• Journal of Korean Neurosurgical Society
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• v.64 no.1
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• pp.60-68
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• 2021

Objective : Until recently, the transfemoral approach (TFA) was used as the primary method of arterial approach in acute ischemic stroke (AIS). However, TFA resulted in longer reperfusion times and worse outcomes in the mechanical thrombectomy (MT) of patients with complex aortic arches and significant carotid tortuosity. We found that the transradial approach (TRA) is a more favorable alternative approach for MT in such cases. Methods : We performed a retrospective review of our institutional database to identify 202 patients who underwent MT for AIS between February 2015 and December 2019. Patient characteristics, cause of TFA failure, procedure time, intra-procedural complications, and outcomes were recorded. Results : Eleven (5.4%) of 202 patients, who underwent MT for AIS, crossed over to TRA for recanalization, and eight (72%) of 11 achieved successful recanalization (≥modified Treatment in Cerebral Infarction 2b). The mean age (mean±standard deviation [median]) was 82.3±6.6 (76) years, and five of the 11 patients were male. The last seen normal to puncture time was 467.9±264.72 (264) minutes; baseline National Institutes of Health Stroke Scale score was 28.9±14.5 (16). Six (55%) of the 11 patients had right vertebrobasilar occlusions, and the remaining five (45%) had anterior circulation occlusive disease. The time from groin puncture to final recanalization time (overall procedural time) was 78.0±20.1 (62) minutes. The mean crossover time from TFA to TRA was 45.2±10.5 (41) minutes. The mean time from radial puncture to final recanalization was 33.8±10.5 (28) minutes. Distal thrombus migration events in previously unaffected territories occurred in 3/8 patients (37%). At 90 days, three patients (28%) had a favorable clinical outcome. Conclusion : Although rare, failure of TFA has been known to occur during MT for AIS. Our results demonstrate that TRA may be an alternative option for AIS intervention for select patients with subsequent timely revascularization. However, the incidence of distal thrombus migration was high, and the first puncture to reperfusion time was prolonged because of the time taken for the crossover to TRA after failure of TFA. This study provides some evidence that the TRA may be a viable alternative option to the TFA for MT of AIS.

• Journal of Preventive Medicine and Public Health
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• v.54 no.6
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• pp.385-394
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• 2021

Objectives: This study aimed to explore the status of regional variations in acute ischemic stroke (AIS) treatment and investigate the association between the presence of a thrombectomy-capable stroke center (TSC) and the case fatality rate (CFR) of AIS within hospital service areas (HSAs). Methods: This observational cross-sectional study analyzed acute stroke quality assessment program data from 262 hospitals between 2013 and 2016. TSCs were defined according to the criteria of the Joint Commission. In total, 64 HSAs were identified based on the addresses of hospitals. We analyzed the effects of structure factors, process factors, and the presence of a TSC on the CFR of AIS using multivariate logistic regression. Results: Among 262 hospitals, 31 hospitals met the definition of a TSC. Of the 64 HSAs, only 20 had a TSC. At hospitals, the presence of a stroke unit, the presence of stroke specialists, and the rate of endovascular thrombectomy (EVT) treatment were associated with reductions in the CFR. In HSAs, the rate of EVT treatment (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.97 to 0.99) and the presence of a TSC (OR, 0.93; 95% CI, 0.88 to 0.99) significantly reduced the CFR of AIS. Conclusions: The presence of a TSC within an HSA, corresponding to structure and process factors related to the quality of care, contributed significantly to lowering the CFR of AIS. The CFR also declined as the rate of treatment increased. This study highlights the importance of TSCs in the development of an acute stroke care system in Korea.

• Journal of Preventive Medicine and Public Health
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• v.56 no.2
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• pp.145-153
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• 2023

Objectives: Although it is difficult to define the quality of stroke care, acute ischemic stroke (AIS) patients with moderate-to-severe neurological deficits may benefit from thrombectomy-capable hospitals (TCHs) that have a stroke unit, stroke specialists, and a substantial endovascular thrombectomy (EVT) case volume. Methods: From national audit data collected between 2013 and 2016, potential EVT candidates arriving within 24 hours with a baseline National Institutes of Health Stroke Scale score ≥6 were identified. Hospitals were classified as TCHs (≥15 EVT case/y, stroke unit, and stroke specialists), primary stroke hospitals (PSHs) without EVT (PSHs-without-EVT, 0 case/y), and PSHs-with-EVT. Thirty-day and 1-year case-fatality rates (CFRs) were analyzed using random intercept multilevel logistic regression. Results: Out of 35 004 AIS patients, 7954 (22.7%) EVT candidates were included in this study. The average 30-day CFR was 16.3% in PSHs-without-EVT, 14.8% in PSHs-with-EVT, and 11.0% in TCHs. The average 1-year CFR was 37.5% in PSHs-without-EVT, 31.3% in PSHs-with-EVT, and 26.2% in TCHs. In TCHs, a significant reduction was not found in the 30-day CFR (odds ratio [OR], 0.92; 95% confidence interval [CI], 0.76 to 1.12), but was found in the 1-year CFR (OR, 0.84; 95% CI, 0.73 to 0.96). Conclusions: The 1-year CFR was significantly reduced when EVT candidates were treated at TCHs. TCHs are not defined based solely on the number of EVTs, but also based on the presence of a stroke unit and stroke specialists. This supports the need for TCH certification in Korea and suggests that annual EVT case volume could be used to qualify TCHs.

• Journal of Cerebrovascular and Endovascular Neurosurgery
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• v.25 no.4
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• pp.462-467
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• 2023

Thrombectomy procedures following intra-aneurysmatic lesions are extremely rare, and few cases have been reported. This article describes a microsurgical intra-aneurysmatic thrombectomy (MIaT) for a distal anterior cerebral artery (DACA) aneurysm. We present the case of a 48-year-old female that was admitted to the emergency room, showing neurologic deterioration with focal deficits. A computed tomography angiography (CTA) scan revealed an aneurysm located in the distal segment of the left anterior cerebral artery. During the surgical procedure, after clipping, a well-formed clot was visualized through the aneurysm's wall obstructing the left DACA flow. We proceeded to open the aneurysm's dome to remove the thrombus and clip the aneurysm neck, re-establishing the flow of the left DACA. Intra-aneurysmatic thrombosis can occur as a complication during clipping, obstructing the distal flow of vital arteries and causing fatal results in the patient's postoperative status. MIaT is a good technique for restoring the flow of the affected vessel and allows a secure aneurysm clipping after thrombus removal.

• Journal of Cerebrovascular and Endovascular Neurosurgery
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• v.25 no.1
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• pp.13-18
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• 2023

Objective: Mechanical thrombectomy (MT) is an effective treatment for patients suffering from acute ischemic stroke secondary to large vessel occlusion. However, recanalization failure rates of interventions were about 20% in literature studies. We report our experience of unsuccessful MT with a focus on technical reasons. Methods: From December 2010 to June 2021, six hundred eight patients with acute ischemic stroke due to large artery occlusion received MT using a stent retriever with or without an aspiration catheter in our institution. We divided the reasons for failure into six categories. We analyzed the reasons for failure by dividing our experience time into 3 periods. Results: A total of 608 cases of thrombectomy for large vessel occlusion were identified in the study period. The successful recanalization rate was 90.4%. In most of the cases (20/57, 35%), the thrombus persisted despite several passes, and the second most common cause was termination of the procedure even after partial recanalization (10/57, 18%). Similar proportions of in-stent occlusion, distal embolization, and termination due to vessel rupture were observed. On analysis of three periods, the successful recanalization rate improved over time. Conclusions: MT fails due to various reasons, and intracranial artery stenosis is the main cause of MT failure. With the development of rescue techniques, the failure rate has gradually decreased. Further development of new devices and techniques could improve the recanalization rates.

• Journal of Yeungnam Medical Science
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• v.31 no.1
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• pp.28-32
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• 2014

Pulmonary thromboembolism (PTE) increases the pressure of the right ventricle and leads to symptoms and signs, such as dyspnea and hypoxia. If PTE causes hemodynamic instability, thrombolytic therapy should be considered. A mechanical thrombectomy is an alternative treatment to thrombolytic therapy and should be considered when thrombolytic therapy is contraindicated. Various devices are used in mechanical maceration and catheter-directed thrombolysis, but there is no standard mechanical device for PTE as yet. We report here on 2 clinical experiences of mechanical thrombectomy using the Arrow-Trerotola percutaneous thrombolytic device to remove residual clots after systemic thrombolysis in patients with massive PTE.

• Journal of Chest Surgery
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• v.40 no.9
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• pp.641-644
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• 2007

A 50-year old man was admitted to our hospital because he complained of sudden abdominal pain. Multidetector abdominal CT showed proximal occlusion of the superior mesenteric artery. Emergency open laparotomy and Fogarty thrombectomy were done on admission day and repeat Fogarty thrombectomy and partial resection of the small bowel were done the next day. We report here on a case of superior mesenteric artery occlusion.

• Journal of Korean Neurosurgical Society
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• v.53 no.6
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• pp.360-363
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• 2013

We recently experienced self-detachment of the Solitaire stent during mechanical thrombectomy of acute ischemic stroke. Then, we tried to remove the detached stent and to recanalize the occlusion, but failed with endovascular means. The following diffusion weighted image MRI revealed no significant increase in infarction size, therefore, we performed surgical removal of the stent to rescue the patient and to elucidate the reason why the self-detachment occurred. Based upon the operative findings, the stent grabbed the main thrombi but inadvertently detached at a severely tortuous, acutely angled, and circumferentially calcified segment of the internal carotid artery. Postoperative angiography demonstrated complete recanalization of the internal carotid artery. The patient's neurological deficits gradually improved, and the modified Rankin scale score was 2 at three months after surgery. In the retrospective case review, bone window images of the baseline computed tomography (CT) scan corresponded to the operative findings. According to this finding, we hypothesized that bone window images of a baseline CT scan can play a role in terms of anticipating difficult stent retrieval before the procedure.

• Journal of Korean Neurosurgical Society
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• v.65 no.4
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• pp.514-522
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• 2022

Objective : A distal navigation of a large bore aspiration catheter during mechanical thrombectomy (MT) is important. However, delivering a large bore aspiration catheter is difficult to a tortuous or atherosclerotic artery. We report the experience of anchoring with balloon guide catheter (BGC) and stent retriever to facilitate the passage of an aspiration catheter in MT. Methods : When navigating an aspiration catheter failed with a conventional co-axial microcatheter delivery, an anchoring technique was used. Two types of anchoring technique were applied to facilitate distal navigation of a large bore aspiration catheter during MT. First, a passage of aspiration catheter was attempted with a proximal BGC anchoring technique. If this technique also failed, another anchoring technique with distal stent retriever was tried. Consecutive patients who underwent MT with an anchoring technique were identified. Details of procedure, radiologic outcomes, and safety variables were evaluated. Results : A total of 67 patients underwent MT with an anchoring technique. Initial trial of aspiration catheter passage with proximal BGC anchoring technique was successful for 35 patients (52.2%) and the second trial with distal stent retriever anchoring was successful for 32 patients (47.8%). Overall, navigation of a large bore aspiration catheter was successful for all patients (100%) without any procedure related complications. Conclusion : Our study showed the usefulness of anchoring technique with proximal BGC and distal stent retriever during MT, especially in those with an unfavorable anatomical structure. This technique could be an alternative option for delivering an of aspiration catheter to a distal location.

• Journal of the Korean Society of Radiology
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• v.81 no.3
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• pp.562-576
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• 2020

Acute ischemic stroke is one of the leading causes of disability and death around the world, especially in developed countries. Since the introduction of the 2nd generation devices, endovascular treatment of acute ischemic stroke has rapidly developed and is now considered to be a standard treatment. Here, we summarize the results of recent randomized clinical trials that have compared endovascular thrombectomy with conventional treatment for acute stroke and review the indications, current devices, and endovascular thrombectomy methods used.