Optimization of Endovascular Therapy in the Neuroangiography Suite to Achieve Fast and Complete (Expanded Treatment in Cerebral Ischemia 2c-3) Reperfusion
2020; Lippincott Williams & Wilkins; Volume: 51; Issue: 7 Linguagem: Inglês
10.1161/strokeaha.119.026736
ISSN1524-4628
AutoresRyan McTaggart, Johanna M. Ospel, Marios‐Nikos Psychogios, Ajit S Puri, Christian Maegerlein, Kendall Lane, Mahesh Jayaraman, Mayank Goyal,
Tópico(s)Traumatic Brain Injury and Neurovascular Disturbances
ResumoHomeStrokeVol. 51, No. 7Optimization of Endovascular Therapy in the Neuroangiography Suite to Achieve Fast and Complete (Expanded Treatment in Cerebral Ischemia 2c-3) Reperfusion Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toSupplementary MaterialsFree AccessResearch ArticlePDF/EPUBOptimization of Endovascular Therapy in the Neuroangiography Suite to Achieve Fast and Complete (Expanded Treatment in Cerebral Ischemia 2c-3) Reperfusion Ryan A. McTaggart, MD, Johanna M. Ospel, MD, Marios-Nikos Psychogios, MD, Ajit S. Puri, MD, Christian Maegerlein, MD, Kendall M. Lane, MD, Mahesh V. Jayaraman, MD and Mayank Goyal, MD, PhD Ryan A. McTaggartRyan A. McTaggart Department of Diagnostic Imaging (R.A.M., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI. Department of Neurology (R.A.M., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI. Department of Neurosurgery (R.A.M., K.M.L., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI. The Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence (R.A.M., K.M.L., M.V.J.). , Johanna M. OspelJohanna M. Ospel Department of Clinical Neurosciences, University of Calgary, Canada (J. M.O., M.G.). Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Switzerland (J.M.O., M.-N. P.). , Marios-Nikos PsychogiosMarios-Nikos Psychogios Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Switzerland (J.M.O., M.-N. P.). , Ajit S. PuriAjit S. Puri Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester (A.S.P.). , Christian MaegerleinChristian Maegerlein Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University of Munich, Germany (C.M.). , Kendall M. LaneKendall M. Lane Department of Neurosurgery (R.A.M., K.M.L., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI. The Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence (R.A.M., K.M.L., M.V.J.). , Mahesh V. JayaramanMahesh V. Jayaraman Department of Diagnostic Imaging (R.A.M., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI. Department of Neurology (R.A.M., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI. Department of Neurosurgery (R.A.M., K.M.L., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI. The Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence (R.A.M., K.M.L., M.V.J.). and Mayank GoyalMayank Goyal Correspondence to: Mayank Goyal, MD, PhD, Departments of Radiology and Clinical Neurosciences, Foothills Medical Centre, University of Calgary, 1403 29th St NW, Calgary, AB T2N2T9, Canada. Email E-mail Address: [email protected] https://orcid.org/0000-0001-9060-2109 Department of Clinical Neurosciences, University of Calgary, Canada (J. M.O., M.G.). Department of Radiology, Seaman Family MR Research Centre, Foothills Medical Centre, Calgary, Canada (M.G.). Originally published17 Jun 2020https://doi.org/10.1161/STROKEAHA.119.026736Stroke. 2020;51:1961–1968is related toStroke Systems of CareSimulation Methods in Acute Stroke TreatmentEssential Workflow and Performance Measures for Optimizing Acute Ischemic Stroke Treatment in IndiaPath From Clinical Research to ImplementationOptimal Imaging at the Primary Stroke CenterLeaving No Large Vessel Occlusion Stroke BehindSee related articles, p 1928, p 1932, p 1941, p 1951, p 1969 and p 1978Endovascular therapy (EVT) is now the standard of care for acute ischemic stroke caused by large vessel occlusion.1 Although the treatment effect for EVT is profound,2 it is also profoundly time dependent. Rapid restoration of blood flow is key as delays to reperfusion increase disability and reduce the likelihood of a good outcome. Just as time to reperfusion is a key metric, quality of reperfusion may be equally important. Although successful reperfusion has historically included the modified Treatment in Cerebral Ischemia 2b designation,2 it has become increasingly evident that complete reperfusion must be the goal, and the expanded Treatment in Cerebral Ischemia (eTICI) score has been introduced, which includes an additional 2c category (defined as near complete perfusion without clearly visible thrombus but with delay in contrast runoff).3 Higher eTICI grade, and particularly eTICI 2c versus eTICI 2b reperfusion, is associated with better outcomes4 (Table I in the Data Supplement). Recently, the concept of first-pass reperfusion has emerged as an independent predictor of good outcome.5,6 Fast complete reperfusion is also important from an economic standpoint: the net monetary benefit in the United States per 1% increase in the final eTICI 2c/3 rate is $17 000 and $10 600 per 10 minutes time to treatment decrease (Mayank Goyal, MD, personal communication, accepted for publication). Thus, we think that the long-term cost savings outweigh the initial additional costs of a multi-device thrombectomy approach. To ensure fast first-pass reperfusion, prehospital workflows and intrahospital processes before thrombectomy (eg, parallel processing in the emergency department) have to be precisely coordinated. Describing these steps is, however, beyond the scope of this review article, which focuses on the last step, ie, the technical details of endovascular stroke treatment. With regard to thrombectomy technique, we think that first-pass complete reperfusion is best achieved by combining a balloon guide catheter (BGC) with both a distal aspiration catheter (DAC) and stent retriever (SR) (primary combined approach, Table II in the Data Supplement),7 as opposed to using SRs or primary aspiration alone. The first part of this review provides a step-by-step guide to optimize EVT for your patients, whereas the second part describes management strategies for frequently encountered challenging situations, which might require additional steps or modification of the thrombectomy approach.Fast and Complete ReperfusionBe Prepared for Your CaseIt is important to review the CT angiogram of the head and neck before EVT. We personally routinely perform multiphase CTA (mCTA)8—to visualize and plan the case. The Table provides an overview and explanation of commonly used types of thrombectomy devices.Table. Devices Used When Performing a Primary Combined Thrombectomy ApproachDeviceRole in the Thrombectomy ProcedureExamplesGuide catheters BGCLarge bore catheter with a balloon at its distal tip. The BGC is placed in the cervical ICA. The balloon is inflated before clot retrieval to achieve flow arrest. This decreases the risk of distal embolization.Flowgate, Cello, Merci Guide catheterCatheter that is used to navigate to in the aorta and establish access to the left common carotid arteryCook Shuttle, Soft-Vu, Penumbra select DACCatheter of intermediate size through which aspiration (suction) can be applied. The DAC is advanced through the BGC. It is used as an additional aspiration tool to minimize the risk of distal embolization of clot fragments.Sofia, CAT 6, React, ACE 68MCs MCSmall catheter that can host a SR. The MC with the SR in its lumen is navigated past the site of occlusion and then pulled back to allow for unsheathing of the stent.Prawler, Rebar 18, Headway Distally fitted MCMC with a bulbous segment close to the catheter tip that obscures the shelf between the MC and the DAC lumen, thereby facilitating navigation of the DAC in tortuous vessel segmentsWedgeWires MicrowireThin and soft wire that is used to cross the site of occlusion. It serves as a guiding structure for the MC.Synchro, Traxcess GuidewireThin wire that serves as a guiding structure and is advanced in the vasculature. Once the guidewire has been advanced, catheters (eg, MCs) can be advanced over the guidewire.Glidewire (flexible), Glidewire advantage (stiff) SRStent that is attached to a wire. The stent is deployed over the clot and its inherent outward force leads to migration of the clot through the struts into the stent lumen. Once the clot is fully integrated in the lumen, the SR and entrapped clot are retrieved via slight pulling on the stent wire. SR are available in different sizes and lengths.Solitaire, Trevo, EmbotrapBGC indicates balloon guide catheter; DAC = distal access catheter; ICA, internal carotid artery; MC, microcatheter; and SR, stent retriever.Examples where CT angiography allows you to prepare a priori for your case include the following:Evaluation of vessel tortuosity. In tortuous vessels, advancing catheters and wires can be difficult because they tend to build up in the proximal vessel. Such situations might warrant a quadraxial approach (with an 8F Shuttle in addition to an 8F BGC) to support the BGC, straighten the vessels, and increase the stiffness of the system. Although femoral access remains our default for anterior circulation stroke sometimes a right radial approach might be the best solution. Severe tortuosity in the cervical internal carotid artery (ICA) may influence the relative available lengths of catheters—a shorter BGC and a longer (160 cm) microcatheter would be advantageous.Appropriate catheter choice (Figure I in the Data Supplement). In young patients with straight vessels, a Cook HB1, HB2, or JB2 catheter with an angle of ≤90° is an appropriate choice, whereas in severely tortuous aortic arches with acute angles at the left common carotid artery origin, a VTK or Sim2 catheter with an acute angle is more appropriate.Distinguishing ICA occlusion versus pseudo-occlusion (ie, slow or completely stagnating flow in the cervical ICA due to an upstream occlusion, with an appearance on CTA and catheter angiography that resembles a real occlusion at the cervical ICA level) versus tandem occlusion. In our experience, mCTA can be helpful to make this distinction.Determining the proximal and distal end of the clot (this may influence SR selection). We have found that the second phase of mCTA is useful to do so.Whether the clot crosses bifurcations such as a persistent fetal posterior cerebral artery (delivering the DAC beyond this point may cause guillotine embolization of clot to a new territory).Standardization of workflow before and during EVT reduces the cognitive load of the neurointerventional team and puncture to reperfusion times.9 In this scenario, the only information that has to be shared with the team before the case is which angiographic catheter and access will be used (radial or femoral). We have long proposed the BRISK (Brisk Recanalization Ischemic Stroke Kit) concept: a standard mechanical thrombectomy equipment package that reduces preparation time. At the time being, ≈50% of physicians use a home-made kit.9a Although there is no formal evidence for the time savings with a preprepared kit, using it seems intuitive and is more time efficient in our personal experience.10Balloon Guide With Large Bore Distal Access Catheter With Dual Aspiration With Stent RetrieverStep 1. BGC DeliveryBGCs are associated with better recanalization and patient outcomes so we use them by default (Table II in the Data Supplement). One problem of BGC is that they may not have enough stability in tortuous vessels. This can be overcome by a quadraxial setup (with a Shuttle in addition to the BGC to stabilize the system) and the stiffer Glidewire advantage wire (Terumo Medical, Somerset, NJ). For femoral approaches, an 8F 45-cm vascular sheath or longer 8F Shuttle sheath provides more proximal support and the Glidewire advantage and angiographic catheters (Cook H1 for right and VTK or Simmons 1 for left anterior circulation selection) allow easy delivery of the BGC to the distal cervical ICA segment (Figure 1A). This avoids an exchange for the BGC, which carries the risk of iatrogenic vessel injury (dissection, perforation) and dislocation of mural plaques, which could then cause strokes. Besides, device exchanges also delay reperfusion. An arch recalcitrant to this access strategy can usually be predicted by the CTA during the planning stage, and either a radial approach or carotid puncture can be chosen if necessary. Of note, the described BADDASS (Balloon Guide With Large Bore Distal Access Catheter With Dual Aspiration With Stent Retriever) technique cannot be used routinely with radial access as, in most patients, the BGC is too big for the radial artery.Download figureDownload PowerPointFigure 1. Balloon guide, distal access catheter and microcatheter navigation. The balloon guide catheter (BGC) is delivered to the distal cervical segment of the right internal carotid artery (ICA) (A). The microcatheter has been delivered beyond the clot into the inferior division of the right middle cerebral artery with a J-configured microwire. Notice that with forward tension on the microcatheter loops rest on all outer curves (B). C, Forward tension has been released from the catheter—microcatheter loops are now on inner curves. As the catheter is relaxed, the distal aspiration catheter (DAC) will typically progress/track intracranially unless hindered by tortuous anatomy.Step 2. Microcatheter and Distal Access Catheter DeliveryOnce the BGC is delivered to the distal cervical ICA segment, the first angiographic run is performed. The field of view should include the tip of the BGC and a portion of the intracranial circulation including the occlusion of interest. Appropriate microcatheter delivery combines knowledge of this angiographic run (where the clot starts), mCTA information (clot length and distal clot end), and Sylvian triangle anatomy (selection of posterior/inferior M2 division is preferred).11A microcatheter should always be led by a J'd wire (the curve at the tip of the wire) as this will preclude selection of small branches which could lead to hemorrhagic or ischemic complications and will often mimic the course of the thromboembolic material and lead you to the occlusion. The J'd wire will typically deliver itself to the clot (Figure 1B). After delivery of the microcatheter, there will be forward tension (or load) on the catheter which can be appreciated by catheter loops on all outer curves. For facile DAC delivery and SR deployment, this forward tension should be reduced (Figure 1C). Because of the straighter course and larger diameter of the inferior M2 division, selection of this branch is preferred (Figure 2A and 2B). The DAC will then advance intracranially toward the clot interface (Figure 1B and 1C), and deployment of the SR will be more controlled. After the microcatheter has been delivered beyond the clot, the microwire is removed.Download figureDownload PowerPointFigure 2. Microcatheter delivery to the inferior division is preferred as the inferior division tends to be larger and, more importantly, straighter as it courses toward the apex of the Sylvian triangle. Stent retriever deployment into the inferior division (A) vs superior division (B).Step 3. SR Deployment and DAC DeliveryAfter delivery of the microcatheter, the SR of choice is opened from its packaging. We prefer longer SR because integration may vary and stent cells beyond the clot provide redundancy if the clot fragments or rolls12,13 (Figure II in the Data Supplement). Whether and how general anesthesia influences thrombectomy outcomes is still not entirely clear.14,15 We personally perform nearly all of our procedures without general anesthesia, and very often the patient moves slightly. Longer stents also reduce the likelihood of incorrect stent placement in such cases. With the SR tip to tip with the microcatheter (Figure 3A1), we ensure that forward tension/load is removed, ie, the microcatheter is in contact with inner walls of curves and retracts from its distal position just slightly. During this adjustment, we advance the DAC as far as possible intracranially before deployment of the SR. That said, do not prematurely deliver the DAC into the clot as this will constrain the SR when deployed across the clot and interfere with intended clot integration. Some users prefer to delay aspiration on the DAC until after SR deployment because continuous aspiration may deleteriously affect collateral inflow (Figure 3A2). Others apply aspiration on the DAC before SR deployment to minimize antegrade flow and the risk of distal embolization, minimize clot burden, and increase the likelihood of a first-pass effect (Figure 3B1).Download figureDownload PowerPointFigure 3. The stent retriever has been delivered tip to tip with the microcatheter in a relaxed/unloaded position on the inner curves. Notice the distal aspiration catheter (DAC) has been advanced toward the clot interface in preparation for the primary combined approach (A1). A2 and B1 differ only in timing of DAC aspiration with respect to stent retriever deployment before in A2 and after B1 (both has been described in the literature). B2, We see the DAC aspirating and securing the proximal face of the clot. B1 and B2, Clot is being dynamically aspirated through the DAC, and the clot burden/bulk is therefore decreasing. C1, We see that the balloon guide catheter (BGC) has been inflated to establish flow reversal, and the clot/stent retriever (SR)/DAC complex is being removed as a unit—attention must be paid to maintain a fixed relationship between the SR and tip of the DAC throughout the removal of the complex. The BGC is deflated and flow is restored in C2.When you begin to deploy the SR (with the microcatheter in a relaxed state), you should first unsheath it to gain wall apposition. Pushing the SR forward in the vessel can cause damage and vessel perforation (particularly if you are in the more tortuous superior M2 division). Once you have unsheathed one-third of the SR, you can deliver the DAC and push out or fluff the SR (active push deployment). Care should be taken to not put too much forward tension on the stent or it will trainwreck and possibly damage the vessel. If this happens, pull the microcatheter back to reduce the trainwreck. If these alternating strategies do not work, deploy the SR with load first, and then remove the load and deliver the DAC afterwards.Step 4. Cork the Clot or Hold It CAPTIVEWith the SR deployed, aspiration is now on. Aspiration can be applied manually with a syringe or automated (either continuous or pulsed) using a pump. With the DAC at the thrombus, the microcatheter is removed to increase flow rates within the DAC16 and further reduce clot burden before removal (Figure 3B2). Another advantage of microcatheter removal at this point is that it can be reprepared (microwire reinserted) in the event a second pass is required.Delivery of the DAC can be difficult in tortuous anatomy. Three strategies are at your disposal: (1) apply traction to the SR delivery wire after the microcatheter is removed to straighten the vascular and facilitate delivery, (2) consider use of a microcatheter with a bulbous distal end such as the Wedge (Microvention, Tustin, CA) or Offset (Stryker, MA) as this minimizes coaxial size mismatching that could lead to a catheter catching a vessel origin or shelf, and finally (3) use a smaller DAC.Step 5. Clot RemovalAt this point, we are ready to remove the clot/SR/DAC complex as one unit through the BGC (Figure 3C1 and 3C2). Please note that once the SR is delivered, a grapple hook or anchor is provided by the SR that may lead to straightening of more proximal tortuosity that prevented initial delivery of the DAC. In contradistinction, the catheter will have to be slightly reloaded (back to the outer walls) to push out the SR as you want to integrate it with the clot (Figure 4A and 4B).17,18 Just before inflation of the BGC, it serves to unload backward tension on the SR wire slightly as this can compress and shorten the DAC. Not performing this maneuver will result in length mismatch between the SR wire and DAC, and as you remove the clot/SR/DAC complex, the DAC will elongate and ride over the SR during removal resulting in decaptive shear as occurs with the Solumbra technique (Figure 5). Appropriate length alignment between the DAC and SR also facilitates changing the angle of the face of the DAC to the clot. After this important adjustment, inflate the BGC to create flow arrest and then slowly withdraw the clot/SR/DAC with aspiration on the DAC and BGC. During withdrawal, the operator should prevent the BGC from riding forward as this could damage the ICA. Never pull the clot/SR/DAC complex through a rotating hemostatic valve—when it gets near the hub of the BGC, just remove the rotating hemostatic valve and aspirate on the hub of the BGC to clear the BGC. We discourage the use of pressurized flushes for these cases as it will only send fragmented clot material forward in the vascular tree.Download figureDownload PowerPointFigure 4. Proper stent retriever (SR) deployment. It is important to deploy at least one-third of the SR beyond the clot to provide cell redundancy if clot rolls and apposition security so the SR can be pushed out to integrate with clot over its length. A, A SR simply unsheathed across the clot, whereas it is fluffed and integrated with it in B. Unsheath the distal one-third of the SR with the microcatheter unloaded (on the inner walls) and integrate the SR with the clot with the microcatheter loaded (on the outer walls).Download figureDownload PowerPointFigure 5. Decaptive shear with Solumbra.A, We see the stent retriever (SR) and clot pulled into the distal access catheter (DAC). Although it is tempting to do this to main intracranial access, it will lead to decaptive shear with embolization to the vascular territory of interest or a new vascular territory (B) and should be avoided. The same phenomenon can occur unintentionally when SR wire is not unloaded so the DAC can relax and elongate after delivery to the clot with the SR wire under tension. If this maneuver is not performed, you fill find a significant length of SR within DAC on removal of the clot/SR/DAC complex.Combined Approach Elsewhere: Tandem OcclusionsAny discussion of tandem occlusions must begin with the distinction between an ICA pseudo-occlusion and a true ICA occlusion. This can be important as a BGC is essential for the former (typically ICA terminus occlusion) and may not be required for the latter as a guide catheter which is mechanically dilating an occlusive lesion in the neck would be functioning as a BGC. In our experience, mCTA is a helpful tool to distinguish the 2 (Figure III in the Data Supplement). For a pseudo-occlusion typically caused by ICA terminus occlusion, aspiration before clot withdrawal can help to reduce clot volume, thereby increasing the likelihood of a first-pass effect. It is essential to not deliver the DAC beyond a fetal posterior cerebral artery or anterior cerebral artery origin as this may guillotine a piece of clot which then embolizes to a new vascular territory.For true tandem ICA occlusions, a distal-to-proximal approach is favored as the distal clot is likely the symptomatic one. In addition, it is likely fresh and easy to remove, and blood flow can be quickly restored across the circle of Willis. Although a BGC can be used, a stiffer guide can allow a more facile traverse of the occlusion and with the guide beyond the ICA occlusion flow reversal is achieved (BGC equivalent). Only in the rarest circumstances will predilatation of the occlusive extracranial carotid lesion be required—do not be afraid to pierce/blindly navigate through the extracranial occlusive lesion. If piercing through the occlusion site without visualization of the distal vessel seems too aggressive (because there is indeed an increased risk of vessel wall dissection and perforation), one can use a microcatheter and microwire to cross the occlusive lesion at the ICA origin and use the DAC with continuous aspiration to clean the proximal distal cervical ICA. If the guide can then be delivered beyond the occlusive extracranial lesion, the microcatheter can be removed and the DAC alone used to clean the cervical ICA beyond the occlusion. The Wedge (Microvention, Tustin, CA) or Offset (Stryker, MA) microcatheter may facilitate delivery of the more proximal catheters with this approach, but, more often than not, the stiffer Glidewire advantage, an angiographic catheter, and a Shuttle are necessary.Although a detailed discussion of tandem lesion treatment is beyond the scope of this article, we think that removal of the intracranial occlusion first allows the earliest restoration of intracranial flow via the circle of Willis. Consideration can then be given to extracranial carotid stenting depending on factors such as (1) lumen size after mechanical dilation with the guide catheter, (2) quality of flow across the circle of Willis and intracranial eTICI achieved, and (3) amount of early ischemic change on initial noncontrast CT and concomitant risk associated with antiplatelet medications. Of note, carotid stenting in the acute phase of stroke is controversial because it requires subsequent antiplatelet therapy, which, especially in combination with intravenous alteplase, might carry an increased risk of hemorrhage. On the other hand, nonrandomized studies have provided limited evidence for safety and efficacy of carotid stenting in the acute stroke setting and did not show increased hemorrhagic complication rates.19 It is advisable to inflate a BGC in the common carotid artery during stent deployment to reverse flow (BGC-protected carotid stenting).Basilar OcclusionsBasilar occlusions are not typically treated with a combined approach as a BGC will not reverse flow in vertebrobasilar vascular anatomy. Furthermore, the first-pass effect seen with anterior circulation occlusions is only presumed to be as meaningful. Thus, a combined approach as described here without a BGC is recommended.20 Basilar occlusions are well-suited for radial approaches especially in the presence of a dominant right vertebral artery.Distal Occlusions and Embolizations to a New Vascular TerritoryThere are primary distal occlusions and secondary distal occlusions after mechanical thrombectomy. For the latter ones, we think that if the clot location is not one you would have considered for treatment in the first place then you should not chase it. Recently, limited evidence for safety and efficacy in distal MCA occlusions has become available.21 For distal occlusions for which you are primarily considering mechanical thrombectomy, such as A2 or M3 occlusions, oftentimes the vessel will be too small to harbor a regular-sized DAC (such as the Sofia catheter). Thus, a smaller DAC (eg, 3MAX, Penumbra) has to be used. Advancing the system in a triaxial manner, as we do for proximal occlusions, is usually not possible because (1) the system is too stiff to be safely navigated in these distal small vessels, and (2) most microcatheters do not fit into a small DAC. Therefore, the microwire and microcatheter are introduced through the BGC without a DAC and navigated past the clot (Figure IVA in the Data Supplement). The stent is deployed and the microcatheter removed (Figure IVB and IVC in the Data Supplement) and only then, the DAC is introduced and navigated to the proximal clot face (Figure IVD through IVF in the Data Supplement). The clot is then withdrawn under double aspiration as usual.Difficult AccessWe think that femoral access should remain the default access for anterior circulation occlusions. Although a discussion of radial access is beyond the scope of this review article, we do think that radial access has relegated direct carotid puncture to Plan C. The radial artery behaves similar to an 8F 45-cm Brite-Tip sheath providing support to the BGC; we currently do an exchange of the Sim2 angiographic catheter and short radial sheath directly for a BGC with inner dilator in this setting. For direct carotid punctures, a 6F short sheath is placed in the common carotid artery with ultrasound. A combined approach is used without a BGC in this situation.When to StopIt is difficult to come up with precise rules for stopping as in our experience it is dependent on many factors including patient age, ischemic changes on initial imaging, and individual anatomy. In general, presence of vasospasm in the target vessel should be a signal to avoid the use of SR. When a primary combined approach fails (eg, due to underlying intracranial stenosis), rescue stenting has been shown to improve outcomes, but angioplasty carries an increased risk of vessel perforation and permanent stent placement requires subsequent antiplatelet medication, thereby potentially increasing the risk of hemorrhagic complications.22 Randomized data for the benefit of rescue angioplasty/stenting are currently not available yet. We think, however, that rescue angioplasty or stenting should be considered for arterial occlusive lesions recalcitrant to a combined approach. If a stent is dropped and flow is established, continue antiplatelet therapy. If it does not establish antegrade flow, then do not continue antiplatelet therapy.ConclusionsIt is clear that better and faster reperfusion leads to better outcomes and is highly cost-effective. On the basis of our experience, the BADDASS technique that has been outlined step-by-step in this review can result in high rates of first-pass eTICI 2c/3 reperfusion by combining the advantages of a BGC, large bore DAC, and SR. Strategies to overcome challenging situations (tandem occlusion, distal occlusions) have been provided. It is clear that technology, tools, and techniques will continue to evolve and improve. Optimization
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