sized catheter

5. 25-mL Syringe

Mid sized catheters Outer Diameter Inner Diameter Lengths

038 DAC 3.9F (0.05”/1.3 mm) 2.9F (0.038”/0.9 mm) 125 cm, 136 cm

044 DAC 4.3F (0.056”/1.45 mm) 3.3F (0.044”/1.1 mm) 115 cm-136 cm

057 DAC 5.2F (0.068”/1.75 mm) 4.3F (0.057”/1.4 mm) 115 cm, 125 cm

058 Navien 5.2F (0.070”) (0.058”) 105-130 cm

072 Navien 6.3F (0.084”) (0.072”) 95-130 cm

3 MAX 4.7F (0.062”, 1.57 mm) 3.8F (0.035”, 0.89 mm) (0.043”) (0.035”, 0.89 mm) 153 cm

4 MAX 6F (0.08”, 2.03 mm) 4.3F (0.041”, 1.04 mm) (0.064”) (0.041”, 1.04 mm) (139 cm

5 MAX 6F (0.08”, 2.03 mm) 5F (0.054”, 1.37 mm) (0.064”) (0.054”, 1.37 mm) 132 cm

ACE 6F (0.08”, 2.03 mm) 5.4F (0.071”, 1.8 mm) (0.068”) (0.060”, 1.52 mm) 132 cm

Evolution of approach

1. Intermittent, manual aspiration thrombectomy as

rescue therapy after failed (intra-arterial tpa or

MERCI clot retrieval)

2.Primary manual aspiration thrombectomy

3.Stentriever mediated manual aspiration

thrombectomy

Rescue therapy with MAT

- UPMC (2008-2011)

- Sample size: 191 patients

- MAT with DAC/Penumbra

- TICI 2b/3: 71%

- Groin to recanalization: 90 minutes

- mRS 0-2 outcomes at 90 days: 54%

Stroke. 2012;43:1408-1411

Primary MAT

- UPMC (2012-2013)

- Sample size: 112 consecutive patients

- MAT with Navien/DAC/Penumbra

- TICI 2b/3: 86%

- Groin to recanalization: 70 minutes

- mRS 0-2 outcomes at 90 days: 46%

Jankowitz et al (JNIS 2014)

Primary MAT via

Transcervical Approach

- Sample size: 7 patients

- MAT with Navien OR Trevo alone

- TICI 2b/3: 87.5%

- Carotid to recanalization: 7-49 minutes

Jadhav et al (JNIS 2014)

Stentriever mediated MAT

Stentriever Mediated Manual Aspiration

Thrombectomy (SMAT) for Acute Ischemic Stroke in

93 Consecutive Patients

Demographics - Median age: 67. Median NIHSS: 17. Patients had the following baseline features:

48% female gender, 72% hypertension, 12% diabetes, 39% atrial fibrillation, 29%

CAD.

- Occlusion distribution included 71% M1, 13% M2, 13% ICAT, 16% VB

- 28% received IV tpa and 34% presented beyond 8 hours

- High quality recanalization (TICI2b/3) was achieved in 88% of patients

- Recanalization required an average of 2.36 passes

- The Solitaire stentriever was used in 81% of cases and the Trevo device was

used in the remainder of cases

- 072/058 Navien in 74% of cases, 043 DAC in 4% of cases and 5Max ACE in 27%

of cases

- Median door to groin puncture time was 69 minutes and median groin puncture to

recanalization time was 47 minutes.

- Symptomatic hemorrhage occurred in 5% of patients.

- Good outcomes were noted in 42% of patients

- In anterior circulation stroke patients who received IV tpa prior to IA therapy, good

outcomes were noted in 50% of patients.

Jadhav et al, ISC 2015

MAT SMAT p value

Sample size 112 93

Age 66.5 66.7 ns

NIHSS 17 16.6 ns

IV tpa 41% 28% 0.048

# passes 2.24 2.3 ns

Good outcomes 46% 42% ns

TICI 2b/3 87% 88% ns

G2R 70 min 47 min P<0.0001

Single center comparison

Jadhav et al, ISC 2015

MAT for VST

Kenmuir et al, SVIN 2014

Summary

1. Manual aspiration thrombectomy is a safe and simple technique which can lead

to fast and high quality recanalization

2. Pure manual aspiration thrombectomy may be a cost effective alternative to

other mechanical retrieval devices

3. Stentreiver mediated manual aspiration thrombectomy may be superior to either

technique alone

4. Future studies will be necessary compare MAT, SMAT and stentrievers with

balloon guide catheters with focus on outcomes and cost

5. Future studies will be necessary to investigate MAT/SMAT with direct

transcervical access in select patients