J Korean Neurosurg Soc.  2020 Jan;63(1):14-25. 10.3340/jkns.2019.0114.

Role of Balloon Guide Catheter in Modern Endovascular Thrombectomy

• Chueh JY
• Kang DH
• Kim BM
• Gounis MJ

• KMID: 2501689
• DOI: http://doi.org/10.3340/jkns.2019.0114

Abstract

Proximal flow control achieved with a balloon guide catheter (BGC) during endovascular treatment of acute ischemic stroke is reviewed in this article. In clinical practice, BGCs offer a multi-faceted approach for clot retrieval by creating proximal flow arrest, reducing embolic burden, and shortening procedure time. Evaluation of frontline thrombectomy procedures with BGCs revealed advantages of combined use over the conventional guide catheter (CGC), notably in the significant reduction of distal emboli to both the affected and previously unaffected territories. Recently, new measures of early and complete reperfusion at first thrombectomy pass have been identified as independent predictors of improved outcomes, which were consistently demonstrated with use of BGC as a safe and effective option to minimize number of passes during intervention. Prior randomized controlled trials reported the positive correlation between BGC-treated patients and a lower risk of mortality as well as shortened procedure time. While BGC use is more common in stent retriever-mediated mechanical thrombectomy, preliminary data has shown the potential benefit of device application during contact aspiration thrombectomy to achieve successful recanalization. However, the question of which major endovascular strategy reigns superior as a frontline remains to be answered. Along with clinical case assessments, BGC performance during in-vitro simulation was analyzed to further understand mechanisms for optimization of thrombectomy technique.

Keyword

Acute stroke; Balloon occlusion; Endovascular thrombectomy; Thrombectomy

Figure

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  Fig. 1. In-vitro observation of clot shear-off from a stent retriever during mechanical thrombectomy. A : A stent retriever is deployed at the MCA to capture the clot (blue arrow). B-E : Prior to clot retrieval, the balloon is inflated (red star) to arrest the ICA flow. Clot fragmentation is observed during clot removal (blue arrows) with the balloon inflated (red star). F : Clot shear-off from a stent retriever is noted, resulting in a portion of the clot remaining (blue arrow) at the tip of the BGC (red star). MCA : middle cerebral artery, ICA : internal carotid artery, BGC : balloon guide catheter.

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  Fig. 2. Simulation of SR-MT in an in-vitro setup allows real-time measurements of MCA flow and pressure prior to clot introduction (A), after deployment of stent retriever (B), after balloon inflation (C), and during clot retrieval (D). ACA : anterior cerebral artery, SR-MT : stent retriever-mediated mechanical thrombectomy, MCA : middle cerebral artery.

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  Fig. 3. Comparison of the pressure gradient (ΔP) across the clot between conventional guide catheters and balloon guide catheters in contact aspiration thrombectomy procedures. A : Contact aspiration under conventional guide catheter (CGC). ΔP = Psys + Pa – Pcol. B : Contact aspiration under balloon inflation of balloon guide catheter (BGC). ΔP = Pa - Pcol. MCA : middle cerebral artery, ICA : internal carotid artery.

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  Fig. 4. Illustration of the off-label use of BGC to clot burden reduction in an intra¬cranial ICA T-type occlusion. Direct manual aspiration using a 60 mL syringe is performed through an 8 F or a 9 F BGC which was positioned in the proximal ICA to create proximal flow arrest. ACA : anterior cerebral artery, ICA : internal carotid artery, MCA : middle cerebral artery, BGC : balloon guide catheter.

Reference

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