Beyond the Catheter: Contemporary Aspiration Pump Systems in Neurointerventional Stroke Therapy

Acute ischemic stroke is the greatest cause of morbidity and mortality among cerebrovascular pathologies. Over time, several therapeutic options have been developed for treating patients with stroke, including IV r-tPA (intravenous recombinant tissue-type plasminogen activator) and IV-TNK (intravenous tenecteplase) thrombolysis, and endovascular mechanical thrombectomy, with the latter showing favorable recanalization rates. Stent retrievers and mechanical aspiration, the 2 types of mechanical thrombectomy, are used for acute ischemic stroke due to large-vessel occlusions. The first reported aspiration thrombectomy dates back to 2002, during which a 50 mL syringe was used to generate negative pressure and aspirate a clot. Since then, extensive research and development have transformed aspiration thrombectomy. Penumbra's first system paved the way for present-day aspiration systems in neurointerventional surgery, such as the Penumbra engine and Thunderbolt aspiration systems. Ongoing innovations have focused on improving access to challenging vascular locations and enabling the removal of large thrombi. Over time, aspiration techniques have also evolved. However, despite successful first-pass complete revascularization, a subset of patients continues to experience poor functional outcomes, highlighting the multifactorial nature of stroke recovery. In this review, we outline in detail the historical development of aspiration pump systems in neuroendovascular surgery, describe the different systems and their technical characteristics, highlight the clinical trials evaluating their efficacy, with particular attention to distinctions between devices, and discuss avenues for future growth.