Clot Aspiration Thrombectomy in Acute Ischemic Stroke

  • Dong-Hun Kang


The first approved treatment for acute ischemic stroke was intravenous recombinant tissue plasminogen activator; however, the efficacy was limited as a result of its narrow time window for administration, certain contraindications, and low recanalization rates. This prompted an evolution in endovascular stroke therapy during the past two decades, moving from intra-arterial thrombolytic infusion to modern mechanical thrombectomy techniques. Among the various endovascular approaches, stent retriever thrombectomy and direct clot aspiration are two dominant methods in the present era. One such mechanical thrombectomy technique, “clot aspiration thrombectomy” or “direct clot aspiration,” is the topic of this chapter. The commonalities and differences between the current two major techniques for clot aspiration thrombectomy, a direct aspiration first pass technique (ADAPT) and forced arterial suction thrombectomy (FAST), will be explained. And the details regarding the combined usage of direct clot aspiration and stent retriever thrombectomy, namely, the switching strategy and the Solumbra technique, will be additionally discussed.


Acute ischemic stroke A direct aspiration first pass technique (ADAPT) Clot aspiration thrombectomy Endovascular stroke therapy Forced arterial suction thrombectomy (FAST) Mechanical thrombectomy 


  1. 1.
    Starck EE, McDermott JC, Crummy AB, et al. Percutaneous aspiration thromboembolectomy. Radiology. 1985;156:61–6.CrossRefPubMedGoogle Scholar
  2. 2.
    Lutsep HL, Clark WM, Nesbit GM, et al. Intraarterial suction thrombectomy in acute stroke. AJNR Am J Neuroradiol. 2002;23:783–6.PubMedGoogle Scholar
  3. 3.
    Chapot R, Houdart E, Rogopoulos A, et al. Thromboaspiration in the basilar artery: report of two cases. AJNR Am J Neuroradiol. 2002;23:282–4.PubMedGoogle Scholar
  4. 4.
    Imai K, Mori T, Izumoto H, et al. Clot removal therapy by aspiration and extraction for acute embolic carotid occlusion. AJNR Am J Neuroradiol. 2006;27:1521–7.PubMedGoogle Scholar
  5. 5.
    Xu GF, Suh DC, Choi CG, et al. Aspiration thrombectomy of acute complete carotid bulb occlusion. J Vasc Interv Radiol. 2005;16:539–42.CrossRefPubMedGoogle Scholar
  6. 6.
    Kang DH, Hwang YH, Kim YS, et al. Direct thrombus retrieval using the reperfusion catheter of the penumbra system: forced-suction thrombectomy in acute ischemic stroke. AJNR Am J Neuroradiol. 2011;32:283–7.CrossRefPubMedGoogle Scholar
  7. 7.
    Turk AS, Spiotta A, Frei D, et al. 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
  8. 8.
    Hwang YH, Kang DH, Kim YW, et al. Outcome of forced-suction thrombectomy in acute intracranial internal carotid occlusion. J Neurointerv Surg Suppl. 2013;1:i81–4.CrossRefGoogle Scholar
  9. 9.
    Chueh JY, Kühn AL, Puri AS, et al. Reduction in distal emboli with proximal flow control during mechanical thrombectomy: a quantitative in vitro study. Stroke. 2013;44:1396–401.CrossRefPubMedGoogle Scholar
  10. 10.
    Gralla J, Schroth G, Remonda L, et al. Mechanical thrombectomy for acute ischemic stroke: thrombus-device interaction, efficiency, and complications in vivo. Stroke. 2006;37:3019–24.CrossRefPubMedGoogle Scholar
  11. 11.
    Saver JL, Jahan R, Levy EI, et al. 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
  12. 12.
    Saver JL, Goyal M, Bonafe A, SWIFT PRIME Investigators, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015;372:2285–95.CrossRefPubMedGoogle Scholar
  13. 13.
    Jahan R. 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. 2010;31:1938–43.CrossRefPubMedGoogle Scholar
  14. 14.
    Nguyen TN, Malisch T, Castonguay AC, et al. 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
  15. 15.
    Kiyosue H, Hori Y, Matsumoto S, et al. Shapability, memory, and luminal changes in microcatheters after steam shaping: a comparison of 11 different microcatheters. AJNR Am J Neuroradiol. 2005;26:2610–1616.PubMedGoogle Scholar
  16. 16.
    Kwon BJ, Im SH, Park JC, et al. Shaping and navigating methods of microcatheters for endovascular treatment of paraclinoid aneurysms. Neurosurgery. 2010;67:34–40.CrossRefPubMedGoogle Scholar
  17. 17.
    Nogueira RG, Lutsep HL, Gupta R, et al. 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
  18. 18.
    Berkhemer OA, Fransen PS, Beumer D, MR CLEAN Investigators, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372:11–20.CrossRefPubMedGoogle Scholar
  19. 19.
    Campbell BC, Mitchell PJ, Kleinig TJ, EXTEND-IA Investigators, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372:1009–18.CrossRefPubMedGoogle Scholar
  20. 20.
    Goyal M, Demchuk AM, Menon BK, ESCAPE Trial Investigators, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372:1019–30.CrossRefPubMedGoogle Scholar
  21. 21.
    Jovin TG, Chamorro A, Cobo E, REVASCAT Trial Investigators, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372:2296–306.CrossRefPubMedGoogle Scholar
  22. 22.
    Kang DH, Kim YW, Hwang YH, et al. Switching strategy for mechanical thrombectomy of acute large vessel occlusion in the anterior circulation. Stroke. 2013;44:3577–9.CrossRefPubMedGoogle Scholar
  23. 23.
    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
  24. 24.
    Lee JS, Hong JM, Lee SJ, et al. The combined use of mechanical thrombectomy devices is feasible for treating acute carotid terminus occlusion. Acta Neurochir. 2013;155:635–41.CrossRefPubMedGoogle Scholar
  25. 25.
    Humphries W, Hoit D, Doss VT, et al. Distal aspiration with retrievable stent assisted thrombectomy for the treatment of acute ischemic stroke. J Neurointerv Surg. 2015;7:90–4.CrossRefPubMedGoogle Scholar
  26. 26.
    Delgado Almandoz JE, Kayan Y, Young ML, et al. Comparison of clinical outcomes in patients with acute ischemic strokes treated with mechanical thrombectomy using either Solumbra or ADAPT techniques. J Neurointerv Surg. 2016;8:1123–8.Google Scholar
  27. 27.
    Eesa M, Almekhlafi MA, Mitha AP, et al. Manual aspiration thrombectomy through balloon-tipped guide catheter for rapid clot burden reduction in endovascular therapy for ICA L/T occlusion. Neuroradiology. 2012;54:1261–5.CrossRefPubMedGoogle Scholar
  28. 28.
    Kim YW, Kang DH, Hwang YH, et al. Efficacy of proximal aspiration thrombectomy for using balloon guide catheter in acute intracranial internal carotid artery occlusion. J Korean Neurosurg Soc. 2016;59:379–84.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Caplan LR, Wityk RJ, Glass TA, et al. New England Medical Center Posterior Circulation registry. Ann Neurol. 2004;56:389–98.CrossRefPubMedGoogle Scholar
  30. 30.
    Hacke W, Zeumer H, Ferbert A, et al. Intra-arterial thrombolytic therapy improves outcome in patients with acute vertebrobasilar occlusive disease. Stroke. 1988;19:1216–22.CrossRefPubMedGoogle Scholar
  31. 31.
    Pfefferkorn T, Holtmannspötter M, Schmidt C, et al. Drip, ship, and retrieve: cooperative recanalization therapy in acute basilar artery occlusion. Stroke. 2010;41:722–6.CrossRefPubMedGoogle Scholar
  32. 32.
    Pfefferkorn T, Mayer TE, Opherk C, et al. Staged escalation therapy in acute basilar artery occlusion: intravenous thrombolysis and on-demand consecutive endovascular mechanical thrombectomy: preliminary experience in 16 patients. Stroke. 2008;39:1496–500.CrossRefPubMedGoogle Scholar
  33. 33.
    Eckert B, Kucinski T, Pfeiffer G, et al. Endovascular therapy of acute vertebrobasilar occlusion: early treatment onset as the most important factor. Cerebrovasc Dis. 2002;14:42–50.CrossRefPubMedGoogle Scholar
  34. 34.
    Schonewille WJ, Wijman CA, Michel P, et al. Treatment and outcomes of acute basilar artery occlusion in the Basilar Artery International Cooperation Study (BASICS): a prospective registry study. Lancet Neurol. 2009;8:724–30.CrossRefPubMedGoogle Scholar
  35. 35.
    Lutsep HL, Rymer MM, Nesbit GM. Vertebrobasilar revascularization rates and outcomes in the MERCI and multi-MERCI trials. J Stroke Cerebrovasc Dis. 2008;17:55–7.CrossRefPubMedGoogle Scholar
  36. 36.
    Mordasini P, Brekenfeld C, Byrne JV, et al. Technical feasibility and application of mechanical thrombectomy with the Solitaire FR Revascularization Device in acute basilar artery occlusion. AJNR Am J Neuroradiol. 2013;34:159–63.CrossRefPubMedGoogle Scholar
  37. 37.
    Eom YI, Hwang YH, Hong JM, et al. Forced arterial suction thrombectomy with the penumbra reperfusion catheter in acute basilar artery occlusion: a retrospective comparison study in 2 Korean university hospitals. AJNR Am J Neuroradiol. 2014;35:2354–9.CrossRefPubMedGoogle Scholar
  38. 38.
    Holmstedt CA, Turan TN, Chimowitz MI. Atherosclerotic intracranial arterial stenosis: risk factors, diagnosis, and treatment. Lancet Neurol. 2013;12:1106–14.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Kasner SE, Chimowitz MI, Lynn MJ, Warfarin Aspirin Symptomatic Intracranial Disease Trial Investigators, et al. Predictors of ischemic stroke in the territory of a symptomatic intracranial arterial stenosis. Circulation. 2006;113:555–63.CrossRefPubMedGoogle Scholar
  40. 40.
    Ryu CW, Kwak HS, Jahng GH, et al. High-resolution MRI of intracranial atherosclerotic disease. Neurointervention. 2014;9:9–20.CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Liu H, Lee DG, Jung SC, et al. A study design to evaluate association between smoking and intracranial atherosclerotic stenosis. Neurointervention. 2014;9:89–93.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Yoon W, Kim SK, Park MS, et al. Endovascular treatment and the outcomes of atherosclerotic intracranial stenosis in patients with hyperacute stroke. Neurosurgery. 2015;76:680–6.CrossRefPubMedGoogle Scholar
  43. 43.
    Kang DH, Kim YW, Hwang YH, et al. Instant reocclusion following mechanical thrombectomy of in situ thromboocclusion and the role of low-dose intra-arterial tirofiban. Cerebrovasc Dis. 2014;37:350–5.PubMedGoogle Scholar
  44. 44.
    Kang HS, Kwon BJ, Roh HG, et al. Intra-arterial tirofiban infusion for thromboembolism during endovascular treatment of intracranial aneurysms. Neurosurgery. 2008;63:230–7.CrossRefPubMedGoogle Scholar
  45. 45.
    Kang DH, Kim YS, Park J, et al. Rescue forced-suction thrombectomy using the reperfusion catheter of the Penumbra System for thromboembolism during coil embolization of ruptured cerebral aneurysms. Neurosurgery. 2012;70:89–93.PubMedGoogle Scholar
  46. 46.
    Kim YW, Kang DH, Hwang JH, et al. Rescue strategy for acute carotid stent thrombosis during carotid stenting with distal filter protection using forced arterial suction thrombectomy with a reperfusion catheter of the Penumbra System: a technical note. Acta Neurochir. 2013;155:1583–8.CrossRefPubMedGoogle Scholar
  47. 47.
    Yoon W, Jung MY, Jung SH, et al. Subarachnoid hemorrhage in a multimodal approach heavily weighted toward mechanical thrombectomy with solitaire stent in acute stroke. Stroke. 2013;44:414–9.CrossRefPubMedGoogle Scholar
  48. 48.
    Chueh JY, Puri AS, Wakhloo AK, et al. Risk of distal embolization with stent retriever thrombectomy and ADAPT. J Neurointerv Surg. 2016;8:197–202.CrossRefPubMedGoogle Scholar
  49. 49.
    Rapp JH, Pan XM, Yu B, et al. Cerebral ischemia and infarction from atheroemboli <100 microm in Size. Stroke. 2003;34:1976–80.CrossRefPubMedGoogle Scholar
  50. 50.
    Hu YC, Stiefel MF. Force and aspiration analysis of the ADAPT technique in acute ischemic stroke treatment. J Neurointerv Surg. 2016;8:244–6.CrossRefPubMedGoogle Scholar
  51. 51.
    Spiotta AM, Chaudry MI, Hui FK, et al. Evolution of thrombectomy approaches and devices for acute stroke: a technical review. J Neurointerv Surg. 2015;7:2–7.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media Singapore 2017

Authors and Affiliations

  1. 1.Department of Neurosurgery and RadiologyKyungpook National University Hospital, School of Medicine, Kyungpook National UniversityDaeguRepublic of Korea
  2. 2.Daegu-Gyeongbuk Cardiocerebrovascular CenterDaeguRepublic of Korea

Personalised recommendations