Balloon Guide Catheter Improves Acute Stroke Outcomes as Adjunct to Stent Retriever

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In patients with acute ischemic stroke, use of a balloon guide catheter in conjunction with a stent-retriever device shortens procedure time, facilitates recanalization, and improves clinical outcomes, according to a registry study published online December 3, 2013, ahead of print in Stroke.

Investigators led by Thanh N. Nguyen, MD, of Boston University School of Medicine (Boston, MA), analyzed data from 338 patients enrolled in the 24-center North American Solitaire Acute Stroke (NASA) registry who did (n = 149) or did not (n = 189) receive a balloon guide catheter. In all cases, acute ischemic stroke was treated with the Solitaire FR stent-retriever device (ev3/Covidien, Irvine, CA).

Superior Recanalization, Less Adjuvant Therapy

Patients receiving a balloon guide catheter were more likely to achieve good recanalization in less time than the control group and showed a trend toward less use of adjuvant therapy. In addition, they experienced a higher mean National Institutes of Health Stroke Scale (NIHSS) score at discharge and more often had a good clinical outcome (modified Rankin score ≤ 2) at 3 months. However, use of a balloon guide catheter had no impact on the incidence of distal emboli or emboli migration to a new territory (table 1).

Table 1. Imaging, Procedural, Clinical Outcomes

 

Balloon Guide Catheter
(n = 149)

No Balloon Guide Catheter
(n = 189)

P Value

Recanalization

(TICI 3)

53.7%

32.5%

<0.0001

Distal Emboli

18.2%

16%

0.7

Emboli in New Territory

5%

5.2%

0.9

Mean Procedure Time, min

120

161

0.02

Adjuvant Therapy

20%

28.6%

0.05

Mean Discharge NIHSS Score

12.0

17.5

0.002

Good Clinical Outcome at 3 Months

 

51.6%

 

35.8%

 

0.02

Abbreviations: TICI, Thrombolysis in Cerebral Infarction.

After adjustment for multiple factors including initial NIHSS score, IV tPA, and use of general anesthesia, deployment of a balloon guide catheter remained an independent predictor of good clinical outcome (OR 2.5; 95% CI 1.2-4.9). This benefit was lost in multivariate analysis of patients with stroke in the posterior circulation (n = 35).

Advantage Attenuated in Patients Receiving tPA

However, in analysis limited to patients who received IV tPA (n = 168), the benefits of balloon guide catheter use (n = 62) were less robust, with only trends toward lower discharge mean NIHSS score (12.8 vs. 16.7; P = 0.2) and higher rates of good clinical outcome (57.8% vs. 44.8%; P = 0.1) compared with a clear advantage for the balloon catheter strategy in the non-IV tPA group (12.0 vs. 18.0; P = 0.02 and 45.2% vs. 30.2%; P = 0.05, respectively).

A  potential confounder, the authors say, is that balloon catheters were used at the discretion of the operator; a decision not to deploy the device may have reflected underlying access difficulty or vessel tortuosity, which in turn may be associated with decreased chances of successful recanalization and worse outcomes.

In an email communication with TCTMD, Dr. Nguyen added that while she expected to see less distal embolization with use of the balloon guide catheter, “the absence of such findings may be related to lack of adjudication of the angiograms by a core lab, or lack of a consistent definition on the meaning of distal emboli.”

The main procedural advantage of a balloon guide catheter is that it permits temporary cessation of antegrade flow, L. Nelson Hopkins, MD, of University at Buffalo Neurosurgery (Buffalo, NY), told TCTMD in an email communication, explaining that the interruption “makes clot removal more successful by partially removing an opposing force.”  

Balloon Catheter Not Always Appropriate

However, a balloon catheter is not appropriate in all scenarios, Dr. Nguyen observed. For example, it “may be less favorable in a smaller-caliber artery, such as the vertebral artery, as it may [carry] a higher risk of dissection,” she noted.  Vessel tortuosity, difficulty of navigation, and extra time to prepare the balloon catheter may also be reasons to forgo a balloon guide catheter.

In addition to logistical issues, personal preference plays a role in the choice of whether to apply such a device, Dr. Hopkins said, adding that some operators do well without one.

In the NASA registry, about 44% of procedures were performed with a balloon catheter, Dr. Nguyen noted. She and Dr. Hopkins agreed that the current data may encourage wider use of the device, which already is recommended by several stent retriever manufacturers. 

Study Details 

The balloon guide catheter group had more hypertension (P = 0.05) and atrial fibrillation (P = 0.001) and were more commonly administered IV tPA (P = 0.02) compared with patients in whom a balloon catheter was not used. In addition, the balloon catheter group differed from the noncatheter group in the proportion of occlusions located in the middle cerebral artery M1 (63.1% vs. 49.7%; P = 0.02) and in the posterior basilar artery (4.7% vs. 14.8%; P = 0.002). There was higher use of a balloon in the anterior compared with the posterior circulation (46.9% vs. 20%; P = 0.002).

  


Source:
Nguyen TN, Malisch T, Castonguay AC, et al. Balloon guide catheter improves revascularization and clinical outcomes with the Solitaire device: Analysis of the North American Solitaire Acute Stroke Registry. Stroke. 2013; Epub ahead of print.

 

 

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Balloon Guide Catheter Improves Acute Stroke Outcomes as Adjunct to Stent Retriever

In patients with acute ischemic stroke, use of a balloon guide catheter in conjunction with a stent retriever device shortens procedure time, facilitates recanalization, and improves clinical outcomes, according to a registry study published online December 3, 2013, ahead
Disclosures
  • Dr. Nguyen reports no relevant conflicts of interest.
  • Dr. Hopkins reports serving as a consultant and trainer for multiple device companies.

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