Controversy: Will large bore catheter kill the BGC?

Controversy: will large-bore catheter kill the BGC?

The large-bore aspiration catheter, with an inner diameter of 0.088 inches and a 50% increased lumen compared to the 6F aspiration catheter, significantly enhances aspiration efficiency, which is regarded as a game-changer in aspiration thrombectomy. The balloon guide catheter (BGC) can reduce the M1 blood flow by less than 20% when blocking the proximal carotid blood flow; whereas the 8F large-bore catheter with an outer diameter of 2.75 mm can easily reach the proximal M1 segment (diameter 2.8-3.0 mm) for aspiration. With the powerful aspiration efficiency, it can anchor the thrombus and form a blood flow reduction of more than 50% in the distal MCA segment, reducing the risk of thrombus escape.

The large-bore catheter coaxial system includes an 8F 0.106-inch 90cm long sheath, a 0.088-inch large-bore catheter, and a matching diameter, self-centering delivery catheter (such as Tenzing 8). The overall delivery coaxial system perfectly deals with the "ledge" effect in areas such as the ophthalmic artery, reducing vascular injuries like traction and dissection, and safely and quickly reaching the target lesion. If the aortic arch is highly curved, the long sheath can be delivered to the distal common carotid artery or internal carotid artery through exchanging techniques starting with the VTK catheter. The Tenzing delivery catheter, which is compatible with 0.014-inch microwire, is used to guide the 0.088 catheter to the proximal end of the thrombus. When the delivery catheter is withdrawn, the negative pressure formed will push the 0.088 catheter to better engage and aspirate the thrombus. The long sheath and 0.088 catheter, as a dual combination, are directly delivered to the thrombus, thus maximum the aspirating efficiency. Navigating with Tenzing delivery catheter or Aristotle guildwire improves the trackability of the 0.088 catheter.

The proportion of cardioembolic stroke in the Caucasian population is significantly higher than in the Asian population, especially in the M1 segment of the middle cerebral artery. Using the ADAPT technique, relatively high first-pass effect (FPE) can be achieved through large-bore catheters in combination with pump aspiration, which is the original design scenario of the large-bore catheter and has almost become the first strategy for such cases. The application of BGC in the posterior circulation is relatively limited, while the 0.088 catheter might have better compatibility and can effectively block blood flow in the dominant vertebral artery, with an intracranial diameter of about 2.8 mm.

However, it should be noted that even for internal carotid artery or M1 segment occlusion, the proportion of first-pass successful recanalization (mTICI 2c-3) is about 67.9%, and some cases still need salvage thrombectomy with intermediate catheters and stent retrievers for distal occlusion. Especially for internal carotid artery tandem occlusion, although it is difficult to achieve FPE with a 0.088 catheter alone, it can still efficiently remove large clot burden, and at this time, the 0.088 catheter can be regarded as a distal access catheter using dual aspiration, or BGC (inner diameter 0.087 inch) combined with intermediate catheter (inner diameter 0.070~0.074 inch). When the thrombus load is large, similar to BGC, the 0.088 catheter may encounter a situation where there is no blood reflow in the catheter but also the target vessel is not recanalized. First, slightly withdrawn the catheter to prevent it from against the vessel wall, if not work, use a larger diameter long stent retriever to remove the thrombus blocked at the catheter head under continuous negative pressure aspiration, but without BGC blood flow blockage, there is still a risk of thrombus escape. For long-segment large-load thrombus involving bifurcations, typically T-ICA, especially for cases where both anterior cerebral arteries originate from the occluded side of the internal carotid artery "one drag three", balloon guide catheter combined with double stent retriever still has its superiority, and the BADDASS technique with an aspiration catheter (inner diameter 0.070 inch or more) compatible with two 0.021 microcatheters can be considered. However, in the East Asian population, intracranial atherosclerosis is highly prevalent, and the M1 and C6, C7 segments are all common sites. When the etiology is unclear, the 0.088 catheter might encounter difficulty passing through the stenosis and cannot effectively conduct contact aspiration at the stenosis, in those cases BGC might be a good option to start with.

The Protect-MT study showed that compared with traditional guide catheters, balloon guide catheters had significantly worse 90-day mRS scores, longer reperfusion time, and higher 90-day all-cause mortality rate (common causes were intracranial hemorrhage) and more frequent severe vasospasm complications, which was heterogeneous with previous observational studies, but the first-generation BGC was mostly used in the study, and it may not be able to draw conclusions applicable to current devices. Considering the heterogeneity of different occlusion sites, etiologies, and technical strategies, as well as the rapid iteration of thrombectomy devices, it may be difficult to implement randomized controlled trials directly comparing BGC with large-bore catheters. Perhaps we do not have to rely on RCT-level evidence. With the help of AI big data to integrate real-world observational studies to simulate RCTs, there may be some inspiration, or in the future, there may also be new-generation large-bore catheters that integrates the advantages of both and achieve both proximal blood flow control and effecient aspiration.

Reference

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