Balloon guide catheter - SLICE Worldwide 2022

Balloon guide catheter – a different tale of an old story

Balloon guide catheters have been around for some time in ischemic stroke intervention, as have been the debates concerning their potential advantages and disadvantages, their potential usefulness, or the lack thereof. Frankly, most technical discussions at any stroke meeting for several years will stumble on the topic of balloon guide, and key-opinion leaders and stroke experts will argue among themselves about this topic. Since no randomized data compare the usefulness of a balloon guide vs. a standard guide catheter, no adequate answer can be given to this question, and the debates will continue. This will be a quick recap of what features could be considered valuable and some tricks and tips for a novel user of balloon guide catheters. 

Effectiveness of balloon guide catheter when and how?

• Overall literature data suggests that balloon-guide catheters have lower odds of mortality, distal emboli, and sICH and higher odds of TICI 3, first-pass effect TICI 3, and a good 90 days mRS.[1]
• Their actual usefulness, as presented in this video, is probably limited to several situations:
  1. Stent-retriever use without distal access catheters. [2,3]
  2. Tandem lesions, carotid stenting cases, and carotid dissections where anterograde flow protection and reversal are productive ways to prevent emboli. [4]
• Their actual usefulness also depends on correct use:
  1. Ability to mount up to the petrous segment to prevent collapse by aspiration.
  2. Once in place with the balloon guide, before inflation, the tension should be taken out of the system to prevent anterograde migration of the inflated balloon during stent retrieval.
  3. Adequate inflation – preventing local dissection and assuring flow arrest.
• As presented in this video balloon guide allows for retrograde visualization of the ICA while preventing distal migration of emboli. This technique is beneficial when treating proximal occlusive lesions such as dissections, stenosis, occlusion, or complications on fractured or displaced stents. Two techniques can be performed:
  1. As presented in the video, a microcatheter can be used to pass the thrombus, and while keeping the balloon guide inflated, – aspiration applied to the balloon guide while injecting through the microcatheter will retrogradely opacify the ICA.
  2. Another essential technique, especially for complex dissection reconstructions, is the contralateral injection with a diagnostic catheter while keeping the balloon guide inflated and aspirating in the dissected ICA. Provided there is an anterior communicating artery, this will reverse the intracranial flow and opacify the whole ICA without needing to pass and with usually better clarity.
• Once the balloon is securely inflated in the ICA (so cutting out ECA flow), cutting the flush on the balloon and opening the three-way stopcock will result in cranial retrograde blood even without aspiration. In the face of a long occlusive lesion, this technique is beneficial to clarify when the ICA is recanalized as – working with an open three-way stopcock, the collateral blood from the contralateral/posterior circulation will start flowing on the table once recanalization is achieved. 
• As for more helpful tips & tricks, do watch the video.
• P.S. Newer balloon-guide catheters are far superior in trackability to old devices but getting them in the desired position is far less accessible with a long 0.38 guidewire than with the usually used 0.35 guidewires. 

Since randomized evidence for balloon guide catheters’ usefulness is lacking, since the best available evidence for their use is not good enough and will still be debatable, we should switch as a community from an “I am a balloon guide user “ and “ I am not a balloon guide user” approach to a more subtle more constructive, technical process in which we ask ourselves before each intervention: could a balloon guide catheter render this intervention safer in theory? Will I be more comfortable with intracranial circulation opened in managing the cervical lesion with or without the balloon guide?

Further reading:

1            Pederson JM, Reierson NL, Hardy N, et al. Comparison of Balloon Guide Catheters and Standard Guide Catheters for Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. World Neurosurg. 2021;154:144-153.e21. doi:10.1016/j.wneu.2021.07.034

2            Blasco J, Puig J, López-Rueda A, et al. Addition of intracranial aspiration to balloon guide catheter does not improve outcomes in large vessel occlusion anterior circulation stent retriever based thrombectomy for acute stroke. J Neurointerv Surg 2022;14:863–7. doi:10.1136/neurintsurg-2021-017760

3            Bourcier R, Marnat G, Labreuche J, et al. Balloon guide catheter is not superior to conventional guide catheter when stent retriever and contact aspiration are combined for stroke treatment. Neurosurgery 2021;88:E83–90. doi:10.1093/neuros/nyaa315

4            Dargazanli C, Mahmoudi M, Cappucci M, et al. Angiographic Patterns and Outcomes Achieved by Proximal Balloon Occlusion in Symptomatic Carotid Artery Stenosis Stenting. Clin Neuroradiol 2020;30:363–72. doi:10.1007/s00062-019-00770-8