In some patients with acute cerebral vessel occlusion, navigating mechanical thrombectomy systems is difficult due to tortuous anatomy of the aortic arch, carotid arteries, or vertebral arteries. Our purpose was to describe a multiple coaxial catheter system used for mechanical revascularization that helps navigation and manipulations in tortuous vessels. A triple or quadruple coaxial catheter system was built in 28 consecutive cases presenting with acute ischemic stroke. All cases were treated by mechanical thrombectomy with the Penumbra System. In cases of unsuccessful thrombo-aspiration, additional thrombolysis or angioplasty with stent placement was used for improving recanalization. The catheter system consisted of an outermost 8-Fr and an intermediate 6-Fr guiding catheter, containing the inner Penumbra reperfusion catheters. The largest, 4.1-Fr, reperfusion catheter was navigated over a Prowler Select Plus microcatheter. The catheter system provided access to reach the cerebral lesions and provided stability for the mechanically demanding manipulations of thromboaspiration and stent navigation in all cases. Apart from their mechanical role, the specific parts of the system could also provide access to different types of interventions, like carotid stenting through the 8-Fr guiding catheter and intracranial stenting and thrombolysis through the Prowler Select Plus microcatheter. In this series, there were no complications related to the catheter system. In conclusion, building up a triple or quadruple coaxial system proved to be safe and efficient in our experience for the mechanical thrombectomy treatment of acute ischemic strok

Bonvin, Christophe

Kulcsár, Zsolt

Lovblad, Karl

Rüfenacht, Daniel

Yilmaz, Hasan

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TECHNICAL NOTEMultiple Coaxial Catheter System for Reliable Accessin Interventional Stroke TherapyZsolt Kulcsa´r • Hasan Yilmaz • Christophe Bonvin •Karl O. Lovblad • Daniel A. Ru¨fenachtReceived: 16 November 2009 / Accepted: 8 January 2010 / Published online: 4 February 2010 Springer Science+Business Media, LLC and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2010Abstract In some patients with acute cerebral vesselocclusion, navigating mechanical thrombectomy systems isdifficult due to tortuous anatomy of the aortic arch, carotidarteries, or vertebral arteries. Our purpose was to describe amultiple coaxial catheter system used for mechanicalrevascularization that helps navigation and manipulationsin tortuous vessels. A triple or quadruple coaxial cathetersystem was built in 28 consecutive cases presenting withacute ischemic stroke. All cases were treated by mechan-ical thrombectomy with the Penumbra System. In cases ofunsuccessful thrombo-aspiration, additional thrombolysisor angioplasty with stent placement was used for improv-ing recanalization. The catheter system consisted of anoutermost 8-Fr and an intermediate 6-Fr guiding catheter,containing the inner Penumbra reperfusion catheters. Thelargest, 4.1-Fr, reperfusion catheter was navigated over aProwler Select Plus microcatheter. The catheter systemprovided access to reach the cerebral lesions and providedstability for the mechanically demanding manipulations ofthromboaspiration and stent navigation in all cases. Apartfrom their mechanical role, the specific parts of the systemcould also provide access to different types of interventions,like carotid stenting through the 8-Fr guiding catheter andintracranial stenting and thrombolysis through the ProwlerSelect Plus microcatheter. In this series, there were nocomplications related to the catheter system. In conclusion,building up a triple or quadruple coaxial system proved to besafe and efficient in our experience for the mechanicalthrombectomy treatment of acute ischemic stroke.Keywords Ischemic stroke  Thrombectomy Coaxial catheter system  Thromboaspiration Intracranial stentIntroductionRecently, a number of mechanical approaches have shownpromise for restoring blood flow in an acutely occludedcerebral artery. However, tortuous anatomy of the aortaand other extracranial vessels may create problems duringacute interventions for revascularization, sometimes mak-ing it very difficult or even impossible to deploy endo-vascular devices to the intracranial vessels. Thus, underthese conditions, these systems may require proximalcatheter support for successful interventions. The Penum-bra System (PS; Penumbra Inc., Alameda, CA, USA) isa new mechanical thrombectomy device, specificallydesigned to remove the thrombus in acute ischemic strokesecondary to large vessel thromboembolism. The purposeof this study is to evaluate whether a special multiplecoaxial catheter system, when used in combination withthe PS, may improve its navigation and revascularizationeffectiveness.Z. Kulcsa´r  H. Yilmaz  D. A. Ru¨fenachtNeurointerventional Division, Department of ClinicalNeurosciences, Geneva University Hospital, Geneva,SwitzerlandC. BonvinNeurology Division, Department of Clinical Neurosciences,Geneva University Hospital, Geneva, SwitzerlandK. O. LovbladDiagnostic Neuroradiology Division, Department of Radiology,Geneva University Hospital, Geneva, SwitzerlandZ. Kulcsa´r (&)  D. A. Ru¨fenachtKlinik Hirslanden, Neurozentrum, Witellikerstrasse 40,8032 Zurich, Switzerlande-mail: kulcsarzsolt22@gmail.com123Cardiovasc Intervent Radiol (2010) 33:1205–1209DOI 10.1007/s00270-010-9815-0Methods and ResultsTechniqueTwenty-eight consecutive patients with a mean age of66 years who presented with acute ischemic stroke weretreated with the PS as first-choice interventional therapy atour stroke center. In 24 cases, the occlusions were locatedin the anterior circulation, and the rest (four cases) were inthe vertebrobasilar arteries. The endovascular interventionwas performed with the use of at least a triple coaxialcatheter system. Mechanical thrombectomy procedureswere performed with the PS and thrombolysis was effectedby intra-arterial administration of r-tPA. Thromboemboliclesions not responding to these interventions were treatedwith the Enterprise self-expanding stent (Codman &Shurtleff, Inc., Raynham, MA, USA). Intracranial occlu-sive atherosclerotic lesions were treated with the Wingspanself-expanding stent (Boston Scientific, Natick, MA, USA).In cases where cervical occlusive atherosclerotic lesionswere causing intracranial perfusion deficit, the Wallstentsystem (Boston Scientific) was used for vesselreconstruction.Standard TechniqueUnder general anesthesia, a standard unilateral 8-Fr trans-femoral approach was used. Periprocedural heparinizationfor systemic anticoagulation was accomplished with abolus dose of 2000 IU followed by boluses of 1000 IUevery 60 min thereafter. Flush solution of the cathetersystem was not heparinized and the anticoagulation statusof the patients was not monitored during the intervention.Catheter System and Revascularization TechniqueAll catheters used were connected to continuous high-pressure saline flush lines. As a first step, a double coaxialsystem was assembled by an outermost 80-cm-long, 8-FrVista Brite Tip catheter (VBT; Cordis Corp., USA) and aninner, 100-cm-long, 5-Fr diagnostic catheter of simple orcomplex tip shape, depending on the vascular anatomy.The system was then introduced over a 0.035- or 0.038-in.Radiofocus guidewire (Terumo Europe, Cedex, France) inthe arterial tree. The intermediate catheter was advanced sothere was a 5- to 10-cm distance between the tips of thetwo catheters. The inner catheter was then advanced byconventional technique over the wire in the target vessel,followed from time to time by the advancement of theVBT, always maintaining a certain distance between thecatheter tips. As soon as the inner catheter had reached thedesired position, together with the guidewire, they wereable to provide enough support to allow for advancementof the outer catheter. The VBT catheter was adjusted toreach the middistal portion of the common carotid or theproximal portion of the subclavian artery. The diagnosticcatheter was then removed and replaced in the majority ofthe cases with a 6-Fr, regular, 90-cm-long guiding catheterto reach the target vessel, i.e., cervical internal carotid orvertebral artery. In a small number of cases, 100-cm-longguiding catheters were used when the natural height of thepatients or the proximal tortuosity of the aorta required amore stable position in the target vessel. The 2-Fr sizedifference between the two guiding catheters was requiredto allow for continuous saline flushing.After positioning of the inner guiding catheter, the PSwas introduced coaxially. In cases of distal vessel lesions,such as thromboembolic occlusions of the M2–M3 seg-ments of the middle cerebral artery or the P2 segment ofthe posterior cerebral artery, intermediate- and smaller-sized (0.032- and 0.028-in.) reperfusion catheters wereused for the revascularization procedure. In such cases thereperfusion catheter was navigated to the lesion site over aregular, 0.014-in. microwire.In more proximal, major vessel occlusions (carotid T,M1 segment, vertebral and basilar arteries, P1 segments),the 0.041-in. reperfusion catheter was used for thromboa-spiration. Although this catheter is highly flexible, navi-gation over a regular microwire to the intracranialvasculature may be problematic, given its relatively largeinner and outer diameter. To overcome this issue, anotherdouble coaxial system was assembled and used inside thealready-placed guiding catheters (a quadruple system).This inner system consisted of an outer 0.041-in. sizedreperfusion catheter and an innermost, microwire-guidedProwler Select Plus microcatheter (PSP; Codman &Shurtleff, Inc., Raynham, MA, USA). The 0.041-in.reperfusion catheter was navigated over the PSP micro-catheter, so that the tip reached the proximal end of the clot(Fig. 1). The inner PSP microcatheter with guidewire wasthen removed. In both systems, a continuous aspiration-debulking process was performed as previously described[1]. If, after six to eight passages of aspiration through theoccluded area, revascularization was not achieved or wasconsidered insufficient, the separator was removed and thePSP microcatheter reintroduced over the wire. Local rt-PAwas then injected in a fractionated manner.Angioplasty with Stenting in Cervical and IntracranialLesionsAdjunctive stent treatment in this patient series was con-sidered and carried out under two conditions. First, incomplete or subtotal occlusion of the cervical origin of theinternal carotid artery, carotid angioplasty and stenting wasperformed at this level. In this setting, the 8-Fr VBT1206 Z. Kulcsa´r et al.: Multiple Coaxial Catheter System123catheter was used for stent delivery under filter protection.After access to the intracranial circulation was re-estab-lished by the angioplasty procedure, the 6-Fr guidingcatheter was advanced to extend beyond the stent.Second, intracranial stenting was performed in persistentintracranial thromboembolic occlusions or concomitantocclusive atherosclerotic stenosis. For the first case sce-nario the same PSP microcatheter was used and providedaccess for deployment of a self-expanding Enterprise stent.This stent has a closed-cell design with flared ends; bothaspects were considered an advantage when it came totrapping a clot along the vessel wall. Given its maximalavailable length of 37 mm, this device is long enough tocover extensive lesions without the need for multiple stentdeployment. In cases of atherosclerotic stenosis or occlu-sion, the Wingspan stent was used for angioplasty anddeobstruction.Differentiation of atherosclerotic lesions from throm-boembolic ones was mainly subjective and based on thefollowing: (1) calcification seen on the preoperative CTscan at the occlusion site was considered as the basis for anatherosclerotic lesion, (2) occlusions at bifurcations(internal carotid artery, medial carotid artery, or basilarartery bifurcations) were taken as thromboembolic lesions,and (3) all lesions were first accessed with the reperfusioncatheters. When the reperfusion catheter was not able to beadvanced through the occlusion site due to mechanicalblockage, an atherosclerotic lesion was again suspected. Incases of stent use, additional thromboembolic protectionmedication was used by IV tirofiban infusion (Aggrastat).The sizes of the specific catheters are listed in Table 1.In our cases, this technique provided a 100% lesion siteaccess rate in a relatively elderly population, where 50% ofpatients were older than 70 years.DiscussionVascular tortuosity is a major cause of difficulty or failurein treating intracranial lesions [2, 3]. Acute ischemic strokepatients are usually from the older population and oftenpresent with risk factors such as atherosclerosis and vesseltortuosity that may render access to the target lesion dif-ficult. In the MERCI and MultiMerci trials, 4 of 151patients (2.6%) and 5 of 171 patients (2.9%), respectively,had an unsuccessful treatment attempt due to vessel tor-tuosity or due to the fact that the clot could not be reachedby the microcatheter [4, 5]. In the Penumbra trial, 3Fig. 1 Acute thromboembolicocclusion of the basilar artery inan 83-year-old woman (A). Toovercome the significantproximal and distal vasculartortuosity, a quadruple coaxialcatheter system was built. Theoutermost 8-Fr VBT catheter ispositioned in the proximal rightsubclavian artery (black arrow);the 6-Fr Envoy catheter, in theproximal V2 segment of theright vertebral artery (whitearrow); the 4.1-Fr Penumbrareperfusion catheter, in thedistal basilar trunk (emptyarrow); and the 2.3-Fr ProwlerSelect Plus microcatheter,containing a 0.014-in.microwire, reaching the P1–P2segment of the left posteriorcerebral artery (curved arrow)(B). Postrevascularizationangiogram showing completereopening of the basilar arteryand its main branches; however,both distal posterior cerebralarteries remained occluded (C)Z. Kulcsa´r et al.: Multiple Coaxial Catheter System 1207123patients of 23 (13%) had to be abandoned because ofaccessing difficulties [1]. Our experience has shown thatfor intracranial thromboembolic vessel occlusions, a mul-tiple coaxial system was useful for providing stable supportfor acute revascularization by the PS.On the other hand, once the lesions are reached with acatheter system that is not stable enough, the system maynot support further mechanically demanding manipulations(like stent advancement) and may become unstable duringthe intervention. The instability and continuous movementof the coaxial system during the procedure may causemechanical irritation of the catheterized vessel wall (i.e.,internal carotid or vertebral artery), leading to vasospasmor even intimal dissection. Lack of proximal support maycause buckling of guiding catheters back in the commoncarotid artery, subclavian arteries, or aortic arch, resultingin sudden unexpected movements at the intracranial level,also being a possible cause of complications.In our practice, the triple or quadruple coaxial systemprovided adequate proximal mechanical support from thegroin to the level of the common carotid or subclavianarteries. In this system an 8-Fr Vista Brite Tip (VBT; CordisCorp.), 80-cm-long catheter was used as the outermostcatheter. This catheter has a consistent large lumen, and iskink resitant. The outermost VBT catheter assured astraighter access path to the precerebral vessels for the 6-Frguiding catheter. The mechanical strain of the 6-Fr guidingcatheter was thus reduced, resulting in a more stable positionat the level of the internal carotid and vertebral arteries. Onthe other hand, this double system was also stiff enough toprevent retrograde bucklings in the aorta or aortic arch.Besides the mechanical advantages, the unique parts ofthe coaxial system could also provide several other options.When needed, the 8-Fr VBT catheter was useful to providean easy access for cervical carotid artery angioplasty andstent placement. After angioplasty had been done, therewas no need for catheter change and the same route wasused to provide access to the 6-Fr guiding catheter. Theinner 6-Fr guiding catheter, besides providing a stablesupport for the revascularization catheters, also providedaccess for intracranial angioplasty with the Wingspan stent.The PSP microcatheter, which was mostly used foradvancement of the 0.041-in. revascularization catheter,was also used for local thrombolysis and, when none ofthese manipulations were effective, stent-assisted revas-cularization with the Enterprise stent.There may be several concerns with regard to using amultiple coaxial system. Building it up is more time-con-suming than using only a double setting, and handling it, interms of both catheterization and having several salineflush lines on the table, may be more demanding from thetechnical point of view. However, in our experience thetime needed to prepare such systems is easily regainedduring the procedure because of the efficiency in accessingthe target lesions and providing stable support. The otherconcern may be related to the size of the outer diameter ofthe external catheter and the risk of vessel wall injuryduring catheterization. The system has a de-escalatingouter diameter and mechanical stiffness profile that aredesigned to be atraumatic for the vasculature. Theadvancement of the VBT catheter over an inner 5- or 6-Frcatheter and a guidewire proved to be safe in our experi-ence. We think that in tortuous anatomy, such a stablesystem carries less risks of vessel wall injury and betterprevents the inadvertent bucklings and movements of theintracranial devices, compared to double coaxial systems.Other Possible Clinical ApplicationsThe multiple coaxial system may be used in almost allneuroendovascular procedures, for example, aneurysmtreatment with or without balloon or stent assistance. Forinterventions demanding a smaller-sized system such asaneurysm treatment of the vertebrobasilar circulation, astep down in size can be used, with an outer 7-Fr VBT andan intermediate 5-Fr catheter.ConclusionsBuilding up a triple or quadruple coaxial system proved tobe safe and efficient in our experience for mechanicalTable 1 Catheters used for coaxial systemsCatheter type Outer diameter (prox./dist.) Inner diameter Usable length (cm)Vista Brite Tip 8 Fr (0.104 in., 2.6 mm) 0.088 in. (2.2 mm) 80Intermediate guiding catheter, Envoy 6 Fr (0.079 in., 2 mm) 0.070 in. (1.8 mm) 90 or 100Penumbra reperfusion catheters0.041 in. 4.1 Fr (0.054 in., 1.37 mm) 0.041 in. (1.04 mm) 1370.032 in. 4.1 Fr (0.054 in., 1.37 mm)/3.4 Fr (0.045 in., 1.14 mm) 0.032 in. (0.81 mm) 1500.026 in. 3.9 Fr (0.051 in., 1.3 mm)/2.8 Fr (0.037 in., 0.94 mm) 0.026 in. (0.66 mm) 150Prowler Select Plus 2.8 Fr (0.037 in., 0.94 mm)/2.3 Fr (0.03 in., 0.76 mm) 0.021 in. (0.53 mm) 1551208 Z. Kulcsa´r et al.: Multiple Coaxial Catheter System123thrombectomy treatment of acute ischemic stroke. Thesystem has major advantages in cases with tortuous anat-omy and severe generalized atherosclerosis, where accessand system stability are of crucial importance. Besidestheir mechanical role, the different parts of the system mayplay different roles,and provide the possibility to performdifferent types of interventions in the same setting. Webelieve that the multiple coaxial system may improve thesuccess rate and provides more safety in neuroendovascularprocedures, without increasing the risk of injuries duringcatheterization.Acknowledgment We gratefully acknowledge the contribution ofSiu Po Sit to manuscript preparation.References1. Bose A, Henkes H, Alfke K, Reith W, Mayer TE, Berlis A, BrancaV, Sit SP (2008) The Penumbra System: a mechanical device forthe treatment of acute stroke due to thromboembolism. Am JNeuroradiol 29:1409–14132. Mori T, Kazita K, Chokyu K, Mima T, Mori K (2000) Short-termarteriographic and clinical outcome after cerebral angioplasty andstenting for intracranial vertebrobasilar and carotid atheroscleroticocclusive disease. Am J Neuroradiol 21:249–2543. Lylyk P, Cohen JE, Ceratto R, Ferrario A, Miranda C (2002)Angioplasty and stent placement in intracranial atheroscleroticstenoses and dissections. Am J Neuroradiol 23:430–4364. Smith WS, Sung G, Saver J, Budzik R, Duckwiler G, LiebeskindDS, Lutsep HL, Rymer MM, Higashida RT, Starkman S, GobinYP, Multi MI, Frei D, Grobelny T, Hellinger F, Huddle D, KidwellC, Koroshetz W, Marks M, Nesbit G, Silverman IE (2008)Mechanical thrombectomy for acute ischemic stroke: final resultsof the Multi MERCI trial. Stroke 39:1205–12125. Smith WS, Sung G, Starkman S, Saver JL, Kidwell CS, Gobin YP,Lutsep HL, Nesbit GM, Grobelny T, Rymer MM, Silverman IE,Higashida RT, Budzik RF, Marks MP (2005) Safety and efficacyof mechanical embolectomy in acute ischemic stroke: results of theMERCI trial. Stroke 36:1432–1438Z. Kulcsa´r et al.: Multiple Coaxial Catheter System 1209123

Multiple Coaxial Catheter System for Reliable Access in Interventional Stroke Therapy

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Multiple Coaxial Catheter System for Reliable Access in Interventional Stroke Therapy

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