Replay Day 2 - Slice WW 2021 - Best technique 2  

My best technique for management vertebral V4 occlusion with hemodynamic instability

Dr. Marc Ribo and Pr. Christophe Cognard           

Live demonstration of the use of equipment and techniques on silicone models filmed in high resolution. These practical highlights present the different techniques from an educational perspective.

Live demonstration of the use of equipment and techniques on silicone models filmed in high resolution. These practical highlights present the different techniques from an educational perspective.

Single functional vertebral V4 occlusion with hemodynamic instability treated with aspiration as first attempt.

Case: Vertebral V4 occlusion with contralateral vertebral hypoplasia/chronic occlusion 

Preferred technique of Dr. Marc Ribo: large bore aspiration catheter + stent-retriever (to secure distal end of the clot with SR in cases of large thrombus)

But for the purpose of the presentation: contact aspiration from large bore catheter – as a first attempt

Remark 1: analyze the underlying cause of the V4 occlusion and adapt the treatment strategy accordingly 

• Dissection – it may be better go with aspiration first
• ICAD – it may be better go with combined approach directly 

Remark 2: adjust the strength of your aspiration, it should not be too strong, otherwise the artery will collapse in front of the clot instead of the catheter sticking to the thrombus

Procedure step by step in angio-suite:

In use: Titan – Gama 17 – Synchro – Solitare – Catch Mini

- (in presented case) large bore catheter (Titan) + microcatheter + microwire

- go with your aspiration catheter + microcatheter + microwire to the vertebral artery.  Problem: your large bore aspiration catheter does not go up at the level of the thrombus. Solution: use the stent-retriever as an anchor, once it is open you will be able to pull up the aspiration catheter (in presented case, that solution has been chosen)

- pass with microcatheter distally to the thrombus and open a stent-retriever in the desired position and then pull up the aspiration catheter

- (in presented case) SR was use only in the purpose to climb up with aspiration catheter, then ADAPT (aspiration only) technique was implemented. Problem: there is a remnant clot in left SCA. Solution: remove the clot from SCA if the artery is big enough (in presented case, that solution has been chosen)

• remark 1: if you decided to go for it, consider SOLUMBRA technique – keep the SR open for a while (10 min) and then, retrieve it into your aspiration catheter maintained in the origin of the artery
• remark 2: you may consider a blind exchange in order to change the aspiration catheter to better adjust vector forces and pinch the clot
• remark 3: you do not need to deploy the stent completely 
• remark 4: you may consider put Milrinone i.a. to prevent spasm

- catheterize the SCA, deploy SR (Catch Mini) and perform the thrombectomy

- evaluate if everything is open

Case: Vertebral V4 occlusion with contralateral vertebral hypoplasia/chronic occlusion

Preferred technique of Pr. Christophe Cognard: depending the length and size of the clot and 

Size of the artery:

• Long, big clot – aspiration + stent-retriever
• Short, small clot – aspiration only
• Big artery – aspiration + stent-retriever

But for the purpose of the presentation: remote aspiration from BCG only – as a first attempt

Procedure step by step in angio-suite:

In use: BCG FlowGate 2 – Sofia 5 – Phenom 21 – pORTAL 14  – pRESET 

- perform a remote aspiration from BCG (works in 15% of cases in case of carotid T occlusion

• problem: clot is too big and does not get aspirated
• solution: perform contact aspiration (in presented case, that solution has been chosen)
• go with aspiration catheter + microcatheter + microwire
• problem: clot was pushed further (more distally)
• solution: secure the distal part of clot by stent-retriever (in presented case, that solution has been chosen)
• deploy the SR distally to the clot and perform the thrombectomy
• problem: there is a remnant clot in left SCA
• solution: remove the clot from SCA if the artery is big enough (in presented case, that solution has been chosen)
• catheterize the SCA, deploy SR and perform the thrombectomy
• evaluate if everything is open

Worth mentioning:

A V4 vertebral occlusion with minor stroke (for example with PICA infarct only) with patent and functional vertebral artery on contralateral site would not have the same treatment indications. In the majority of these cases medical therapy would be the first-line treatment:

• high risk of aggravation of the patient by sending emboli to the basilar artery and its branches during thrombectomy
• possible drugs for medical therapy: heparin +/- antiplatelets +/- statins