Mechanical thrombectomy devices for endovascular management of acute ischemic stroke: Duke stroke center experience

Mechanical thrombectomy devices are gaining popularity in large vessel occlusions where chemical thrombolysis is usually futile. MERCI, Multi-MERCI, Penumbra and SWIFT trails have elevated the status of mechanical thrombectomy from being a complementary treatment modality to mainstream stroke intervention. The aim of this study was to compare our immediate recanalization rates with available mechanical devices.

A retrospective review from March 2009 to August 2012 was performed on patients who underwent mechanical thrombectomy for large vessel occlusion. Cases where IATPA and/or balloon angioplasty was performed without mechanical thrombectomy were excluded from the study. Recanalization rates were assessed immediately post-procedure by follow-up angiography. TICI scores were used to quantify the extent of recanalization and the residual clot burden.

Twenty two procedures were performed on 20 patients using Merci (MER):5; Penumbra (PEN):11; Solitaire-FR (SOL):6. Two patients underwent intervention using both Merci and Penumbra devices. The M:F ratio was 1.2:1. The most common vascular territory involved was the right MCA (9/20) followed by left MCA (5/20), left ICA (2/20), basilar (3/20) and vertebral arteries (1/20). The average door to needle time was 210 minutes [MER: 184.4; PEN: 249.2; SOL: 162]. Additional procedures were performed in 63.4% (14/22) of the patients [MER: 80% (4/5); PEN: 72.7% (8/11) and SOL: 33.3% (2/6)]. Vasospasm was observed in MER: 20% (1/5); PEN: 9.1% (1/11); SOL: 0% (0/6)]. Complete recanalization was achieved in 59.1% (13/22) [MER: 40% (2/5); PEN: 45.5% (5/11); SOL: 100% (6/6)]. The rate of complete recanalization was statistically significant for the Solitaire group vs. the MERCI group (P=0.0062) as well as the Penumbra group (0.0025). The average pre-procedure TICI was 0.4 [MER: 0.6; PEN: 0.3; SOL: 0.3], while the average post-procedure TICI was 2.5 [MER: 2.4; PEN: 2.3; SOL: 3.0].

The study reveals a higher rate of angiographic recanalization using the Solitaire-FR device, requiring a lesser number of passes and other associated procedures as compared to MERCI and Penumbra. Thus, Stentrievers (Solitaire-FR) are advantageous in faster device delivery and quick flow restoration. However, future prospective randomized large trials are required to confirm these early results.