Advertisement

Clinical Neuroradiology

, Volume 28, Issue 3, pp 327–338 | Cite as

Maximizing First-Pass Complete Reperfusion with SAVE

  • Volker Maus
  • Daniel Behme
  • Christoph Kabbasch
  • Jan Borggrefe
  • Ioannis Tsogkas
  • Omid Nikoubashman
  • Martin Wiesmann
  • Michael Knauth
  • Anastasios Mpotsaris
  • Marios Nikos Psychogios
Original Article

Abstract

Background

Endovascular techniques for treatment of large vessel occlusions (LVO) in patients with acute ischemic stroke (AIS) have advanced in recent years. We report a multicenter experience using a combined aspiration and stent retriever technique for mechanical thrombectomy (MT).

Methods

We retrospectively analyzed 32 consecutive MT patients using a novel, combined approach of Stent retriever Assisted Vacuum-locked Extraction (SAVE) by 3 operators at 3 stroke centers. Primary endpoint was successful first-pass reperfusion with a modified Thrombolysis in Cerebral Infarction (mTICI) score of 3. Secondary endpoints were number of passes, time from groin puncture to reperfusion, embolization to new territories (ENT), postinterventional symptomatic intracranial hemorrhage (sICH) and clinical outcome at discharge.

Results

First-pass mTICI 3 reperfusion was achieved in 23 out of 32 patients (72%) with a mean groin puncture to reperfusion time of 36.0 min ± 15.8 and mTICI 3 was accomplished in 25 out of 32 cases (78%) with a maximum of 3 attempts. Successful reperfusion (mTICI ≥ 2b) was achieved in all patients (100%) with a mean time from groin puncture to reperfusion of 44.5 min ± 25.8 and an average of 1.2 ± 0.7 attempts. The rate of ENT was 0% and 1 patient with sICH after MT died on postoperative day 4. At discharge, the median National Institutes of Health Stroke Scale (NIHSS) score was 4 (range 0−17) and favorable neurological outcome by the modified Rankin score (mRS ≤ 2) was achieved in 19 out of 32 patients (59%).

Conclusion

SAVE is fast and appears to be very effective in terms of first-pass complete reperfusion in patients with LVO.

Keywords

Acute ischemic stroke Large vessel occlusion Mechanical thrombectomy SAVE 

Notes

Compliance with ethical guidelines

Conflict of interests

V. Maus reports minor travel grants from Stryker Neurovascular. D. Behme reports minor travel grants from Stryker Neurovascular. C. Kabbasch reports minor travel grants from Stryker Neurovascular. J. Borggrefe has nothing to disclose. I. Tsogkas has nothing to disclose. O. Nikoubashman has nothing to disclose. M. Wiesmann reports grants and personal fees from Stryker Neurovascular, non-financial support from Covidien, non-financial support from Penumbra, non-financial support from Microvention/Terumo. M. Knauth has nothing to disclose. A. Mpotsaris reports personal fees for consultancy from Neuravi and Penumbra. M.N. Psychogios has nothing to disclose.

Ethical standards

According to the guidelines of the respective local ethics committees, no approval was necessary for this anonymous study, which was conducted in accordance to the Declaration of Helsinki (in its current revised form). Due to the retrospective nature of the study informed consent from participants was deemed unnecessary. Consent was obtained from any patients identifiable from images or other information in the manuscript.

Supplementary material

Illustrative video case of SAVE technique

References

  1. 1.
    Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, Schonewille WJ, Vos JA, Nederkoorn PJ, Wermer MJ, van Walderveen MA, Staals J, Hofmeijer J, van Oostayen JA, Lycklama à Nijeholt GJ, Boiten J, Brouwer PA, Emmer BJ, de Bruijn SF, van Dijk LC, Kappelle LJ, Lo RH, van Dijk EJ, de Vries J, de Kort PL, van Rooij WJ, van den Berg JS, van Hasselt BA, Aerden LA, Dallinga RJ, Visser MC, Bot JC, Vroomen PC, Eshghi O, Schreuder TH, Heijboer RJ, Keizer K, Tielbeek AV, den Hertog HM, Gerrits DG, van den Berg-Vos RM, Karas GB, Steyerberg EW, Flach HZ, Marquering HA, Sprengers ME, Jenniskens SF, Beenen LF, van den Berg R, Koudstaal PJ, van Zwam WH, Roos YB, van der Lugt A, van Oostenbrugge RJ, Majoie CB, Dippel DW; MR CLEAN Investigators. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372:11–20.CrossRefPubMedGoogle Scholar
  2. 2.
    Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, Roy D, Jovin TG, Willinsky RA, Sapkota BL, Dowlatshahi D, Frei DF, Kamal NR, Montanera WJ, Poppe AY, Ryckborst KJ, Silver FL, Shuaib A, Tampieri D, Williams D, Bang OY, Baxter BW, Burns PA, Choe H, Heo JH, Holmstedt CA, Jankowitz B, Kelly M, Linares G, Mandzia JL, Shankar J, Sohn SI, Swartz RH, Barber PA, Coutts SB, Smith EE, Morrish WF, Weill A, Subramaniam S, Mitha AP, Wong JH, Lowerison MW, Sajobi TT, Hill MD; ESCAPE Trial Investigators. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372:1019–30.CrossRefPubMedGoogle Scholar
  3. 3.
    Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, Albers GW, Cognard C, Cohen DJ, Hacke W, Jansen O, Jovin TG, Mattle HP, Nogueira RG, Siddiqui AH, Yavagal DR, Baxter BW, Devlin TG, Lopes DK, Reddy VK, du Mesnil de Rochemont R, Singer OC, Jahan R; SWIFT PRIME Investigators. Stent-retriever thrombectomy after intravenous t‑PA vs. t‑PA alone in stroke. N Engl J Med. 2015;372:2285–95.CrossRefPubMedGoogle Scholar
  4. 4.
    Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, Yan B, Dowling RJ, Parsons MW, Oxley TJ, Wu TY, Brooks M, Simpson MA, Miteff F, Levi CR, Krause M, Harrington TJ, Faulder KC, Steinfort BS, Priglinger M, Ang T, Scroop R, Barber PA, McGuinness B, Wijeratne T, Phan TG, Chong W, Chandra RV, Bladin CF, Badve M, Rice H, de Villiers L, Ma H, Desmond PM, Donnan GA, Davis SM; EXTEND-IA Investigators. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372:1009–18.CrossRefPubMedGoogle Scholar
  5. 5.
    Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, San Román L, Serena J, Abilleira S, Ribó M, Millán M, Urra X, Cardona P, López-Cancio E, Tomasello A, Castaño C, Blasco J, Aja L, Dorado L, Quesada H, Rubiera M, Hernandez-Pérez M, Goyal M, Demchuk AM, von Kummer R, Gallofré M, Dávalos A; REVASCAT Trial Investigators. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372:2296–306.CrossRefPubMedGoogle Scholar
  6. 6.
    Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke. 2007;38:967–73.CrossRefPubMedGoogle Scholar
  7. 7.
    Deshaies EM. Tri-axial system using the solitaire-FR and penumbra aspiration microcatheter for acute mechanical thrombectomy. J Clin Neurosci. 2013;20:1303–5.CrossRefPubMedGoogle Scholar
  8. 8.
    Humphries W, Hoit D, Doss VT, Elijovich L, Frei D, Loy D, Dooley G, Turk AS, Chaudry I, Turner R, Mocco J, Morone P, Fiorella D, Siddiqui A, Mokin M, Arthur AS. Distal aspiration with retrievable stent assisted thrombectomy for the treatment of acute ischemic stroke. J Neurointerv Surg. 2015;7:90–4.CrossRefPubMedGoogle Scholar
  9. 9.
    Turk AS, Spiotta A, Frei D, Mocco J, Baxter B, Fiorella D, Siddiqui A, Mokin M, Dewan M, Woo H, Turner R, Hawk H, Miranpuri A, Chaudry I. Initial clinical experience with the ADAPT technique: a direct aspiration first pass technique for stroke thrombectomy. J Neurointerv Surg. 2014;6:231–7.CrossRefPubMedGoogle Scholar
  10. 10.
    Kabbasch C, Möhlenbruch M, Stampfl S, Mpotsaris A, Behme D, Liebig T. First-line lesional aspiration in acute stroke thrombectomy using a novel intermediate catheter: Initial experiences with the SOFIA. Interv Neuroradiol. 2016;22:333–9.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Wiesmann M, Brockmann MA, Heringer S, Müller M, Reich A, Nikoubashman O. Active push deployment technique improves stent/vessel-wall interaction in endovascular treatment of acute stroke with stent retrievers. J Neurointerv Surg. 2016 Mar 14. [Epub ahead of print]CrossRefPubMedGoogle Scholar
  12. 12.
    Nikoubashman O, Alt JP, Nikoubashman A, Büsen M, Heringer S, Brockmann C, Brockmann MA, Müller M, Reich A, Wiesmann M. Optimizing endovascular stroke treatment: removing the microcatheter before clot retrieval with stent-retrievers increases aspiration flow. J Neurointerv Surg. 2016 Apr 15. [Epub ahead of print]CrossRefPubMedGoogle Scholar
  13. 13.
    Massari F, Henninger N, Lozano JD, Patel A, Kuhn AL, Howk M, Perras M, Brooks C, Gounis MJ, Kan P, Wakhloo AK, Puri AS. ARTS (Aspiration-Retriever Technique for Stroke): Initial clinical experience. Interv Neuroradiol. 2016;22:325–32.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Turk AS, Frei D, Fiorella D, Mocco J, Baxter B, Siddiqui A, Spiotta A, Mokin M, Dewan M, Quarfordt S, Battenhouse H, Turner R, Chaudry I. ADAPT FAST study: a direct aspiration first pass technique for acute stroke thrombectomy. J Neurointerv Surg. 2014;6:260–4.CrossRefPubMedGoogle Scholar
  15. 15.
    Kowoll A, Weber A, Mpotsaris A, Behme D, Weber W. Direct aspiration first pass technique for the treatment of acute ischemic stroke: initial experience at a European stroke center. J Neurointerv Surg. 2016;8:230–4.CrossRefPubMedGoogle Scholar
  16. 16.
    Nguyen TN, Malisch T, Castonguay AC, Gupta R, Sun CH, Martin CO, Holloway WE, Mueller-Kronast N, English JD, Linfante I, Dabus G, Marden FA, Bozorgchami H, Xavier A, Rai AT, Froehler MT, Badruddin A, Taqi M, Abraham MG, Janardhan V, Shaltoni H, Novakovic R, Yoo AJ, Abou-Chebl A, Chen PR, Britz GW, Kaushal R, Nanda A, Issa MA, Masoud H, Nogueira RG, Norbash AM, Zaidat OO. Balloon guide catheter improves revascularization and clinical outcomes with the Solitaire device: analysis of the North American Solitaire Acute Stroke Registry. Stroke. 2014;45:141–5.CrossRefPubMedGoogle Scholar
  17. 17.
    Lee JS, Hong JM, Lee SJ, Joo IS, Lim YC, Kim SY. The combined use of mechanical thrombectomy devices is feasible for treating acute carotid terminus occlusion. Acta Neurochir (Wien). 2013;155:635–41.CrossRefGoogle Scholar
  18. 18.
    Dippel DW, Majoie CB, Roos YB, van der Lugt A, van Oostenbrugge RJ, van Zwam WH, Lingsma HF, Koudstaal PJ, Treurniet KM, van den Berg LA, Beumer D, Fransen PS, Berkhemer OA; MR CLEAN Investigators. Influence of device choice on the effect of intra-arterial treatment for acute Ischemic stroke in MR CLEAN (Multicenter randomized clinical trial of endovascular treatment for acute ischemic stroke in the Netherlands). Stroke. 2016;47:2574–81.CrossRefPubMedGoogle Scholar
  19. 19.
    Zaidat OO, Castonguay AC, Gupta R, Sun CH, Martin C, Holloway WE, Mueller-Kronast N, English JD, Linfante I, Dabus G, Malisch TW, Marden FA, Bozorgchami H, Xavier A, Rai AT, Froehler MT, Badruddin A, Nguyen TN, Taqi MA, Abraham MG, Janardhan V, Shaltoni H, Novakovic R, Yoo AJ, Abou-Chebl A, Chen PR, Britz GW, Kaushal R, Nanda A, Issa MA, Nogueira RG. North American Solitaire Stent Retriever Acute Stroke registry: post-marketing revascularization and clinical outcome results. J Neurointerv Surg. 2014;6:584–8.CrossRefPubMedGoogle Scholar
  20. 20.
    Delgado Almandoz JE, Kayan Y, Young ML, Fease JL, Scholz JM, Milner AM, Hehr TH, Roohani P, Mulder M, Tarrel RM. Comparison of clinical outcomes in patients with acute ischemic strokes treated with mechanical thrombectomy using either Solumbra or ADAPT techniques. J Neurointerv Surg. 2015;8:1123–8.CrossRefPubMedGoogle Scholar
  21. 21.
    Turk AS, Turner R, Spiotta A, Vargas J, Holmstedt C, Ozark S, Chalela J, Turan T, Adams R, Jauch EC, Battenhouse H, Whitsitt B, Wain M, Chaudry MI. Comparison of endovascular treatment approaches for acute ischemic stroke: cost effectiveness, technical success, and clinical outcomes. J Neurointerv Surg. 2015;7:666–70.CrossRefPubMedGoogle Scholar
  22. 22.
    Vargas J, Spiotta A, Fargen K, Turner R, Chaudry I, Turk A. Long term experience using the ADAPT technique for the treatment of acute ischemic stroke. J Neurointerv Surg. 2016 Apr 18. [Epub ahead of print]CrossRefPubMedGoogle Scholar
  23. 23.
    Möhlenbruch MA, Kabbasch C, Kowoll A, Broussalis E, Sonnberger M, Müller M, Wiesmann M, Trenkler J, Killer-Oberpfalzer M, Weber W, Mpotsaris A, Bendszus M, Stampfl S. Multicenter experience with the new SOFIA Plus catheter as a primary local aspiration catheter for acute stroke thrombectomy. J Neurointerv Surg. 2016 Dec 20. [Epub ahead of print]CrossRefPubMedGoogle Scholar
  24. 24.
    Velasco A, Buerke B, Stracke CP, Berkemeyer S, Mosimann PJ, Schwindt W, Alcázar P, Cnyrim C, Niederstadt T, Chapot R, Heindel W. Comparison of a balloon guide catheter and a non-balloon guide catheter for mechanical thrombectomy. Radiology. 2016;280:169–76.CrossRefPubMedGoogle Scholar
  25. 25.
    Mocco J, Zaidat OO, von Kummer R, Yoo AJ, Gupta R, Lopes D, Frei D, Shownkeen H, Budzik R, Ajani ZA, Grossman A, Altschul D, McDougall C, Blake L, Fitzsimmons BF, Yavagal D, Terry J, Farkas J, Lee SK, Baxter B, Wiesmann M, Knauth M, Heck D, Hussain S, Chiu D, Alexander MJ, Malisch T, Kirmani J, Miskolczi L, Khatri P; THERAPY Trial Investigators*. Aspiration thrombectomy after intravenous alteplase versus intravenous alteplase alone. Stroke. 2016;47:2331–8.CrossRefPubMedGoogle Scholar
  26. 26.
    Haussen DC, Rebello LC, Nogueira RG. Optimizating clot retrieval in acute stroke: the push and fluff technique for closed-cell stentrievers. Stroke. 2015;46:2838–42.CrossRefPubMedGoogle Scholar
  27. 27.
    Nogueira RG, Lutsep HL, Gupta R, Jovin TG, Albers GW, Walker GA, Liebeskind DS, Smith WS; TREVO 2 Trialists. Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trial. Lancet. 2012;380:1231–40.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Pereira VM, Gralla J, Davalos A, Bonafé A, Castaño C, Chapot R, Liebeskind DS, Nogueira RG, Arnold M, Sztajzel R, Liebig T, Goyal M, Besselmann M, Moreno A, Schroth G. Prospective, multicenter, single-arm study of mechanical thrombectomy using solitaire flow restoration in acute ischemic stroke. Stroke. 2013;44:2802–7.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Almekhlafi MA, Menon BK, Freiheit EA, Demchuk AM, Goyal M. A meta-analysis of observational intra-arterial stroke therapy studies using the Merci device, Penumbra system, and retrievable stents. AJNR Am J Neuroradiol. 2013;34:140–5.CrossRefPubMedGoogle Scholar
  30. 30.
    Bracard S, Ducrocq X, Mas JL et al. Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomised controlled trial. Lancet Neurol 2016;15:1138–47.Google Scholar
  31. 31.
    Broderick JP, Palesch YY, Demchuk AM et al. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Engl J Med 2013;368:893–903.Google Scholar
  32. 32.
    Saver JL, Jahan R, Levy EI, Jovin TG, Baxter B, Nogueira RG, Clark W, Budzik R, Zaidat OO; SWIFT Trialists. Solitaire flow restoration device versus the Merci retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial. Lancet. 2012;380:1241–9.CrossRefPubMedGoogle Scholar
  33. 33.
    Singer OC, Berkefeld J, Nolte CH et al. Mechanical recanalization in basilar artery occlusion: the ENDOSTROKE study. ANN NEUROL 2015;77:415–424.Google Scholar
  34. 34.
    McTaggart RA, Tung EL, Yaghi S, Cutting SM, Hemendinger M, Gale HI, Baird GL, Haas RA, Jayaraman MV. Continuous aspiration prior to intracranial vascular embolectomy (CAPTIVE): a technique which improves outcomes. J Neurointerv Surg. 2016 Dec 16. [Epub ahead of print]PubMedCentralCrossRefPubMedGoogle Scholar
  35. 35.
    Brinjikji W, Rabinstein AA, Kallmes DF, Cloft HJ. Patient outcomes with endovascular embolectomy therapy for acute ischemic stroke: a study of the national inpatient sample: 2006 to 2008. Stroke. 2011;42:1648–52.CrossRefPubMedGoogle Scholar
  36. 36.
    Zhu W, Xiao L, Lin M, Liu X, Yan B. Large-vessel occlusion is associated with poor outcome in stroke patients aged 80 years or older who underwent intravenous thrombolysis. J Stroke Cerebrovasc Dis. 2016;25:2712–6.CrossRefPubMedGoogle Scholar
  37. 37.
    Sauer EM, Sauer R, Kallmunzer B, Blinzler C, Breuer L, Huttner HB, Schwab S, Köhrmann M. Impaired renal function in stroke patients with atrial fibrillation. J Stroke Cerebrovasc Dis. 2014;23:1225–8.CrossRefPubMedGoogle Scholar
  38. 38.
    Chueh JY, Puri AS, Wakhloo AK, Gounis MJ. Risk of distal embolization with stent retriever thrombectomy and ADAPT. J Neurointerv Surg. 2016;8:197–202.CrossRefPubMedGoogle Scholar
  39. 39.
    Chueh JY, Kühn AL, Puri AS, Wilson SD, Wakhloo AK, Gounis MJ. Reduction in distal emboli with proximal flow control during mechanical thrombectomy: a quantitative in vitro study. Stroke. 2013;44:1396–401.CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2017

Authors and Affiliations

  • Volker Maus
    • 1
  • Daniel Behme
    • 2
  • Christoph Kabbasch
    • 1
  • Jan Borggrefe
    • 1
  • Ioannis Tsogkas
    • 2
  • Omid Nikoubashman
    • 3
  • Martin Wiesmann
    • 3
  • Michael Knauth
    • 2
  • Anastasios Mpotsaris
    • 1
  • Marios Nikos Psychogios
    • 2
  1. 1.Department of Diagnostic and Interventional RadiologyUniversity Hospital CologneCologneGermany
  2. 2.Department of Diagnostic and Interventional RadiologyUniversity of GöttingenGöttingenGermany
  3. 3.Department of Diagnostic and Interventional NeuroradiologyUniversity Hospital of AachenAachenGermany

Personalised recommendations