ORIGINAL RESEARCH
ADAPT FAST study: a direct aspiration first pass
technique for acute stroke thrombectomy
Aquilla S Turk,
1
Don Frei,
2
David Fiorella,
3
J Mocco,
4
Blaise Baxter,
5
Adnan Siddiqui,
6
Alex Spiotta,
7
Maxim Mokin,
3
Michael Dewan,
8
Steve Quarfordt,
5
Holly Battenhouse,
9
Raymond Turner,
7
Imran Chaudry
1
For numbered affiliations see
end of article.
Correspondence to
Dr A S Turk, Department of
Radiology and Radiological
Sciences, Medical University of
South Carolina, 96 Jonathan
Lucas Street, CSB 210,
Charleston, SC 29425, USA;
turk@musc.edu
Received 16 January 2014
Revised 4 February 2014
Accepted 5 February 2014
Published Online First
25 February 2014
▸ http://dx.doi.org/10.1136/
neurintsurg-2014-011187
To cite: Turk AS, Frei D,
Fiorella D, et al. J
NeuroIntervent Surg
2014;6:260–264.
ABSTRACT
Background The development of new revascularization
devices has improved recanalization rates and time, but
not clinical outcomes. We report a prospectively collected
clinical experience with a new technique utilizing a direct
aspiration first pass technique with large bore aspiration
catheter as the primary method for vessel recanalization.
Methods 98 prospectively identified acute ischemic
stroke patients with 100 occluded large cerebral vessels
at six institutions were included in the study. The ADAPT
technique was utilized in all patients. Procedural and
clinical data were captured for analysis.
Results The aspiration component of the ADAPT
technique alone was successful in achieving Thrombolysis
in Cerebral Infarction (TICI) 2b or 3 revascularization in
78% of cases. The additional use of stent retrievers
improved the TICI 2b/ 3 revascularization rate to 95%.
The average time from groin puncture to at least TICI 2b
recanalization was 37 min. A 5MAX demonstrated
similar success to a 5MAX ACE in achieving TICI 2b/3
revascularization alone (75% vs 82%, p=0.43). Patients
presented with an admitting median National Institutes
of Health Stroke Scale (NIHSS) score of 17.0 (12.0–21.0)
and improved to a median NIHSS score at discharg e of
7.3 (1.0–11.0). Ninety day functional outcomes were
40% (modified Rankin Scale (mRS) 0–2) and 20% (mRS
6). There were two procedural complications and no
symptomatic intracerebral hemorrhages.
Discussion The ADAPT technique is a fast, safe,
simple, and effective method that has facilitated our
approach to acute ischemic stroke thrombectomy by
utilizing the latest generation of large bore aspiration
catheters to achieve previously unparalleled angiographic
outcomes.
INTRODUCTION
Early and efficient revascularization of large vessel
occlusions has been shown to correlate with
improved outcomes in selected patients with acute
ischemic stroke.
1–3
Aspiration thrombectomy using
the Penumbra system, while an effective technique
for achieving revascularization, has yielded only
modest clinical results.
4–6
Stent retrievers have also
been shown to be effective for vessel recanalization,
with similar clinical outcomes.
23
Recent advances in catheter technology have
included very large, easily trackable, aspiration
thrombectomy catheters that can now more easily
and reliably navigate the cerebrovasculature. A
novel technique using this newest generation of
large bore aspiration catheters as a first approach
for thrombectomy has recently been reported.
7
The
purpose of this study was to follow-up the initial
experience with a prospective report of all stroke
cases that had undergone a direct aspiration first
pass technique (ADAPT) with a large bore aspir-
ation catheter as the primary method for vessel
recanalization.
METHODS
Under an institutional review board approved
protocol, prospectively identified patient data were
collected on all stroke patients undergoing the
ADAPT technique at the Medical University of
South Carolina, Swedish Medical Center,
Vanderbilt University, Stonybrook University,
Erlanger Medical Center, and University of Buffalo.
Patients were selected for intervention as per the
investigator protocol at each site. Usual practice
was advanced imaging with CT/CT angiography
and CT perfusion for patient selection. Patients
included in this study were identified to have a
large vessel cerebral vessel occlusion with viable
ischemic penumbra and less than one-third ische-
mic vascular territory.
The ADAPT technique has been described previ-
ously.
7
Briefly, a large guide catheter (Neuron 088;
Penumbra, Oakland, California, USA) was
advanced as far distally into the cervical or prox-
imal petrous internal carotid artery (ICA) as pos-
sible. The largest caliber aspiration catheter that the
vessel would accommodate was selected for each
case, usually a 5MAX (Penumbra) or 5MAX ACE
(Penumbra), for distal ICA, proximal middle cere-
bral artery, and basilar occlusions. This catheter was
advanced to the level of the thrombus, usually
coaxially over a 016 microwire (Fathom; Boston
Scientific Corp, Fremont, California, USA) and
Velocity microcatheter (Penumbra). Other obturat-
ing catheters, such as 3MAX or smaller microcath-
eters, can also be used in conjunction with any
compatible microwire. With the large bore aspir-
ation catheter at the face of the thrombus, aspir-
ation was applied with either a 20 or 60 mL
syringe or Penumbra aspiration pump. Absence of
flow within the aspiration system confirmed
engagement with the thrombus. At this point, the
catheter was gently advanced for 1–2 mm to ensure
solid engagement with the thrombus. Aspiration
was left for approximately 20 s, and if no flow
through the system was found then the catheter
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260 Turk AS, et al. J NeuroIntervent Surg 2014;6:260–264. doi:10.1136/neurintsurg-2014-011125
Ischemic stroke
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was slowly withdrawn. If aspiration failed, then the large aspir-
ation catheter was reinserted up to the level of the thrombus
and repeat aspiration attempted. At the operator’s discretion,
additional devices (such as stent retrievers) were used if aspir-
ation alone failed.
Patient demographic, angiographic, and clinical data were col-
lected. The degree of vessel occlusion before and after treatment
was defined by the modified Thrombolysis in Cerebral
Infarction (TICI) classification and adjudicated by the operator.
Successful revascularization was defined as a TICI score ≥2b
post-treatment. Procedure time was defined as the time from
groin access to at least TICI 2b revascularization. Symptomatic
intracerebral hemorrhage (sICH) was defined as presence of
hemorrhage after treatment, with worsening of clinical examin-
ation by ≥4 points on the National Institutes of Health Stroke
Scale (NIHSS). The 90 day functional outcomes were deter-
mined by the modified Rankin Scale (mRS), and were obtained
from the available clinic records. A good functional outcome
was defined as an mRS score of ≤2 at 90 days. Mortality was
defined as death occurring within 90 days of initial presentation.
The 5MAX ACE became clinically available during the present
study. Outcomes for 5MAX and 5MAX ACE were compared.
Data were tracked at each site. De-identified data were sub-
mitted to the sponsoring institution (Medical University of
South Carolina) which performed the primary analysis.
Statistical analyses were performed using SAS V.9.3 (SAS
Institute, Cary, North Carolina, USA). Differences between
groups were tested using Student’s t test for continuous mea-
sures and a χ
2
test for categorical measures. Differences between
groups were tested using Fisher’s exact test for categorical mea-
sures with expected cell sizes <5. All tests were two sided and
assessed at a significance level of 0.05.
RESULTS
Patient demographics and procedural data
Ninety-eight patients with 100 occlusions were treated at the six
institutions, including 46 women, with an average age of
66 years (median 69, SD=15.7). The average time from when
the patient was last seen normal to groin puncture was 8.5 h
(mean 507 min; median 241.5 min, SD=506 min). The overall
successful revascularization rate (TICI 2b-3) was 95%. The
average time to TICI 2b or 3 revascularization was 36.6 min
(SD=26.4 min). The aspiration component of the ADAPT tech-
nique alone was successful in achieving successful revasculariza-
tion of the occluded vessel 78% of the time. When the
aspiration component of ADAPT was successful as a standalone
technique, the average time from femoral access to final revascu-
larization was 31.6 min (SD=23.3 min). In those cases where an
adjunctive device was required, revascularization times were sig-
nificantly (p<0.0001) prolonged (average 56.8 min
(SD=29.1 min)).
Ten of 100 (10%) cases had downstream emboli within the
initially affected territory, all of which were subsequently
removed with either subsequent aspiration at the occlusion site
or utilization of a stent retriever. There were no instances of
embolization to a new territory (ENT). Two (2%) device related
complications were encountered. One case was related to vessel
dissection trying to advance the 5MAX catheter through an
occlusion that after aspiration thrombectomy revealed an under-
lying intracranial stenosis, which was successfully stented. One
complication was related to advancing a 5MAC ACE from the
distal ICA into the mid M1 middle cerebral artery without using
an obturating microwire or microcatheter, and resulted in sig-
nificant vessel dissection, which was unable to be opened.
The primary ADAPT revascularization catheter was 5MAX in
44 cases, 5MAX ACE in 44 cases, 4MAX (Penumbra) in six
cases, 3MAX (Penumbra) in four cases, Navien 058 (EV3
Covidien) in one case, and Neuron 088 MAX (Penumbra) in
one case. TICI 2b or 3 revascularization with aspiration alone
was achieved in 75% of cases in which a 5MAX was the
primary catheter versus 82% (p=0.44) when a 5MAX ACE was
used (table 1).
Clinical outcomes
There were no incidences of postprocedure sICH. The present-
ing NIHSS was 17.2 (median 17.0; SD=6.4) on average and
improved to an average of 7.3 (median 4.0; SD=7.5) at dis-
charge (table 2).
mRS was available in 81 of 98 patients (83%) (table 3). Forty
per cent of patients achieved an mRS score of 0–2 and 20% an
mRS score of 6 at the 3 month follow-up. In the 78% of cases
Table 2 Baseline characteristics
Variable
Mean age (years) 66.3
Gender
Men (n (%)) 46 (47)
Women (n (%)) 52 (53)
NIHSS
Pretreatment 17.2/17.0*
Post-treatment 7.3/4.0*
IV tPA
Yes (n (%)) 27 (28)
No (n (%)) 70 (72)
Average time to groin puncture (h) 8.5
Average time to TICI 2b/3 recanalization (min) 37
Site of occlusion (n (%))
Right M1 20 (20)
Right M2 11 (11)
Right ICA 3 (3)
Right ICA terminus 3 (3)
Left M1 23 (23)
Left M2 7 (7)
Left ICA 6 (6)
Left ICA terminus 11 (11)
Basilar 5 (5)
Right cervical ICA–MCA 8 (8)
Left cervical ICA–MCA 3 (3)
*Mean/median values.
ICA, internal carotid artery; IV tPA, intravenous tissue plasminogen activator; MCA,
middle cerebral artery; NIHSS, National Institutes of Health Stroke Scale; TICI,
Thrombolysis in Cerebral Infarction.
Table 1 Comparison of the 5MAX and 5MAX ACE final outcomes
5MAX 5MAX ACE p Value
No of cases 44 44
Mean time to revascularization (min) 37.7 35.6 0.71
TICI 2b (%) 54.6 36.4 0.09
TICI 3 (%) 40.9 61.4 0.06
mRS 0–2 (%) 34 50 0.19
TICI 3 revascularization was achieved more frequently with 5MAX ACE than with
5MAX (61.4% vs 40.9%; p=0.055).
mRS, modified Rankin Scale; TICI, Thrombolysis in Cerebral Infarction.
Turk AS, et al. J NeuroIntervent Surg 2014;6:260–264. doi:10.1136/neurintsurg-2014-011125 261
Ischemic stroke
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on August 10, 2022 at India:BMJ-PG Sponsored.http://jnis.bmj.com/J NeuroIntervent Surg: first published as 10.1136/neurintsurg-2014-011125 on 25 February 2014. Downloaded from
where ADAPT alone was successful, 47% of patients achieved
an mRS score of 0–2 and 14% resulted in an mRS score of 6. In
the cases where ADAPT required a stent retriever or was unsuc-
cessful, 18% achieved mRS 0–2 and 35% resulted in mRS 6.
DISCUSSION
Catheter aspiration thrombectomy has been reported previously,
but as either a bailout after traditional techniques had failed or
as a strategy by which to achieve revascularization of an
occluded large extracranial artery.
8–12
ADAPT represents a novel
revascularization strategy made possible by the availability of
newer, flexible, atraumatic, large bore aspiration catheters.
These catheters are easily navigated into the intracranial circula-
tion and provide a large cross sectional area for the aspiration
and engagement of the occluding thrombus. This technique is
based on using aspiration alone as the primary mechanism of
thrombectomy and, if initially unsuccessful, then incorporating
adjunctive alternatives such as a stent retriever to achieve revas-
cularization. The technique was successful alone in achieving
TICI 2b/3 revascularization in 78% of cases or with adjunctive
devices in 95% of cases. On average, revascularization was
achieved within 37 min of groin puncture, and in 15 min or less
from groin puncture in more than 20 cases. These efficient
revascularization metrics were manifest clinically, with average
discharge NIHSS improvement of 10 points and with favorable
clinical functional outcomes (mRS 0–2 at 90 days) in 40% of
cases.
Compared with the outcomes of stent retriever data, ADAPT
yielded similar rates of good functional outcome (mRS 0–2),
mortality, and device related complications (table 4).
2313–16
In the present series using ADAPT, fewer sICH were
observed, and times to recanalization were, on average, probably
shorter. It is likely that ADAPT produced higher rates of recana-
lization; however, this is difficult to establish with the documen-
ted methods of assessing successful recanalization used in the
predicate stent retriever studies. With ADAPT, TICI 2b-3 revas-
cularization was achieved with aspiration alone in 78% of cases
compared with rates of TICI 2a-3 recanalization (ranging from
68% to 83%) for stent retrievers. A modified TICI score of 2a
indicates a large area of non-perfused brain parenchyma and is
increasingly not considered technically successful revasculariza-
tion.
17
The final procedural TICI 2b/3 revascularization was
95% with ADAPT, which is higher than that achieved in the
STAR study (85%) and in the NASA study (76%).
14 16
The NASA registry recently reported an organized retrospect-
ive experience of 354 stroke cases from 24 centers.
14
The
overall results were similar to those reported in the
meta-analysis by Walcott et al.
13
A subgroup analysis from
the NASA study was subsequently reported to determine if the
use of a balloon guide catheter (BGC) improved outcomes.
18
The use of a BGC significantly improved TICI 3 revasculariza-
tion rates to 54%, although overall TICI 2b/3 revascularization
rates remained similar at 75%. This is similar to the TICI 3 rate
of 51% but remains lower than the final 95% TICI 2b/3 revas-
cularization we were able to achieve with ADAPT. Stent retriever
Table 3 Demographics and outcomes of ADAPT FAST cases
Outcome parameter
TICI pretreatment (n (%))
0 96 (96)
1 1 (1)
2a 3 (3)
TICI post-treatment (n (%))
0–2a 5 (5)
2b 44 (44)
3 51 (51)
NIHSS
Pretreatment 17.2
Post-treatment 7.3
90 day mRS (n (%))
0 10 (13)
1 16 (20)
2 5 (6)
3 12 (15)
4 11 (14)
5 8 (10)
6 15 (19)
Missing 23 (23)
sICH (n (%)) 0 (0)
The90 day mRS outcomes calculated on percentage of patients that had a follow-up
(n=79).
mRS, modified Rankin Scale; NIHSS, National Institutes of Health Stroke Scale; sICH,
symptomatic intracerebral hemorrhage; TICI, Thrombolysis in Cerebral Infarction.
Table 4 Comparison of outcomes from current ADAPT FAST, SWIFT, TREVO, NASA, and stent retriever meta-analysis
ADAPT FAST
(n=100)
SWIFT trial
(n=89)
TREVO trial
(n=88)
STAR study
(n=202)
NASA registry
(n=354)
Solitaire data*
(n=355)
Trevo data*
(n=221)
TICI 2a/2b/3 (%) N/A 83† 90 N/A 87.5 82 83
Device TICI 2b/3 (%) 78 75.9‡ 68‡ 79‡
91§
72.5 NR NR
Final TICI 2b/3 (%) 95 75.9‡ 68‡ 85 72.5 82 83
mRS 0–2 (%) 40 36 40 55 42 47 51
Mortality (%) 20 17 34 19 30.2 14 31
Time to final revascularization (min) 37 NR NR NR 50¶ NR NR
Device related complications (%) 2 8.6 9 7.5 NR 6 5
Symptomatic ICH (%) 0 2 7 4 9.9 6 8
*Meta-analysis of real world published experience.
†Site reported rate of recanalization.
‡Core laboratory reported.
§Site investigator reported data.
¶Time to revascularize after guide catheter access.
ICH, intracerebral hemorrhage; mRS, modified Rankin Scale; N/A, not applicable; NR, not reported; TICI, Thrombolysis in Cerebral Infarction.
262 Turk AS, et al. J NeuroIntervent Surg 2014;6:260–264. doi:10.1136/neurintsurg-2014-011125
Ischemic stroke
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on August 10, 2022 at India:BMJ-PG Sponsored.http://jnis.bmj.com/J NeuroIntervent Surg: first published as 10.1136/neurintsurg-2014-011125 on 25 February 2014. Downloaded from
procedures have been shown to be significantly faster with use
of a BGC (average of 120 min), which is markedly longer than
the average 38 min ADAPT case.
16
However, the times are diffi-
cult to compare as the BGC definition of procedure time was
from groin access to groin closure whereas the ADAPT proced-
ure time was groin access to at least TICI 2b revascularization.
Finally, average discharge NIHSS score in those with BGC was
12 versus 17.5 when a BGC was not used, which is higher than
our average discharge NIHSS score of 7.
One main advantage of ADAPT as a firstline approach is that
it is versatile. The technique does not preclude the operator
from incorporating other devices if aspiration alone is not
working. Having the large bore aspiration catheter at the face of
the clot facilitates the use of adjunctive devices, such as stent
retrievers, as it provides a direct conduit to the thrombus. The
technique of using stent retrievers in conjunction with local
aspiration at the face of the clot has also been reported, with
very high rates of technical success and good neurological out-
comes. This approach was originally proposed to address the
high incidence of ENT that has been reported with thrombec-
tomy.
19
Kurre et al
19
reported in 175 occluded vessels a TICI
2b/3 revascularization rate of 91% and an improvement in ENT
to 3.5% from 14% when distal aspiration was used with stent
retrievers. Using combined local aspiration with stent retrieval,
20
Humphries et al
20
recently reported minimal ENT (<5%) with
very high rates of revascularization (TICI 2b-3 of 88%) and low
(5%) sICH rates. This approach is also being validated in the
ongoing Penumbra three-dimensional separator trial.
ADAPT is technically straightforward, requiring only the navi-
gation of a catheter to the face of the occlusion followed by the
application of aspiration. The operator typically does not have
to completely traverse the occlusion, and in most cases no add-
itional devices have to be deployed or manipulated. Aspiration
alone with the larger 5MAX ACE (0.060 inner diameter) cath-
eter resulted, on average, in 82% TICI 2b/3 revascularization
rates compared with the original 5MAX (0.054 inner diameter)
catheter of 75%. This validates the intuitive concept of the
improved aspiration performance of a larger bore catheter. In
addition, clot extraction with ADAPT places little or no traction
on the parent artery and regional penetrating arteries. As such,
the potential for endothelial injury is likely to be far lower, pos-
sibly accounting for the absence of sICH in our current series.
21
The ability of ADAPT to engage the face of the thrombus and
avoid superselective contrast injections into the ischemic region
may also contribute to the lower hemorrhage rate.
22
Intracranial
hemorrhage reportedly occurs in as many as 41% of stroke
patients after thrombectomy with stent retrievers, of which
approximately one-fifth lead to a symptomatic
deterioration.
2351418
ADAPT was, on average, faster than traditional methods of
thrombectomy, particularly when the strategy worked as a stan-
dalone technique, as it did in the majority of cases. Moreover,
thrombus which was difficult to extract with ADAPT, and was
also typically challenging to clear with adjunctive devices,
reflected in the marked prolongation of procedural times (57 vs
32 min) observed in those cases in which adjunctive devices
were required.
ADAPT seemed to cause minimal clot disruption and frag-
mentation, often allowing the extraction of the occlusive
embolus en bloc with a single pass. This may decrease the fre-
quency and number of downstream emboli. In vitro tests have
shown that stent retriever and traditional aspiration thrombec-
tomy (performed with a separator) result in fragmentation of
the embolus during extraction, creating downstream emboli and
potentially emboli to previously uninvolved vascular territor-
ies.
23
When fragmentation of the embolus did occur with
ADAPT (observed in 10% of cases in the present series), the
emboli were usually large enough and proximal enough to
allow extraction using aspiration alone with a smaller catheter,
such as 3MAX in the M2 middle cerebral artery segment or a
stent retriever.
Similar functional outcomes (mRS 0–2) of 40% were found
with ADAPT as with other previously reported thrombectomy
strategies,
2351418
despite a relatively long average time (8.5 h)
from symptom onset to treatment in the present series. These
rates of favorable neurological outcome are similar to those
reported in previous studies using a modern perfusion guided
imaging paradigm to select patients for intervention rather than
time alone.
24
The variability in patient selection can affect clin-
ical outcomes and is a limitation of this study. It is important to
consider however, that the operator reported assessments in the
current study are more prone to bias in comparison with inde-
pendently assessed and monitored outcomes reported in some
of the comparative thrombectomy device trials.
CONCLUSION
This multicenter series supports the hypothesis that, in compari-
son with modern thrombectomy techniques, ADAPT is a fast,
simple, efficient, and safe strategy to achieve revascularization in
patients with acute ischemic stroke secondary to a large vessel
occlusion. In the minority of cases in which aspiration alone is
unsuccessful in achieving complete revascularization, the plat-
form is versatile, allowing the rapid incorporation of adjunctive
devices (such as stent retrievers).
Author affiliations
1
Department of Radiology, Medical University of South Carolina, Charleston, South
Carolina, USA
2
Department of Interventional Neuroradiology, Radiology Imaging Associates,
Englewood, Colorado, USA
3
Department of Neurological Surgery, Stony Brook Medicine, Stony Brook,
New York, USA
4
Department of Radiology and Radiological Sciences, Vanderbilt University,
Nashville, Tennessee, USA
5
Tennessee Interventional Associates, Chattanooga, Tennessee, USA
6
Department of Neurosurgery, University of Buffalo, Buffalo, New York, USA
7
Division of Neurosciences, Department of Neurosurgery, Medical University of South
Carolina, Charleston, South Carolina, USA
8
Department of Neurological Surgery, Vanderbilt University, Nashville, Tennessee,
USA
9
Department of Public Health Sciences, Medical University of South Carolina,
Charleston, South Carolina, USA
Contributors Each author listed above should receive authorship credit based on
material contribution to the article, revision of the article, and final approval of the
article for submission to this journal.
Competing interests AST reports grants and non-financial support from
Penumbra, grants from Microvention, grants and non-financial support from Stryker,
non-financial support from Microvention, non-financial support from Covidien,
non-financial support from Siemens, and grants and non-financial support from
Boston Scientific, outside the submitted work. BB reports non-financial support from
Stryker, non-financial support from Penumbra, non-financial support from Covidien,
non-financial support from Silk Road, non-financial support from Reverse Medical,
and non-financial support from Rapid Medical, outside the submitted work. AS
reports non-financial support from Pulsar Vascular and grants from Simbionix,
outside the submitted work. JM reports non-financial support from Lazarus Effect,
non-financial support from Medina Medical, non-financial support from Pulsar
Vascular, non-financial support from Reverse Medical, and non-financial support
from Edge Therapeutics, outside the submitted work. RT reports grants and
non-financial support from Penumbra, grants and non-financial support from
Microvention, and grants and non-financial support from Stryker, outside the
submitted work. IC reports grants and non-financial support from Penumbra, grants
and non-financial support from Microvention, and non-financial support from
Stryker, outside the submitted work.
Turk AS, et al. J NeuroIntervent Surg 2014;6:260–264. doi:10.1136/neurintsurg-2014-011125 263
Ischemic stroke
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on August 10, 2022 at India:BMJ-PG Sponsored.http://jnis.bmj.com/J NeuroIntervent Surg: first published as 10.1136/neurintsurg-2014-011125 on 25 February 2014. Downloaded from
Ethics approval The study was approved by the institutional review board of the
Medical University of South Carolina.
Provenance and peer review Not commissioned; externally peer reviewed.
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