In mechanical endovascular thrombectomy (MET) for acute basilar artery occlusion (ABAO) in the elderly, navigating a guide catheter via the femoral artery may be difficult due to the approach route’s significant tortuosity. To resolve this problem, we have been performing a technique that uses a direct brachial approach (DiBA) with a large-bore aspiration catheter. We reported our preliminary clinical experience with this technique. MET for ABAO using the DiBA technique was performed on 4 consecutive patients between August 2017 and December 2018. In all patients, thrombolysis in cerebral infarction 2B or 3 recanalization was achieved, but the modified Rankin Scale at 90 days was ≥4. There were no technical difficulties or complications with this technique. The DiBA technique is an effective and feasible approach in MET for ABAO. Although excellent clinical outcomes could not be achieved, the angiographic outcomes were excellent with no technical complications. This approach can be an alternative to the femoral artery approach, particularly for tortuous arteries in the elderly.
Recently, mechanical endovascular thrombectomy (MET)’s efficacy for acute ischemic stroke (AIS) with large vessel occlusion (LVO) in the anterior circulation has been demonstrated [
To shorten the time for guide catheter placement during MET for acute basilar artery occlusion (ABAO), all METs for ABAO have been performed via the transbrachial approach with a largebore aspiration catheter without using a guide catheter since August 2017. In this technique, which we called the direct brachial approach (DiBA), we used the Penumbra 5MAX ACE reperfusion catheter (Penumbra Inc., Alameda, CA, USA) as a guide catheter. Herein, we reported our preliminary clinical experience with this technique.
We retrospectively analyzed the data of 4 consecutive patients who underwent MET for ABAO using the DiBA technique between August 2017 and December 2018. Patient characteristics, endovascular procedure details, technical complications, and angiographic and clinical outcomes were analyzed. Particularly, the technical complications of the transbrachial approach included spasm, occlusion, and pseudoaneurysm of the brachial artery and median nerve palsy. The outcome variables of interest included puncture to guide (PTG) time, which was defined as the duration from puncture to guide catheter placement in the appropriate position, and puncture to recanalization (PTR) time. The other outcomes analyzed included thrombolysis in cerebral infarction (TICI) grade, score on the modified Rankin Scale (mRS) at 90 days, death due to any cause, and symptomatic intracranial hemorrhage, which was defined as an exacerbation based on the National Institutes of Health Stroke Scale score. All procedures were performed by board-certified neurosurgeons (T.S., Y.N., and M.M.) or an interventional neurologist (M.O.) of the Japanese Society of Neuroendovascular Therapy. The Institutional Review Board approval was obtained at the Nagoya City University Graduate School of Medical Sciences in Nagoya, Japan.
On admission, the patients underwent brain computed tomography (CT) and CT angiography (CTA). CTA was performed from the aortic arch to the cerebral vertex to assess the presence of LVO and the access route in case MET was necessary. If AIS in the posterior circulation was confirmed, brain magnetic resonance imaging was performed to exclude any large brainstem infarction. Subsequently, the DiBA technique was performed (
First, the diameter of the bilateral VA was confirmed on CTA. MET was performed via the right brachial artery as long as the diameter of the right VA was large enough to accommodate the 5MAX ACE, irrespective of dominancy. If the right VA was hypoplastic or aplastic, MET was performed via the left brachial artery. A 6-F introducer sheath measuring 25 cm was inserted in a brachial artery. The 5MAX ACE was directly inserted into this introducer sheath with a 0.035-inch guidewire, and navigated from the subclavian artery to the VA at the V2 position. Alternatively, a 4-F catheter was positioned at the VA, and then the 5MAX ACE was navigated into the VA using a catheter exchange technique. A combination of stent retriever (Solitaire FR, Medtronic Inc., Minneapolis, MN, USA) and aspiration techniques were performed [
Four patients were included in our study. The patient characteristics are summarized in
In this study, we analyzed the efficacy and feasibility of the DiBA technique in patients with ABAO. In all patients, TICI 2B or 3 recanalization was achieved and there were no technical difficulties or complications. The PTR time has been recommended to be within 30 minutes [
In an era of MET where effective devices are available, the time from puncture to placement of a guide catheter should be crucial to achieving a rapid recanalization. Anatomical configuration can cause difficulty in manipulation of catheters. It is quite apparent that placement of a guide catheter to the right VA through a type III aorta via the femoral artery is more difficult compared with an approach via the ipsilateral brachial artery. In this study, the DiBA technique was successfully used to navigate a guide catheter to a targeted vessel in all 4 patients. Lee et al. [
In 2018, Ishikawa et al. [
Using a balloon guide catheter (BGC) with a stent retriever had been reported to improve revascularization and clinical outcomes [
For this reason, to prevent ENT, the use of the Penumbra system is recommended during MET for ABAO. In case of using both a guide catheter and the 5MAX ACE, an 8-F or larger guide catheter (or a 6-F or larger guide sheath) is needed, but such a large profile guide catheter can be wedged in the VA. When the wedge of the VA and flow restriction occur, brainstem infarction in patients with hypoplasia of the contralateral VA or spinal cord infarction may occur [
Atherosclerotic plaque is abundant in the infrarenal abdominal arota, iliac and femoral bifurcations, and carotid bifurcations; the routes from radial or brachial artery are considered to elicit less mechanical irritations of the aforementioned atherosclerotic plaques compared with the transfemoral route, resulting in a lower risk of cholesterol embolization [
Iwata et al. [
Some points need careful consideration when performing the DiBA technique. The soft tip of the 5MAX ACE could make insertion into an introducer sheath difficult. In such a case, using an attached inserter would facilitate smooth insertion of the 5MAX ACE into the introducer sheath.
When the 5MAX ACE becomes clogged with thrombus or when the techniques such as CAPTIVE [
In this study, the mean PTR time was longer and the rate of poor outcome was higher compared with the recommended PTR time [
We described the DiBA technique, in which the Penumbra 5MAX ACE reperfusion catheter was used via the brachial artery as a guide catheter. In all patients, the 5MAX ACE could be easily navigated into the VA, and TICI 2B or 3 recanalization was achieved with no technical complications. It was considered to be useful, especially for tortuous arteries in the elderly. Further studies on the DiBA technique are needed.
None.
The Institutional Review Board approval was obtained at the Nagoya City University Graduate School of Medical Sciences in Nagoya, Japan.
The authors have no conflicts to disclose.
The DiBA technique for an ABAO. CTA shows an ABAO (A) and the assessment of the access route including the right VA ostium (B, arrow). (C) A 6-F introducer sheath measuring 25 cm is inserted in the right brachial artery (arrow), and the 5MAX ACE (Penumbra Inc., Alameda, CA, USA) is navigated using a 0.035-inch guidewire or a catheter exchange technique. The 5MAX ACE is positioned at the VA V2 position (D, arrow), and a microcatheter and a microwire are navigated (E) to cross the thrombus. (F) After deployment of the stent retriever to the site of occlusion and positioning of the 5MAX ACE to the proximal site of the occlusion (arrow), immediate flow restoration was observed. (G) Finally, TICI 3 recanalization was achieved. DiBA, direct brachial approach; ABAO, acute basilar artery occlusion; CTA, computed tomography angiography; VA, vertebral artery; TICI, thrombolysis in cerebral infarction.
Clinical and procedural data and outcomes for all patients
Case No. | Age (years) | Gender | Presenting NIHSS | Etiology | Occlusion site of BA | IV tPA | Approach site | PTG time (minutes) | PTR time (minutes) | Guide Catheter | First device | Additional device | TICI | mRS | |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
DiBA (n=4) | |||||||||||||||
1 | 69 | Female | 40 | CES | Mid | N | R BrA | 31 | 87 | 5MAX ACE | Solitaire FR | LIF | 3 | 5 | |
2 | 80 | Female | 30 | CES | Mid | Y | R BrA | 21 | 50 | 5MAX ACE | Solitaire FR | 3 | 6 | ||
3 | 79 | Male | 24 | ESUS | Mid | N | L BrA | 36 | 51 | 5MAX ACE | Solitaire FR | 2B | 6 | ||
4 | 89 | Female | 36 | ESUS | Mid | N | R BrA | 10 | 49 | 5MAX ACE | Solitaire FR | 3MAX | 2B | 4 | |
Mean | 79 | 33 | 25 | 59 |
NIHSS, National Institutes of Health Stroke Scale; BA, basilar artery; tPA, tissue plasminogen activator; PTG, puncture to guide; PTR, puncture to recanalization; TICI, thrombolysis in cerebral ischemia; mRS, modified Rankin Scale; DiBA, direct brachial approach; CES, cardioembolic stroke; N, no; R, right; BrA, brachial artery; LIF, local intraarterial fibrinolysis; Y, yes; L, left; ESUS, embolic stroke of undetermined source.