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Principles for Complication Avoidance and Management in Thrombectomy for Ischemic Stroke

  • Alexander G. Chartrain
  • Ahmed J. Awad
  • J MoccoEmail author
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Abstract

Endovascular thrombectomy has achieved a dramatical shift in our management strategies for ischemic stroke. With the benefits of increased reperfusion rates and improved outcomes, endovascular thrombectomy represents a significant improvement to the available management approaches. The cornerstone of this technique resides in its ability to achieve rapid recanalization of occluded vessels by direct removal of the occluding thrombus. Because of its endovascular nature, several complications can accompany the procedure. The most common associated complications include intracranial hemorrhage, vasospasm, and distal embolization. Other procedure-related complications accompany the endovascular approach and thus been recognized more recently, including arterial dissection and inadvertent thrombectomy device detachment. The severity can range widely, and the clinician must be familiar with these complications and the available management options when performing the endovascular thrombectomy procedure. This chapter will review the common complications, familiarize the reader with avoidance techniques, and discuss the current management options.

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References

  1. 1.
    Rha J-H, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke. 2007;38:967–73.CrossRefPubMedGoogle Scholar
  2. 2.
    Saqqur M, et al. Site of arterial occlusion identified by transcranial Doppler predicts the response to intravenous thrombolysis for stroke. Stroke. 2007;38:948–54.CrossRefPubMedGoogle Scholar
  3. 3.
    Bhatia R, et al. Low rates of acute recanalization with intravenous recombinant tissue plasminogen activator in ischemic stroke: real-world experience and a call for action. Stroke. 2010;41:2254–8.CrossRefPubMedGoogle Scholar
  4. 4.
    Ciccone A, et al. Endovascular treatment for acute ischemic stroke. N Engl J Med. 2013;368:904–13.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Kidwell CS, et al. A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med. 2013;368:914–23.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Broderick JP, et al. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Engl J Med. 2013;368:893–903.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Berkhemer OA, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372:11–20.CrossRefPubMedGoogle Scholar
  8. 8.
    Goyal M, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372:1019–30.CrossRefPubMedGoogle Scholar
  9. 9.
    Campbell BCV, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372:1009–18.CrossRefPubMedGoogle Scholar
  10. 10.
    Saver JL, 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
  11. 11.
    Jovin TG, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372:2296–306.CrossRefPubMedGoogle Scholar
  12. 12.
    Touma L, et al. Stent retrievers for the treatment of acute ischemic stroke. JAMA Neurol. 2016;73:275.CrossRefPubMedGoogle Scholar
  13. 13.
    Yarbrough CK, Ong CJ, Beyer AB, Lipsey K, Derdeyn CP. Endovascular thrombectomy for anterior circulation stroke. Stroke. 2015;46:3177–83.CrossRefPubMedGoogle Scholar
  14. 14.
    Badhiwala JH, et al. Endovascular thrombectomy for acute ischemic stroke. JAMA. 2015;314:1832.CrossRefPubMedGoogle Scholar
  15. 15.
    Powers WJ, et al. 2015 American Heart Association/American Stroke Association focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46(2015):3020–35.CrossRefPubMedGoogle Scholar
  16. 16.
    Fifi JT, et al. Complications of modern diagnostic cerebral angiography in an academic medical center. J Vasc Interv Radiol. 2009;20:442–7.CrossRefPubMedGoogle Scholar
  17. 17.
    Dawkins AA, et al. Complications of cerebral angiography: a prospective analysis of 2,924 consecutive procedures. Neuroradiology. 2007;49:753–9.CrossRefPubMedGoogle Scholar
  18. 18.
    Goyal M, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016;387:1723–31.CrossRefPubMedGoogle Scholar
  19. 19.
    Papanagiotou P, White CJ. Endovascular reperfusion strategies for acute stroke. JACC Cardiovasc Interv. 2016;9:307–17.CrossRefPubMedGoogle Scholar
  20. 20.
    Nogueira RG, 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
  21. 21.
    Raychev R, Saver JL. Mechanical thrombectomy devices for treatment of stroke. Neurol Clin Pract. 2012;2:231–5.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Henderson RD, Phan TG, Piepgras DG, Wijdicks EFM. Mechanisms of intracerebral hemorrhage after carotid endarterectomy. J Neurosurg. 2001;95:964–9.CrossRefPubMedGoogle Scholar
  23. 23.
    Abou-Chebl A, et al. Intracranial hemorrhage and hyperperfusion syndrome following carotid artery stenting. J Am Coll Cardiol. 2004;43:1596–601.CrossRefPubMedGoogle Scholar
  24. 24.
    Adhiyaman V, Alexander S. Cerebral hyperperfusion syndrome following carotid endarterectomy. QJM. 2007;100:239–44.CrossRefPubMedGoogle Scholar
  25. 25.
    Hacke W, et al. Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Lancet. 1998;352:1245–51.CrossRefPubMedGoogle Scholar
  26. 26.
    Hacke W, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359:1317–29.CrossRefPubMedGoogle Scholar
  27. 27.
    Raychev R, et al. Determinants of intracranial hemorrhage occurrence and outcome after neurothrombectomy therapy: insights from the solitaire FR with intention for thrombectomy randomized trial. Am J Neuroradiol. 2015;36:2303–7.CrossRefPubMedGoogle Scholar
  28. 28.
    Loh Y, et al. Recanalization rates decrease with increasing thrombectomy attempts. Am J Neuroradiol. 2010;31:935–9.CrossRefPubMedGoogle Scholar
  29. 29.
    Peschillo S, Diana F, Berge J, Missori P. A comparison of acute vascular damage caused by ADAPT versus a stent retriever device after thrombectomy in acute ischemic stroke: a histological and ultrastructural study in an animal model. J Neurointerv Surg. 2016;9(8):743–9.  https://doi.org/10.1136/neurintsurg-2016-012533.CrossRefPubMedGoogle Scholar
  30. 30.
    Gory B, et al. Histopathologic evaluation of arterial wall response to 5 neurovascular mechanical thrombectomy devices in a swine model. Am J Neuroradiol. 2013;34:2192–8.CrossRefPubMedGoogle Scholar
  31. 31.
    Pan J, Konstas A-A, Bateman B, Ortolano GA, Pile-Spellman J. Reperfusion injury following cerebral ischemia: pathophysiology, MR imaging, and potential therapies. Neuroradiology. 2007;49:93–102.CrossRefPubMedGoogle Scholar
  32. 32.
    Gascou G, et al. Stent retrievers in acute ischemic stroke: complications and failures during the perioperative period. Am J Neuroradiol. 2014;35:734–40.CrossRefPubMedGoogle Scholar
  33. 33.
    Janssen H, et al. General anesthesia versus conscious sedation in acute stroke treatment: the importance of head immobilization. Cardiovasc Intervent Radiol. 2016;39:1239–44.CrossRefPubMedGoogle Scholar
  34. 34.
    Intracerebral hemorrhage after intravenous t-PA therapy for ischemic stroke. The NINDS t-PA Stroke Study Group. Stroke. 1997;28:2109–18.Google Scholar
  35. 35.
    Hemphill JC, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46:2032–60.CrossRefPubMedGoogle Scholar
  36. 36.
    Shi Z-S, et al. Predictors of subarachnoid hemorrhage in acute ischemic stroke with endovascular therapy. Stroke. 2010;41:2775–81.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Castaño C, et al. Unwanted detachment of the solitaire device during mechanical thrombectomy in acute ischemic stroke. J Neurointerv Surg. 2016.  https://doi.org/10.1136/neurintsurg-2015-012156.
  38. 38.
    Emprechtinger R, Piso B, Ringleb PA. Thrombectomy for ischemic stroke: meta-analyses of recurrent strokes, vasospasms, and subarachnoid hemorrhages. J Neurol. 2017;264(3):432–6.  https://doi.org/10.1007/s00415-016-8205-1.CrossRefPubMedGoogle Scholar
  39. 39.
    Kurre W, et al. Does mechanical thrombectomy in acute embolic stroke have long-term side effects on intracranial vessels? An angiographic follow-up study. Cardiovasc Intervent Radiol. 2013;36:629–36.CrossRefPubMedGoogle Scholar
  40. 40.
    Behme D, et al. Complications of mechanical thrombectomy for acute ischemic stroke—a retrospective single-center study of 176 consecutive cases. Neuroradiology. 2014;56:467–76.CrossRefPubMedGoogle Scholar
  41. 41.
    Mizutani T. Natural course of intracranial arterial dissections. J Neurosurg. 2011;114:1037–44.CrossRefPubMedGoogle Scholar
  42. 42.
    Akins PT, Amar AP, Pakbaz RS, Fields JD. Complications of endovascular treatment for acute stroke in the SWIFT trial with solitaire and merci devices. Am J Neuroradiol. 2014;35:524–8.CrossRefPubMedGoogle Scholar
  43. 43.
    Davalos A, et al. Retrospective multicenter study of solitaire FR for revascularization in the treatment of acute ischemic stroke. Stroke. 2012;43:2699–705.CrossRefPubMedGoogle Scholar
  44. 44.
    Pereira VM, et al. Prospective, multicenter, single-arm study of mechanical thrombectomy using solitaire flow restoration in acute ischemic stroke. Stroke. 2013;44:2802–7.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Weber R, et al. Comparison of outcome and interventional complication rate in patients with acute stroke treated with mechanical thrombectomy with and without bridging thrombolysis. J Neurointerv Surg. 2017;9(3):229–33.  https://doi.org/10.1136/neurintsurg-2015-012236.CrossRefPubMedGoogle Scholar
  46. 46.
    Groves AP, Kansagra AP, Cross DT, Moran CJ, Derdeyn CP. Acute management and outcomes of iatrogenic dissections during cerebral angiography. J Neurointerv Surg. 2016;9(5):499–501.  https://doi.org/10.1136/neurintsurg-2016-012285.CrossRefPubMedGoogle Scholar
  47. 47.
    Lyrer P, Engelter S. In: Lyrer P, editor. The cochrane database of systematic reviews. Wiley; 2003. p. 1–45.  https://doi.org/10.1002/14651858.CD000255.
  48. 48.
    Markus HS, et al. Antiplatelet treatment compared with anticoagulation treatment for cervical artery dissection (CADISS): a randomised trial. Lancet Neurol. 2015;14:361–7.CrossRefPubMedGoogle Scholar
  49. 49.
    Delgado F, et al. Endovascular treatment in the acute and non-acute phases of carotid dissection: a therapeutic approach. J Neurointerv Surg. 2017;9:11–6.  https://doi.org/10.1136/neurintsurg-2016-012475.CrossRefPubMedGoogle Scholar
  50. 50.
    Stampfl S, et al. Combined proximal balloon occlusion and distal aspiration: a new approach to prevent distal embolization during neurothrombectomy. J Neurointerv Surg. 2016.  https://doi.org/10.1136/neurintsurg-2015-012208.
  51. 51.
    Chueh J-Y, Puri AS, Wakhloo AK, Gounis MJ. Risk of distal embolization with stent retriever thrombectomy and ADAPT. J Neurointerv Surg. 2016;8:197–202.CrossRefPubMedGoogle Scholar
  52. 52.
    Kabbasch C, et al. First-line lesional aspiration in acute stroke thrombectomy using a novel intermediate catheter: initial experiences with the SOFIA. Interv Neuroradiol. 2016;22:333–9.CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Masoud H, et al. Inadvertent stent retriever detachment: a multicenter case series and review of device experience FDA reports. Interv Neurol. 2015;4:75–82.CrossRefPubMedPubMedCentralGoogle Scholar
  54. 54.
    Kwon H-J, Chueh J-Y, Puri AS, Koh H-S. Early detachment of the solitaire stent during thrombectomy retrieval: an in vitro investigation. J Neurointerv Surg. 2015;7:114–7.CrossRefPubMedGoogle Scholar
  55. 55.
    Parthasarathy R, Gupta V, Goel G, Mahajan A. Solitaire stentectomy: ‘deploy and engage’ and ‘loop and snare’ techniques. BMJ Case Rep. 2016.  https://doi.org/10.1136/bcr-2016-012547.
  56. 56.
    Yub Lee S, Won Youn S, Kyun Kim H, Rok Do Y. Inadvertent detachment of a retrievable intracranial stent: review of manufacturer and user facility device experience. Neuroradiol J. 2015;28:172–6.CrossRefPubMedPubMedCentralGoogle Scholar
  57. 57.
    Dorn F, Stehle S, Lockau H, Zimmer C, Liebig T. Endovascular treatment of acute intracerebral artery occlusions with the solitaire stent: single-centre experience with 108 recanalization procedures. Cerebrovasc Dis. 2012;34:70–7.CrossRefPubMedGoogle Scholar
  58. 58.
    Youn SW, Kim HK. Refinement of a thrombectomy technique to treat acute ischemic stroke: technical note on microcatheter advance during retrieving self-expandable stent. J Korean Soc Radiol. 2012;67:1.CrossRefGoogle Scholar
  59. 59.
    Akpinar S, Yilmaz G. Spontaneous Solitaire™ AB thrombectomy stent detachment during stroke treatment. Cardiovasc Intervent Radiol. 2015;38:475–8.CrossRefPubMedGoogle Scholar
  60. 60.
    Kang D-H, Park J, Hwang Y-H, Kim Y-S. Inadvertent self-detachment of solitaire AB stent during the mechanical thrombectomy for recanalization of acute ischemic stroke: lessons learned from the removal of stent via surgical embolectomy. J Korean Neurosurg Soc. 2013;53:360.CrossRefPubMedPubMedCentralGoogle Scholar
  61. 61.
    Kim ST, et al. Unexpected detachment of solitaire stents during mechanical thrombectomy. J Korean Neurosurg Soc. 2014;56:463–8.CrossRefPubMedPubMedCentralGoogle Scholar
  62. 62.
    Goyal M, et al. Evaluation of interval times from onset to reperfusion in patients undergoing endovascular therapy in the interventional management of stroke III trial. Circulation. 2014;130:265–72.CrossRefPubMedPubMedCentralGoogle Scholar
  63. 63.
    Khatri P, et al. Time to angiographic reperfusion and clinical outcome after acute ischaemic stroke: an analysis of data from the Interventional Management of Stroke (IMS III) phase 3 trial. Lancet Neurol. 2014;13:567–74.CrossRefPubMedPubMedCentralGoogle Scholar
  64. 64.
    Abilleira S, et al. Outcomes of a contemporary cohort of 536 consecutive patients with acute ischemic stroke treated with endovascular therapy. Stroke. 2014;45:1046–52.CrossRefPubMedGoogle Scholar
  65. 65.
    Kaesmacher J, Kleine JF. Bridging therapy with i. v. rtPA in MCA occlusion prior to endovascular thrombectomy: a double-edged sword? Clin Neuroradiol. 2016.  https://doi.org/10.1007/s00062-016-0533-0.
  66. 66.
    Guedin P, et al. Prior IV thrombolysis facilitates mechanical thrombectomy in acute ischemic stroke. J Stroke Cerebrovasc Dis. 2015;24:952–7.CrossRefPubMedGoogle Scholar
  67. 67.
    Menon BK, et al. Optimal workflow and process-based performance measures for endovascular therapy in acute ischemic stroke: analysis of the solitaire FR thrombectomy for acute revascularization study. Stroke. 2014;45:2024–9.CrossRefPubMedGoogle Scholar
  68. 68.
    Turk AS, 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
  69. 69.
    Delgado Almandoz JE, 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. 2015.  https://doi.org/10.1136/neurintsurg-2015-012122.
  70. 70.
    Turk AS, et al. ADAPT FAST study: a direct aspiration first pass technique for acute stroke thrombectomy. J Neurointerv Surg. 2014;6:260–4.CrossRefPubMedGoogle Scholar
  71. 71.
    Vargas J, et al. Long term experience using the ADAPT technique for the treatment of acute ischemic stroke. J Neurointerv Surg. 2017;9(5):437–41.  https://doi.org/10.1136/neurintsurg-2015-012211.CrossRefPubMedGoogle Scholar
  72. 72.
    Romano D, et al. Manual thromboaspiration technique as a first approach for endovascular stroke treatment: a single-center experience. Interv Neuroradiol. 2016;22(5):529–34.  https://doi.org/10.1177/1591019916653256.CrossRefPubMedPubMedCentralGoogle Scholar
  73. 73.
    Kowoll A, Weber A, Mpotsaris A, Behme D, Weber W. Direct aspiration first pass technique for the treatment of acute ischemic stroke: initial experience at a European stroke center. J Neurointerv Surg. 2016;8:230–4.CrossRefPubMedGoogle Scholar
  74. 74.
    Lapergue B, et al. A direct aspiration, first pass technique (ADAPT) versus stent retrievers for acute stroke therapy: an observational comparative study. Am J Neuroradiol. 2016;1–6.  https://doi.org/10.3174/ajnr.A4840.
  75. 75.
    Baek J-H, et al. Stenting as a rescue treatment after failure of mechanical thrombectomy for anterior circulation large artery occlusion. Stroke. 2016;47:2360–3.CrossRefPubMedGoogle Scholar
  76. 76.
    Seo JH, Jeong HW, Kim ST, Kim E-G. Adjuvant tirofiban injection through deployed solitaire stent as a rescue technique after failed mechanical thrombectomy in acute stroke. Neurointervention. 2015;10:22.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Alexander G. Chartrain
    • 1
  • Ahmed J. Awad
    • 1
  • J Mocco
    • 1
    Email author
  1. 1.Mount Sinai Health SystemNew YorkUSA

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