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CASE REPORT
Year : 2022 | Volume
: 8
| Issue : 4 | Page : 215-218
Mechanical thrombectomy with a novel beveled tip aspiration catheter: A technical case report
Cagin Senturk
Neurovascular and Spine Associates, Orange County, CA, USA; Department of Interventional and Neuroendovascular Radiology, Izmir Tinaztepe University, Izmir, Turkey
Correspondence Address:
Cagin Senturk
Neurovascular and Spine Associates 2151 N. Harbor Suite 1500 Fullerton, CA 92835 USA
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/bc.bc_47_22
Recent data suggested aspiration thrombectomy as the first-pass approach in endovascular treatment of acute stroke and is accepted as a safe and efficient alternative to stent-retriever thrombectomy. The efficiency of mechanical thrombectomy for complete removal of the clot is directly related to the catheter trackability, aspiration force, and inner diameter of the aspiration catheter. Zoom 71 Aspiration catheter (Imperative Care, Campbell, California, USA) is a novel aspiration catheter with a beveled tip aiming to increase the tip surface area, increased suction force, and advanced trackability. This case report describes the successful use of Zoom 71 aspiration catheter in a left middle cerebral artery M2 branch occlusion and highlights technical details including navigation without the support of a microcatheter microwire combination.
Keywords: Aspiration thrombectomy, better trackability, bevel tip, increased suction force, Zoom 71 aspiration catheter
Aspiration thrombectomy (AT) as a first-pass approach is accepted as a safe and efficient alternative to stent-retriever thrombectomy.[1] The efficiency of mechanical thrombectomy is directly related to the catheter trackability, aspiration force, and inner diameter of the aspiration catheter.[2],[3] A novel design of a beveled tip aspiration catheter aimed at better navigation and increasing the aspiration force by increasing tip surface area. This case report describes the successful use of Zoom 71 aspiration catheter in a left middle cerebral artery (MCA) M2 branch occlusion and highlights technical details including navigation without the support of a microcatheter microwire combination.
Case ReportAn 84-year-old female who did not have any history of stroke or previous neurological deficit presented to the emergency department with acute stroke symptoms including right-sided weakness, slurred speech, and left-sided gaze deviation. The patient was last well known approximately 9 h ago and the National institute of health (NIH) stroke scale at initial presentation was 13. Head computed tomography (CT) did not show any acute intracranial abnormality. CT angiogram of the head demonstrated occlusion of the superior M2 branch of the left MCA. CT perfusion showed significant perfusion deficit with ischemic penumbra and significant mismatch in the left MCA territory corresponding to MCA branch occlusion [Figure 1]. Considering the high NIH stroke scale and a large ischemic penumbra, endovascular treatment with mechanical thrombectomy was suggested. The patient's family agreed on the procedure and informed consent was signed by the patient's daughter. Under general anesthesia, a short 6F introducer was placed in the right common femoral artery that was exchanged with a Neuron Max (Penumbra, Alameda, CA, USA) long sheath. Neuron Max was placed in the left common carotid artery over a 125 cm 5F diagnostic catheter and 0.035 hydrophilic guidewire combination. Angiogram showed complete occlusion of the proximal segment of the left MCA superior M2 trunk [Figure 2]. Then, a Zoom 71 aspiration catheter (Imperative Care, Campbell, CA, USA) was introduced over a Velocity microcatheter (Penumbra, Alameda, CA, USA) and Synchro 0.014 standard microwire (Stryker Neurovascular, Fremont, CA, USA). Zoom 71 was navigated to the level of the left internal carotid artery (ICA) cavernous segment. From the level of the ICA cavernous segment to the occlusion at the left MCA superior M2 branch, Zoom 71 aspiration catheter was navigated as sole catheter without the support of the microcatheter microwire combination [Video 1]. In addition to the tight curve at ICA petrous segment that is shown in [Figure 3], the patient had a tight curve of the cavernous segment and approximately 180° turn of the ICA cervical segment. Clot was engaged and aspiration pump was connected, and the catheter was left in the aspiration mode. Approximately 2 min after, there was normal backflow in the aspiration catheter, and the catheter was withdrawn to the left ICA supraclinoid segment. Control angiogram showed thrombolysis in cerebral infarction (TICI) recanalization in the left MCA territory [Figure 3]. There was no evidence of distal thromboembolism. Aspiration catheter and long sheath were removed and hemostasis in the right groin puncture site was achieved with a 6F Angio-seal vascular closure device (St. Jude Medical, Plymouth, MN, USA). There was no periprocedural complication. Follow-up magnetic resonance imaging (MRI) 48 h after the procedure showed millimetric areas of acute infarction in the left external capsule and left frontoopercular region without any evidence of a territorial large infarct [Figure 4]. The patient had near complete recovery in the following day with a discharge NIH stroke scale of 1. The modified Rankin Scale at discharge and 90 days was 1.
Figure 1: Perfusion deficit with ischemic penumbra and significant mismatch in the left MCA territory corresponding to MCA M2 branch occlusion. MCA: Middle cerebral artery
Figure 2: Red arrow shows complete occlusion of the left MCA superior M2 trunk. MCA: Middle cerebral artery
Figure 3: Angiogram immediately after thrombectomy demonstrated TICI3 recanalization in the left MCA territory. MCA: Middle cerebral artery
Figure 4: Millimetric area of acute infarction in the left external capsule and left frontoopercular region without any evidence of a territorial large infarct in the follow-up MRI. MRI: Magnetic resonance imaging Discussion Mechanical thrombectomy is established as the main treatment for appropriate acute stroke patients with large vessel occlusion.[4] Although there is not any established consensus on which technique to be used as the first approach in endovascular treatment of acute stroke, COMPASS trial revealed noninferior functional outcomes at 90 days with AT compared with stent-retriever first-line thrombectomy.[5] AT mitigates the need for passing the clot and navigating in the distal small caliber arteries with possible risk of distal clot migration or vessel injury.
This case report describes the successful use of a novel beveled tip aspiration catheter, Zoom 71 (Imperative Care, Campbell, CA, USA) in an acute stroke case due to left MCA M2 occlusion. To our knowledge, there is only one study[6] that evaluated Zoom 71 aspiration catheter. According to the manufacturer, Zoom 71 has an inner diameter of 0.071”, outer diameter of 0.083”, and working length of 137 cm. The catheter has a distal component with flexible nitinol coil and progressively softer polymers. Sixty-degree bevel tip and distal 2 cm of advanced tracking technology make this aspiration catheter unique. Several large bore aspiration catheters have been used in the market with similar inner diameter sizes and structural compounds.[7] Compared to a standard flat tip 0.071” ID aspiration catheter (AC), the 60° bevel tip of Zoom 71 provides an equivalent of 0.076” ID and a tip surface are approximately 15% greater than other ACs with similar size. Several in vitro analyses have demonstrated that larger tip surface area is associated with increased suction force and improved recanalization rates.[3],[8] Other possible mechanisms that can potentially improve the aspiration efficiency of a beveled tip catheter are the better alignment of the catheter with the vessel axis and beveled tip may help to separate the clot from the vessel wall for better ingestion.[9],[10] It was shown that an angle of interaction higher than 125° between the catheter tip and thrombus was associated with increased success in clot removal. Vargas et al.[6] proposed that a beveled tip catheter allows for better alignment along the vessel wall and a higher angle of interaction with the thrombus face.
Another crucial factor for successful thrombectomy is to reach the level of the thrombus. This is more critical for patients with tortuous vessel anatomy. The most common method for navigating ACs to the level of target occlusion is to carry the AC over a microcatheter microwire combination. In tortuous anatomy, methods like anchoring with stent retriever can also be used if routine methods of navigation fail.[11] In this case report, Zoom 71 could be pushed without the support of a microcatheter microwire combination as the sole device from the level of ICA cavernous segment to MCA superior M2 branch [Video 1]. Raymond et al.[12] in a retrospective observational study attempted to navigate a React 71 aspiration catheter without the support of microcatheter microwire combination and only in 21% of the attempts React 71 could reach the clot successfully. The trackability of Zoom 71 can be compared with other similar ACs in an in vitro study. To date, there is not any study that has compared the trackability of Zoom 71 with other ACs.
In the only study that evaluated the clinical efficiency of Zoom 71 aspiration catheter, Vargas et al.[6] found that there was the lower number of total aspiration attempts, reduced stent retriever usage, more frequent TICI 2C or better recanalization, and a lower discharge and 90-day modified Rankin scale score. In our case, TICI3 recanalization was achieved with first pass in a left MCA M2 branch occlusion. Follow-up MRI after thrombectomy did not show a territorial infarct and the patient had significant clinical recovery with a discharge NIH stroke scale of 1. Although this current study has an inherent limitation as a case report, it highlights the safe and effective use of Zoom 71 aspiration catheter for mechanical thrombectomy. Further prospective randomized multicenter trials are required to compare this novel beveled tip catheter with other aspiration catheters available in the armamentarium.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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