Acta Neurochirurgica

, Volume 159, Issue 9, pp 1671–1677 | Cite as

Effective use of balloon guide catheters in reducing incidence of mechanical thrombectomy related distal embolization

  • Dong Hoon Lee
  • Jae Hoon SungEmail author
  • Sang Uk Kim
  • Ho Jun Yi
  • Jae Taek Hong
  • Sang Won Lee


Background and purpose

The clinical benefit of endovascular stroke therapy has been demonstrated in several prospective randomized trials. However, in a relevant percentage of patients, mechanical thrombectomy bears the risk of causing new infarction in initially unaffected vascular territories through thrombus fragmentation and migration of clot debris. The goal of this study was to evaluate the use of the balloon guide catheter (BGC) to effectively achieve flow arrest and thrombus aspiration during the intervention to avoid distal embolization.


A retrospective study was performed in 139 patients between October 2010 and May 2016 to analyze occlusions in the middle cerebral artery (MCA) or internal carotid artery (ICA) by using a stent retriever with a BGC (n = 73) or a non-BGC (n = 66). The following data were collected: patient age and gender, along with history of diabetes mellitus, hypertension, atrial fibrillation, smoking, obesity, dyslipidemia, and previous ischemic stroke. Data on procedure time, number of passes, and angiographic findings were also collected. The final reperfusion score was rated based on the Thrombolysis in Cerebral Infarction (TICI) grading scale. Successful recanalization was defined as TICI 3 or 2b.


A total of 139 patients underwent mechanical thrombectomy with the stent retriever. Of the 139 patients, 73 (52.5%) underwent placement of a BGC. The mean age was 65.8 ± 13.5 years, and the median National Institutes of Health Stroke Scale (NIHSS) score was 11. The average initial NIHSS score was lower in the BGC group compared with the non-BGC group (mean, 11.2 ± 5.6 vs. 13.2 ± 5.6; P = 0.03). Patients with BGC had fewer incidences of previous ischemic stroke (12.3% vs. 28.8%; P = 0.01). The numbers of passes were similar between the two groups. The procedure time (99 ± 49.4 min vs. 124 ± 72.2 min; P = 0.02) and the time from onset of symptoms to procedure end (302 ± 102 min vs. 357.2 ± 136.1 min; P = 0.009) were shorter in the BGC group. TICI 3 or 2b recanalization scores were higher in the BGC group compared to the non-BGC group [63/73, 86.3% vs. 48/66, 72.7%; odds ratio (OR), 0.6; 95% confidence interval (CI), 0.2–1.4; P = 0.04]. Importantly, distal embolization was less frequent in the BGC group (5/73, 6.8% vs. 21/66, 31.8%; OR, 6.3; 95% CI, 2.2–18.0; P < 0.001).


The risk of distal embolization was significantly decreased with the use of a BGC.


Mechanical thrombectomy Distal embolization Balloon-guided catheter 


Compliance with ethical standards

Conflict of interest

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements) or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.


No funding was received for this research.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. For this type of study formal consent is not required.

Informed consent

Additional informed consent was obtained from all individual participants for whom identifying information is included in this article.


  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, Nijeholt GJ LA, 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 (2015) A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 372:11–20CrossRefPubMedGoogle Scholar
  2. 2.
    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 (2015) Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 372:1009–1018CrossRefPubMedGoogle Scholar
  3. 3.
    Chueh JY, Kuhn AL, Puri AS, Wilson SD, Wakhloo AK, Gounis MJ (2013) Reduction in distal emboli with proximal flow control during mechanical thrombectomy: a quantitative in vitro study. Stroke 44:1396–1401CrossRefPubMedGoogle Scholar
  4. 4.
    Chueh JY, Wakhloo AK, Gounis MJ (2012) Effectiveness of mechanical endovascular thrombectomy in a model system of cerebrovascular occlusion. AJNR Am J Neuroradiol 33:1998–2003CrossRefPubMedGoogle Scholar
  5. 5.
    Demerath T, Reinhard M, Elsheikh S, Keuler A, Urbach H, Meckel S (2016) Balloon guide catheter in complex anterior circulation mechanical thrombectomy: beyond proximal occlusion and flow reversal. Clin Neuroradiol 26:369–373Google Scholar
  6. 6.
    Dorn F, Stehle S, Lockau H, Zimmer C, Liebig T (2012) Endovascular treatment of acute intracerebral artery occlusions with the solitaire stent: single-centre experience with 108 recanalization procedures. Cerebrovascular diseases (Basel, Switzerland) 34:70–77CrossRefGoogle Scholar
  7. 7.
    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 (2015) Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 372:1019–1030CrossRefPubMedGoogle Scholar
  8. 8.
    Gralla J, Schroth G, Remonda L, Nedeltchev K, Slotboom J, Brekenfeld C (2006) Mechanical thrombectomy for acute ischemic stroke: thrombus-device interaction, efficiency, and complications in vivo. Stroke 37:3019–3024CrossRefPubMedGoogle Scholar
  9. 9.
    Imai K, Mori T, Izumoto H, Takabatake N, Kunieda T, Shimizu H, Watanabe M (2006) Clot removal therapy by aspiration and extraction for acute embolic carotid occlusion. AJNR Am J Neuroradiol 27:1521–1527PubMedGoogle Scholar
  10. 10.
    Jahan R (2010) Solitaire flow-restoration device for treatment of acute ischemic stroke: safety and recanalization efficacy study in a swine vessel occlusion model. AJNR Am J Neuroradiol 31:1938–1943CrossRefPubMedGoogle Scholar
  11. 11.
    Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, San Roman L, Serena J, Abilleira S, Ribo M, Millan M, Urra X, Cardona P, Lopez-Cancio E, Tomasello A, Castano C, Blasco J, Aja L, Dorado L, Quesada H, Rubiera M, Hernandez-Perez M, Goyal M, Demchuk AM, von Kummer R, Gallofre M, Davalos A (2015) Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 372:2296–2306CrossRefPubMedGoogle Scholar
  12. 12.
    Mayer TE, Hamann GF, Brueckmann HJ (2002) Treatment of basilar artery embolism with a mechanical extraction device: necessity of flow reversal. Stroke 33:2232–2235CrossRefPubMedGoogle Scholar
  13. 13.
    Mokin M, Kass-Hout T, Levy EI (2012) Solitaire FR--a promising new device for acute ischemic stroke treatment. World neurosurgery 78:557–558CrossRefPubMedGoogle Scholar
  14. 14.
    Mordasini P, Frabetti N, Gralla J, Schroth G, Fischer U, Arnold M, Brekenfeld C (2011) In vivo evaluation of the first dedicated combined flow-restoration and mechanical thrombectomy device in a swine model of acute vessel occlusion. AJNR Am J Neuroradiol 32:294–300CrossRefPubMedGoogle Scholar
  15. 15.
    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 (2014) Balloon guide catheter improves revascularization and clinical outcomes with the solitaire device: analysis of the north American solitaire acute stroke registry. Stroke 45:141–145CrossRefPubMedGoogle Scholar
  16. 16.
    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 (2015) Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 372:2285–2295CrossRefPubMedGoogle Scholar
  17. 17.
    Tomsick TA, Khatri P, Jovin T, Demaerschalk B, Malisch T, Demchuk A, Hill MD, Jauch E, Spilker J, Broderick JP (2010) Equipoise among recanalization strategies. Neurology 74:1069–1076CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    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 (2014) Initial clinical experience with the ADAPT technique: a direct aspiration first pass technique for stroke thrombectomy. Journal of Neurointerventional Surgery 6:231–237CrossRefPubMedGoogle Scholar
  19. 19.
    Velasco A, Buerke B, Stracke CP, Berkemeyer S, Mosimann PJ, Schwindt W, Alcazar P, Cnyrim C, Niederstadt T, Chapot R, Heindel W (2016) Comparison of a balloon guide catheter and a non-balloon guide catheter for mechanical thrombectomy. Radiology 280:169–176CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Austria 2017

Authors and Affiliations

  • Dong Hoon Lee
    • 1
  • Jae Hoon Sung
    • 1
    Email author
  • Sang Uk Kim
    • 1
  • Ho Jun Yi
    • 1
  • Jae Taek Hong
    • 1
  • Sang Won Lee
    • 1
  1. 1.Department of Neurosurgery, St. Vincent’s Hospital, The Catholic University of KoreaSuwonSouth Korea

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