Guidewire interaction with stent retriever thrombectomy for stroke with large or medium vessel bifurcation occlusion: a retrospective cohort study

Introduction

Stroke is the second leading cause of death globally (1), with approximately 87% of cases being ischemic strokes and 10–20% being large vessel occlusive (LVO) strokes (2). Timely recanalization is essential to improve neurologic outcomes and reduce mortality. Mechanical thrombectomy (MT) is an important treatment strategy for acute ischemic stroke (AIS) secondary to LVO. However, nearly 40% of patients with anterior circulation ischemic stroke failed to achieve successful reperfusion after treatment with standard MT, especially for patients with vessel bifurcation occlusion (3,4).

Double-stent retrieval thrombectomy is an available rescue technique for vessel bifurcation occlusions that are refractory to standard MT procedures with comparable reperfusion rates (5,6). Nevertheless, double-stent retrieval thrombectomy is associated with considerable endothelial damage, increases the risk of stent entanglement, leading to difficulties in retrieval, and is not appropriate for medium vessel occlusion (MeVO), which limits its clinical dissemination to some extent (7-9).

Due to the above challenges encountered in standard MT, we present a novel strategy for the treatment of AIS caused by vessel bifurcation occlusion using a guidewire, a microcatheter, and a stent retriever, termed “guidewire interaction with stent retriever thrombectomy (WISE)”, and assessed the efficacy and safety of this technique at our stroke center. We present this article in accordance with the STROBE reporting checklist (available at https://jni.amegroups.com/article/view/10.21037/jni-25-10/rc).

Methods

Study design and patient selection

This retrospective cohort study enrolled consecutive stroke patients with occlusion in the terminal of the internal carotid artery (TICA) bifurcation or the bifurcation of the middle cerebral artery (MCA) treated with the WISE technique from June 2020 to October 2023 at the Advanced Stroke Center of Daping Hospital. The eligibility criteria were the following: (I) age ≥18 years old; (II) digital subtraction angiography (DSA) confirmed occlusion in the bifurcation of TICA or the M1 or M2 segment of MCA; (III) the National Institutes of Health Stroke Scale (NIHSS) scores ≥6 (10); (IV) onset-to-puncture time within 24 hours; (V) modified Rankin Scale (mRS) score <2 (10); and (VI) completion of 3 months of follow-up (Figure 1).

Figure 1 Flow diagram for stroke patients treated with WISE technique. MT, mechanical thrombectomy; WISE, guidewire interaction with stent retriever thrombectomy.

WISE technique procedure

MT was first performed using a direct aspiration first pass technique (ADAPT), stent retrieval thrombectomy, or Solitaire FR/stent with intracranial support catheter for mechanical thrombectomy (SWIM). The failure of the standard technique was defined as the failure of recanalizing the target vessel using the above techniques at least once. The WISE technique would be attempted after the failure of standard MT. An 8-French guiding catheter (Cordis, Hialeah, FL, USA) was positioned in the internal carotid artery (ICA), and then, an intracranial support catheter (6-French AXS Catalyst, Stryker, Kalamazoo, MI, USA), a 3MAX or 4MAX reperfusion catheter (Penumbra Inc., Alameda, CA, USA) was introduced. A microcatheter (Rebar 18, ev3, Plymouth, MN, USA) was navigated over a 0.014-inch guidewire (Synchro, Stryker) through the occluded segment to one of its distal branches. A stent retriever (Solitaire FR 4 mm × 20 mm; Solitaire AB 6 mm × 30 mm or 4 mm × 20 mm, ev3; Captor 6 mm × 30 mm, HeartCare Medical, Shanghai, China; or Aperio 3.5 mm × 28 mm or 4.5 mm × 30 mm, Acandis, Pforzheim, Germany) was introduced via the microcatheter and deployed. The 0.014-inch guidewire guides the microcatheter through the stent mesh to the distal end of the other branch vessel beyond the bifurcation. For TICA occlusion, the stent retriever and guidewire were positioned in the MCA and anterior cerebral artery, respectively. The guidewire can be passed individually through the stent mesh to reach the distal end of the other vessel when the microcatheter encounters difficulty passing through the released stent mesh. Five to 10 minutes later, the stent retriever, guidewire, and microcatheter were gradually retrieved from the guiding catheter, while the intracranial support catheter was continuously aspirated. A schematic diagram showing the technique is provided in Figure 2.

Figure 2 Schematic diagram of MT with the WISE technique. MT for the treatment of AIS caused by LVO occlusion (A). Schematic diagram of MT with the WISE technique for M2 bifurcation clot of the MCA (B). Digital subtraction angiography confirmed occlusion at the M2 bifurcation of the MCA (①). A microcatheter was navigated over a guidewire through the occluded segment to one of its distal branches (②). A stent retriever was introduced via the microcatheter and deployed (③). The guidewire guides the microcatheter through the stent mesh to the distal end of the other branch vessel beyond the bifurcation (④). While continuously aspirating with the 4MAX reperfusion catheter, the stent retriever, guidewire, and microcatheter were withdrawn from the vessel (⑤), resulting in successful reperfusion (⑥). AIS, acute ischemic stroke; LVO, large vessel occlusion; MCA, middle cerebral artery; MT, mechanical thrombectomy; WISE, guidewire interaction with stent retriever thrombectomy.

Outcome analysis

The technical efficacy of the endovascular treatment in establishing successful reperfusion was defined by a modified Thrombolysis in Cerebral Infarction (mTICI) score of 2b or 3 (11). Symptomatic intracranial hemorrhage (ICH) was defined as clinical worsening of at least 4 points on the NIHSS, attributed to parenchymal hematoma, subarachnoid, or intraventricular hemorrhage (12). The early neurological improvement was defined as a decrease of at least 4 points on the NIHSS at 7 days or discharge and good clinical outcome was defined as an mRS score of 0–2 at 90 days (13).

In vitro model

A simplified bifurcated vessel model with an internal diameter of approximately 1.5 mm was utilized to simulate MT of MeVO. The displacement distance of the vessel bifurcation during thrombectomy was measured to indirectly reflect the extent of traction exerted on the vessel by different thrombectomy methods.

Statistical analysis

Descriptive statistics were generated using SPSS version 20 software (IBM, Armonk, NY, USA). Categorical variables are presented as absolute values and percentages, and continuous variables are tested for normality and are expressed as mean ± standard deviation (SD) if normally distributed, or median and interquartile range (IQR) if not normally distributed. After confirming homogeneity of variance, one-way analysis of variance (ANOVA) followed by the least significant difference (LSD) was used to compare the displacement distance of the different thrombectomy methods in the in vitro model. A two-sided P value of less than 0.05 was considered statistically significant.

Ethical declaration

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the ethics committee of Daping Hospital (No. 2023-167). All patients or their relatives provided written informed consent.

Results

Patient demographics

A total of 14 patients were enrolled in the study, including 10 males, with a mean age of 65 years (range, 55–80 years). The primary Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification was attributed to cardioembolism (50.0%), followed by large-artery atherosclerosis (21.4%) and stroke of undetermined etiology (21.4%). The intracranial occlusion site was M2 bifurcation of the MCA in 10 patients (71.4%), including 2 patients who experienced clot migration to the M2 segment during endovascular treatment, M1 bifurcation of the MCA in 3 patients (21.4%), and TICA bifurcation in 1 patient (7.1%). The mean NIHSS score on admission was 16±8. Intravenous thrombolysis was administered to 6 patients (42.9%) before MT. Hypertension was the most common risk factor (9/14, 64.3%), followed by atrial fibrillation (7/14, 50.0%). Patients’ demographics and basic clinical baseline characteristics are reported in Table 1.

Procedural results

Of the 14 patients, 9 patients (64.3%) underwent rescue thrombectomy with the WISE technique, while the remaining 5 patients (35.7%) underwent thrombectomy directly with the WISE technique. Successful reperfusion was achieved in 13 (92.9%) of the 14 patients, including 11 patients (78.6%) who achieved mTICI 3 and 2 patients (14.3%) who achieved mTICI 2b. Among the 9 patients who underwent the WISE rescue thrombectomy, 8 patients (88.9%) achieved successful reperfusion. Reperfusion was not achieved in 1 patient after undergoing 3 SWIM thrombectomy procedures, 2 WISE thrombectomy procedures, and another SWIM thrombectomy procedure. Of the 13 patients successfully recanalized, 12 patients were recanalized after 1 time of the WISE procedure and 1 patient was recanalized after 2 times of the WISE procedure. The mean time from symptom onset to reperfusion was 670±326 minutes (13 patients). One example of MT using the WISE technique is depicted in Figure 3 (case 14).

Figure 3 Occlusion of the M2 bifurcation of the MCA treated with the WISE technique. The right internal carotid artery angiography showed occlusion of the M2 upper trunk of the MCA (arrow) (A). Angiography showed a contrast filling defect at the M2 bifurcation of the MCA (white dashed circle) after undergoing one catheter aspiration procedure (B). Solitaire AB 4 mm × 20 mm (white arrow, distal markers) was deployed in one distal branch beyond the occlusion (C). The guidewire (black arrow) was advanced through the stent mesh (white arrow, distal markers) to reach the other branch vessel beyond the occlusion (D). The stent retriever, guidewire, and microcatheter were simultaneously extracted extraluminally, and angiography demonstrated successful reperfusion (arrow) (E). Clot was gripped by the stent retriever and guidewire (F). MCA, middle cerebral artery; WISE, guidewire interaction with stent retriever thrombectomy.

Clinical outcome

Twelve patients (85.7%) demonstrated improved neurological function either 7 days post-surgery or at the time of discharge. At 90-day follow-up, 7 patients (50.0%) exhibited good clinical outcomes (mRS ≤2), 6 patients (42.9%) had a poor prognosis, and 1 patient (7.1%) died due to neurological deterioration. For patients who underwent the WISE rescue thrombectomy (n=9), 7 patients (77.8%) showed improvement in neurological function at 7 days post-surgery or at discharge, and 4 patients (44.4%) demonstrated good clinical outcomes (mRS ≤2) at 90-day follow-up. The detailed patient outcomes and the specific clinical profiles of each patient are presented in Table 2 and Table S1, respectively.

Safety and procedural complications

ICH was present in 3 (21.4%) patients, and no patients experienced symptomatic ICH. The 2 cases of asymptomatic ICH patients (case 6 and case 10) experienced large infarcts and malignant cerebral edema after MT, which remained stable following decompressive craniectomy. Two patients (14.3%) experienced mild vasospasm, one of which was attributed to the stent retriever, while the other exhibited ICA spasm due to vessel wall irritation caused by the guiding catheter. Following a period of observation, both patients demonstrated alleviation of vasospasm. One patient (7.1%) with tortuous carotid artery developed complications of iatrogenic dissection of the C1 segment of the ICA and subsequently underwent ICA stenting. The complication is presented in Table 2.

In the in vitro model, the results revealed that the distance of vessel bifurcation movement in the WISE group was significantly shorter than that in the double-stent thrombectomy group (0.60±0.13 vs. 1.18±0.13 cm; P<0.0001), and there was no significant difference between the WISE group and the single-stent thrombectomy group (0.60±0.13 vs. 0.56±0.09 cm; P=0.533) (Figure 4A,4B).

Figure 4 Distance of vessel bifurcation displacement by different thrombectomy methods in the in vitro model. Displacement distance of vessel bifurcation under different MT (A). Statistical results of vessel bifurcation displacement distances under different MT (B). n=8. ****, P<0.0001; ns, not significant. DS, double-stent thrombectomy; MT, mechanical thrombectomy; SS, single-stent thrombectomy; WISE, guidewire interaction with stent retriever thrombectomy.

Discussion

Patients with LVO have severe clinical symptoms and high rates of death and disability (14). Occlusion of the large vessel bifurcation represents one of the most critical subtypes, often leading rapidly to massive cerebral infarction in the absence of timely treatment, resulting in significant disability and mortality (15). Due to the specific location of embolization, MT for occlusion at large vessel bifurcations encounters challenges such as a low success rate in single thrombectomy, difficulty in achieving complete reperfusion, and potential clot migration (16). Thus, MT for occlusion of large vessel bifurcations poses a formidable challenge in interventional therapy (17). In this study, we demonstrate that the WISE technique can achieve a reperfusion rate of 92.9% in patients suffering from AIS caused by vessel bifurcation occlusion with technical feasibility and favorable safety.

A repeated number of passes during MT leads to worse clinical outcomes in AIS (18). Therefore, improving the first-pass reperfusion rate is crucial for the clinical prognosis. The double-stent retrieval thrombectomy employs 2 stents in parallel or in tandem to enhance the efficacy of MT. Currently, it is mainly used as a rescue technique for refractory clots at large vessel bifurcations where standard thrombectomy has failed, such as the end of the ICA, the M1 segment of MCA, or the apical segment of the basilar terminus (8,19). In a randomized in vitro evaluation, the front-line double-stent retrieval thrombectomy showed a more effective rate than the single-stent retriever in achieving first-pass reperfusion in the treatment of MCA occlusions that present saddle thrombus (64% vs. 14%; P=0.011) (20). Imahori et al. (21) performed the double-stent retriever thrombectomy in 2 patients with anterior circulation LVO who failed to achieve reperfusion by conventional thrombectomy, and both patients were successfully recanalized in one pass. Likewise, the study conducted by Klisch et al. (8) revealed that the double-stent thrombectomy achieved an effective reperfusion rate of 80% in a series of 10 patients with refractory anterior circulation LVO. These findings suggested that the double-stent retrieval thrombectomy can be used as a rescue technique for failed thrombectomy.

Despite the high reperfusion rate of double-stent retrieval thrombectomy, its potential risks cannot be ignored (7,8,22). The main concern is vessel trauma and arterial displacement when two stent retrievers are used simultaneously, which may lead to ICH (7,8,23). In the Solitaire FR with the Intention for Thrombectomy (SWIFT) trial, the reported perioperative symptomatic ICH and subarachnoid hemorrhage complication rates for single-stent thrombectomy were 4.9% and 7.6%, respectively (23). However, in the study above conducted by Li et al. (7), 50.0% of patients (2/4) with MCA occlusion and 7.1% of patients (1/14) with terminal carotid occlusion experienced complications of subarachnoid hemorrhage after undergoing multiple single-stent retriever and Y-stent passes, which was significantly higher than the reported incidence for single-stent thrombectomy. Therefore, it is recommended to use this technique cautiously in the treatment of MCA bifurcation occlusion. Moreover, the double-stent thrombectomy is mainly used for occlusion of large intracranial proximal vessel bifurcation but is not recommended for distal MeVO (5,8,24). However, approximately 25–40% of AIS with an identifiable vessel occlusion are caused by MeVO (9,25). In the present study, 71.4% (10/14) of the patients had an occlusion at the M2 bifurcation of the MCA, which was not suitable for the double-stent thrombectomy according to previous clinical experience. Vasospasm is another common complication of the double stent thrombectomy, with approximately 50–70% of patients experiencing mild vasospasm following the double-stent thrombectomy, potentially attributed to excessive vessel stretching caused by the deployment of two stents (8,19). Although our in vitro model cannot fully replicate the cerebral vasculature, it indirectly reflects the fact that the traction and invasiveness of the WISE technique on the vessels is significantly lower than that of the double-stent thrombectomy. Therefore, the WISE technique may be a safe and effective strategy for AIS patients with vessel bifurcation occlusion and may be a reliable rescue method for patients who have failed to achieve reperfusion with standard MT. Whether the first-line WISE technique is superior to standard MT remains to be validated by prospective cohort studies. Additionally, this method may also have potential advantages for patients with posterior circulation bifurcation occlusion.

The mechanisms of the WISE technique to facilitate the efficacy of MT remain to be further investigated. One possible interpretation is the formation of a gripping interaction between the guidewire, microcatheter, and stent, which enhances the clot grasping ability, similar to the Y-stent thrombectomy technique (Video 1) (7). To improve the efficacy of the WISE technique for MT and minimize endothelial damage, we recommend releasing the stent in a branch with less tortuosity or a high clot load, while positioning the guidewire and microcatheter in the other branch. Occupation of the lumen of the other vessel branch beyond the bifurcation by guidewire and microcatheter to prevent clot fragmentation and migration is another important contributing factor to enhancing the success rate of the WISE technique. In this study, no clot migration was observed during thrombectomy using the WISE technique.

This study has some limitations. First, the sample size was relatively small, and the effectiveness and complications of the WISE technique, especially the risks of dissection, distal embolism and symptomatic ICH, still need to be further verified by prospective multicenter clinical trials. Second, the cases enrolled were patients with occlusion at the bifurcation of the anterior circulation vessels, and whether it is effective in patients with posterior circulation vessels needs to be further investigated.

Conclusions

In this preliminary study, the WISE technique demonstrates a high reperfusion rate and an acceptable complication rate in AIS patients with vessel bifurcation occlusion. For refractory clots, the WISE technique may have a lower risk of complications, is easy to perform, and has lower costs compared with the double-stent thrombectomy, particularly in MeVO. Due to the limited sample size, further prospective, multicenter, case-control studies are needed to validate this technique.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jni.amegroups.com/article/view/10.21037/jni-25-10/rc

Data Sharing Statement: Available at https://jni.amegroups.com/article/view/10.21037/jni-25-10/dss

Peer Review File: Available at https://jni.amegroups.com/article/view/10.21037/jni-25-10/prf

Funding: This study was supported by the National Natural Science Foundation of China (82071322).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jni.amegroups.com/article/view/10.21037/jni-25-10/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the ethics committee of Daping Hospital (No. 2023-167). All patients or their relatives provided written informed consent.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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