Background

Following the results of the recent clinical studies, Mechanical Thrombectomy using stent retrievers is now the first line treatment for acute ischemic stroke with proximal occlusions. Although the use of balloon guide catheters (BGC) is recommended, it is not systematically used by all neurointerventionalists.

Methods

Patients from the Solitaire arm of SWIFT PRIME were selected to evaluate the value of BCG when used in combination with stent retrievers. SWIFT PRIME was a randomized controlled trial comparing intravenous rtPA versus rtPA and mechanical thrombectomy using Solitaire device for anterior circulation strokes with confirmed proximal intracranial vessel occlusions and salvageable brain. The trial was conducted in high volume and experienced centers and focused on improving the workflow of the patients until final assigned treatment. The use of BGC was left up to the physicians’ preference.

Results

A total of 87 patients were treated with mechanical thrombectomy using the Solitaire device: 48 patients with BGC and 39 patients without BCG. There were no significant differences in age (p = 0.07), sex (p = 0.67), baseline NIHSS (p = 0.54), main comorbidities (Hypertension (p = 1.00), Diabetes (p = 1.00), Hyperlipidemia (p = 0.47), atrial fibrillation), baseline blood pressure, occlusion location, side of occlusion and onset to randomization times. Although there was a nominal difference in baseline ASPECTS score, with higher baseline scores in the BGC group, there was no difference in the baselie infarct volumes. Procedures where BGC were used compared to non-BGC procedures had the same groin to first pass time intervals (27+14 on both groups) but shorter overall procedure times (60+25 vs. 65+30 min, p = 0.49). We also observed fewer devices passes (1.6+0.8 vs. 1.9+1.0, p = 0.14) and a higher proportion of TICI 3 reperfusion in the BGC group (73.9% vs. 62.2%, p = 0.25). Infarct size at 27 h was significantly lower in the BGC group (39.8+55 ml versus 80+111 ml, p = 0.03) as was the absolute difference in infarct volume (66.0 +/- 106.3 vs. 23.4 +/- 29.7 p = 0.017). Greater than 90% reperfusion of the territory at risk on perfusion imaging at 27 h (based on Tmax >6 s, TICI 2b-3 if Tmax not available) was higher in the BGC group (94.1% vs. 68.2%, p = 0.02). Although not reaching statistical significance, there were nominal differences in clinical outcomes at 3 months favoring the BGC group including functional independence (mRS 0–2, 66.7% vs 53.8%, p = 0.272) and mortality (4.2% vs. 10.3%, p = 0.401),

Conclusion

BGC use in the SWIFT PRIME cohort of patients treated with rTPA and mechanical thrombectomy with Solitaire demonstrated significantly lower infarct size and higher reperfusion rates at 27 h. Overall procedure times were shorter for BGC group. These findings suggest that there is likely benefit from use of BGC when treating AIS with mechanical thrombectomy; however, randomized trials are required to confirm this finding.

Disclosures

V. Pereira: 2; C; Covidien. A. Siddiqui: 2; C; Covidien. T. Jovin: 2; C; Covidien. D. Yavagal: 2; C; Covidien. E. Levy: 2; C; Covidien. A. Bonafé: 2; C; Covidien. C. Cognard: 2; C; Covidien. O. Jansen: 2; C; Covidien. R. Nogueira: 2; C; Covidien. R. Jahan: 2; C; Covidien. L. Slater: None. J. Coutinho: None. J. Saver: 2; C; Covidien. M. Goyal: 2; C; Covidien.

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