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Balloon guide catheters: use, reject, or randomize?
Mayank Goyal1,2, Manon Kappelhof3, Johanna M Ospel4,5
1Department of Clinical Neurosciences, University of Calgary, Calgary, Canada. mgoyal@ucalgary.ca.
Insights
Balloon guide catheters (BGCs) improve endovascular stroke treatment by reversing blood flow and reducing clot risks. Randomized trials are needed to confirm their routine use despite current clinical reluctance.
Area of Science:
- Neuroendovascular interventions
- Vascular surgery
- Neurology
Background:
- Balloon guide catheters (BGCs) facilitate flow reversal during thrombectomy, potentially reducing clot fragmentation and distal embolization.
- Observational studies suggest BGCs improve reperfusion and clinical outcomes compared to conventional catheters in endovascular stroke treatment.
- Despite evidence, BGC adoption in clinical practice remains low due to technical and cost concerns.
Discussion:
- The reluctance to adopt BGCs may stem from perceived technical complexities and associated costs.
- High-level evidence, specifically from randomized clinical trials, is crucial to support the routine implementation of BGCs.
- Overcoming obstacles is necessary to conduct a definitive trial evaluating BGCs in acute ischemic stroke treatment.
Key Insights:
- BGCs offer a method to enhance safety and efficacy in thrombectomy procedures.
- A significant gap exists between observational evidence favoring BGCs and their current clinical utilization.
- Randomized controlled trials are essential to provide definitive evidence for BGCs' role in stroke care.
Outlook:
- Future research should focus on designing and executing robust randomized trials to address the BGC implementation question.
- Addressing technical and cost barriers will be vital for increasing BGC adoption.
- The goal is to determine if routine BGC use is warranted in endovascular treatment for acute ischemic stroke.
Abstract:
Thrombectomy devices played an important role in the success of endovascular treatment trials over the past five years. A balloon guide catheter (BGC) is an adjunctive device used to arrest and reverse flow by inflating the balloon at its tip, which allows for flow reversal in intracranial arteries during retrieval of thrombectomy devices by applying concomitant aspiration through its lumen. Thereby, it can decrease the risk of clot fragmentation and distal embolization. Despite the numerous benchtop and clinical observational studies showing the superiority of BGC to conventional guide catheters in improving reperfusion quality and clinical outcome, its use is still low in clinical practice. The reasons behind this reluctance might be related to technical and cost issues. Therefore, high level evidence data, i.e., a randomized clinical trial, are needed to increase its implementation in thrombectomy procedures. Nonetheless, several obstacles and challenges can prevent the completion of such a trial, and efforts are needed to overcome them. We provide an overview of the current opinions about BGCs in the neurointerventional community and discuss the feasibility and challenges of a possible randomized trial to answer the question "should a BGC be routinely used in endovascular treatment of acute ischemic stroke?"
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