Simple aspiration with balloon catheter technique (simple ABC technique) against proximal internal carotid artery occlusion in cases of cardiogenic cerebral embolism

Abstract

Background

In cases of acute ischemic stroke, manual aspiration of the thrombus is commonly performed with a balloon guiding catheter placed in the cervical segment of the internal carotid artery (ICA). However, most manual aspirations using a balloon guiding catheter are combined with inner catheters, as in the direct aspiration first pass technique (ADAPT). We experienced some cases of acute ischemic stroke with proximal ICA occlusion due to cardiogenic thrombus where we obtained sufficient recanalization by simple manual aspiration from inflated Optimo 9F balloon catheters (Tokai Medical Products, Japan) placed in the origin of the cervical segment of the ICA without any inner catheter or stent retriever. We perform by preference this procedure, named the simple Aspiration with Balloon Catheter (simple ABC) technique. Herein, we report two recent cases and discuss this procedure.

Case presentation

Case 1: An 80-year-old man with paroxysmal atrial fibrillation developed left ICA occlusion. We performed the simple ABC technique and obtained a large amount of dark red and white thrombus. Puncture-to-reperfusion time was 14 minutes with Thrombolysis in Cerebral Infarction (TICI) grade 3. Case 2: A 69-year-old man with chronic atrial fibrillation developed left internal carotid occlusion. We performed the simple ABC technique and obtained a large amount of dark red thrombus. Puncture-to-reperfusion time was 15 minutes with TICI grade 2b.

Conclusion

The simple ABC technique is useful to deal with a large amount of thrombus, shortens procedure time, enables less invasive thrombectomy, and can shift immediately to subsequent procedures such as delivering a stent retriever or ADAPT.

Introduction

Multiple randomized controlled trials have shown the efficacy of endovascular thrombectomy with stent retriever for acute ischemic stroke caused by occlusion of the proximal anterior circulation.^1–6 Likewise, the efficacy of a direct aspiration first pass technique (ADAPT) using a Penumbra 5MAX ACE thrombus aspiration catheter (Penumbra, Oakland, California, USA) has also been pointed out.^7–9 For these procedures, it is recommended to place a balloon guiding catheter in the cervical segment of the internal carotid artery (ICA), which is fundamental to all procedures of thrombectomy.¹⁰

Although manual aspiration of the thrombus is commonly performed with a balloon guiding catheter placed in the cervical segment of the ICA, most manual aspirations using a balloon guiding catheter are combined with inner catheters, as in ADAPT.^11–13 No report has shown that simple aspiration from a balloon guiding catheter is effective for acute ischemic stroke, as is thrombectomy with stent retriever or the ADAPT. We experienced some cases of acute ischemic stroke with proximal ICA occlusion due to cardiogenic thrombus where we obtained sufficient recanalization by simple manual aspiration from Optimo 9F balloon catheters (Tokai Medical Products, Aichi, Japan) placed in the cervical segment of the ICA. We perform by preference this procedure, named the simple Aspiration with Balloon Catheter (simple ABC) technique. Herein, we report two recent cases and discuss this procedure.

Case presentation

Case 1

An 80-year-old man on the 12th day after gastric cancer surgery suddenly presented with stupor, total aphasia, and right complete paralysis. Non-contrast computed tomography (CT) did not show the left putamen and insular clearly. CT angiography did not show the left ICA. Perfusion CT showed lowering of arterial blood flow and axial blood volume and delay of mean transit time in the left middle cerebral artery perfusion area. Alteplase was not administered because the patient was in the postoperational acute phase, and the patient was moved to the angiography room.

A 9F sheath 25 cm (Medikit, Tokyo, Japan) was inserted into the right femoral artery, and a bolus of 6000 IU heparin was administered. A Radifocus Guidewire Half-Stiff type 0.035 inch 180 cm (Terumo, Tokyo, Japan) preceded the system. An Optimo balloon catheter 9F was advanced to the left common carotid artery via the co-axial method using MEDIKIT catheter JB 2 6F 130 cm (Medikit). A left common carotid angiography confirmed occlusion of the origin of the left ICA (Figure 1(a)). The Optimo 9F was placed into the origin of the left ICA and the balloon was inflated. Manual aspiration was performed with a 20 mL syringe connected to the main port of the Optimo 9F. Suction was performed until the blood collection stopped due to the thrombus inside the lumen, and the catheter was pulled out, applying negative pressure. The procedure was performed twice. A large amount of dark red and white thrombus was collected (Figure 1(b)). After confirming that no thrombus was aspirated in the left ICA, the catheter was moved to the left common carotid artery. Angiographies revealed complete recanalization of the left ICA and intracranial arteries as Thrombolysis in Cerebral Infarction (TICI) grade 3 (Figure 1(c) to (e)). The puncture-to-reperfusion time was 14 minutes and the onset-to-reperfusion time was 120 minutes. Puncture site hemostasis was achieved with Angio-Seal 8 F (St. Jude Medical, St. Paul, MN, USA).

Figure 1.

Perioperative images of Case 1. (a) A lateral view of a left CCAG showing occlusion of the origin of the left ICA. (b) The aspirated great mass of mixture of dark red and white thrombus. (c) to (e) Angiographies showing complete recanalization of the left ICA and intracranial arteries as TICI grade 3: (c) carotid lateral view, (d) cranial anterior-posterior view, (e) cranial lateral view. (f) DW-MRI showing cerebral infarction of the left frontal lobe mainly in the area of perforating arteries.

CCAG: common carotid angiography; DW-MRI: diffusion weighted magnetic resonance imaging; ICA: internal carotid artery; TICI: Thrombolysis in Cerebral Infarction.

After the endovascular therapy, Argatroban 2.5 mg/h and free radical scavenger Edaravone 60 mg/day were administered. We diagnosed cardiogenic cerebral embolism caused by paroxysmal atrial fibrillation and started Apixaban 10 mg/day the next day. Postoperative diffusion weighted magnetic resonance imaging (DW-MRI) revealed cerebral infarction of the left frontal lobe, mainly in the area of perforating arteries (Figure 1(f)). While the patient’s consciousness disturbance and aphasia disappeared, mild right paralysis persisted for a week postoperatively (Modified Rankin Scale (mRS) 2).

Case 2

A 69-year-old man with chronic atrial fibrillation but without anticoagulant therapy suddenly presented with total aphasia and right complete paralysis. A non-contrast CT showed no abnormal findings. A CT angiography did not show the left ICA. Perfusion CT showed lowering of axial blood volume and delay of mean transit time in the left middle cerebral artery perfusion area. Alteplase 0.6 mg/kg was administered and the patient was moved to the angiography room.

A 4F sheath 11 cm (Medikit) was inserted into the right femoral artery and a 4F catheter JB2 100 cm was advanced to the left common carotid artery. A left common carotid angiography confirmed persistent occlusion of the origin of the left ICA (Figure 2(a)). The 4F sheath was exchanged for a 9F sheath 25 cm, and a bolus of 5000 IU heparin was administered. A Radifocus Guidewire Half-Stiff type 0.035 inch 180 cm preceded the system. An Optimo balloon catheter 9F was advanced to the left common carotid artery via the co-axial method using MEDIKIT catheter JB 2 6F 130 cm. The Optimo 9F was placed into the origin of the left ICA and the balloon was inflated. Manual aspiration was performed with a 20 mL syringe connected to the main port of the Optimo 9F. Suction was performed five times. A large amount of dark red thrombus was collected, and we confirmed that no thrombus was being aspirated in the left ICA any longer (Figure 2(b)). Angiographies revealed complete recanalization of the left ICA but a remnant occlusion of a branch of the inferior trunk of the left middle cerebral artery (TICI grade 2b) (Figure 2(c) to (e)). We planned further thrombectomy, but a microguidewire Chikai 0.014 inch 200 cm (Asahi, Aichi, Japan) did not penetrate the thrombus. We stopped the procedure. The puncture-to-reperfusion time was 15 minutes and the onset-to-reperfusion time was 189 minutes. Puncture site hemostasis was achieved with Angio-Seal 8 F.

Figure 2.

Perioperative images of Case 2. (a) A lateral view of a left CCAG showing occlusion of the origin of the left ICA. (b) The aspirated great mass of dark red thrombus. (c) to (e) Angiographies showing complete recanalization of the left ICA but a remnant occlusion of a branch of the inferior trunk of the left middle cerebral artery: (c) carotid lateral view, (d) cranial anterior-posterior view, (e) cranial lateral view. (f) DW-MRI showing some high-intensity spots on the left putamen and parietal and temporal lobes.

CCAG: common carotid angiography; DW-MRI: diffusion weighted magnetic resonance imaging; ICA: internal carotid artery; TICI: Thrombolysis in Cerebral Infarction.

After the endovascular therapy, Argatroban 2.5 mg/h and free radical scavenger Edaravone 60 mg/day were administered. We diagnosed cardiogenic cerebral embolism caused by chronic atrial fibrillation and started Apixaban 10 mg/day the next day. Postoperative DW-MRI revealed some high-intensity spots on the left putamen and parietal and temporal lobes (Figure 2(f)). The patient’s neurological deficit disappeared and he was discharged after a week (mRS 0).

Discussion

Placing a balloon guiding catheter in the cervical segment of the ICA is fundamental to thrombectomy in acute ischemic stroke caused by occlusion of the proximal anterior circulation.¹⁰ We consider that the concept of the simple ABC technique is useful to enable thrombus aspiration at the beginning of thrombectomy. This procedure is the best way of dealing with what may theoretically be a large amount of thrombus in the proximal ICA in cases of cardiogenic cerebral embolism, contributes to shortening of puncture-to-reperfusion time by aspirating thrombus without additional procedures, enables less invasive thrombectomy due to simple manual aspiration, and can shift immediately to subsequent procedures such as delivering a stent retriever or ADAPT. Furthermore, the simple ABC technique could also be adopted for distal internal carotid artery occlusion, as a recent report pointed out, although we have not yet adopted the technique for such cases.¹⁴

A balloon catheter with as large a lumen as possible is desirable for a large amount of thrombus. The Optimo 9F has a lumen of 0.090 inches and is currently the balloon catheter with the largest lumen. The simple ABC technique is the best way of dealing with what may theoretically be a large amount of thrombus in the proximal ICA in cases of cardiogenic cerebral embolism. In both the presented cases, a large amount of thrombus was collected. Especially in Case 1, there is no doubt that any available catheter would have been occluded with thrombus. In such cases, simple aspiration without an inner catheter is considered the best way of obtaining a balloon catheter lumen as wide as possible. As a caution to this procedure, suction under incomplete blood flow stasis can cause dispersal of thrombus.^11–13 The balloon should be inflated in a bale shape to block completely the blood flow in the ICA. When the catheter lumen is filled with thrombus, deflating the balloon and pulling out the Optimo should be performed with the syringe kept at negative pressure.

Occasionally, ADAPT has a problem in that raising a large-diameter catheter of 5 MAX ACE 5.4 F to the ICA and taking time for the procedure results in high wall shear stress.^7–9,13 In the simple ABC technique, especially for those with a hair-pin-curved cervical segment of the ICA, as in the presented cases, it is possible to avoid mechanical wall shear stress and to treat the diseased vessel gently by simple aspiration without additional procedures. In addition, this simple procedure contributes to shortening puncture-to-reperfusion time compared with the reported endovascular thrombectomy (Table 1).^{2,5,7,13–16}

Table 1.

Reported puncture-to-reperfusion time of endovascular thrombectomy.

Reference	N	Median (min)	Range	Procedure
Turk et al.7 (2014)	88	36.6 (mean)	±26.4	ADAPT
Jovin et al.5 (2015)	103	86	–	Stent retriever
Goyal et al.2,15 (2015)	144	30	18–45.5	Stent retriever
Kim et al.13 (2016)	33	94.5	61.8–136	Stent retriever or ADAPT
	53	56	35–99	Stent retriever or proximal aspiration
Yamaguchi et al.16 (2017)	1	26	26	Transbrachial stent retriever
Haussen et al.14 (2017)	3	14	7–37	Manual aspiration (Simple ABC)
Our cases (2017)	2	14.5	14–15	Simple ABC

ABC: aspiration with balloon catheter; ADAPT: a direct aspiration first pass technique.

Whether a thrombus is collected by the simple ABC technique can be confirmed by observing thrombus in aspirated blood or feeling that the catheter is occluded with thrombus as a resistance to suction. If the catheter is occluded with a large amount of thrombus, re-placement of the catheter is required, as in Case 1. On the other hand, if thrombus is not collected at all, the procedure should be changed to stent retriever delivery or ADAPT immediately. In such cases, hard thrombus or poor collateral circulation is suspected.

Conclusions

The simple ABC technique proposed in this paper is a prompt, minimally invasive, and highly compatible procedure. Since we have just started this procedure, accumulation of further cases is needed to show the treatment outcome.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.