Background: Over the course of the thrombectomy procedure, clot fragments may become dislodged and lead to downstream emboli due to manipulation of an endovascular device. The EmboTrap thrombectomy system features an inner stent channel with an outer stent trap design that may potentially reduce the risk of distal clot fragmentation during clot removal. We tested the hypothesis that distal emboli to both the same and new territory generated during mechanical thrombectomy are a function of device design. Methods: EmboTrap and Solitaire thrombectomy were conducted in an in vitro model system that mimicked a middle-cerebral artery (MCA) occlusion within a complete circle of Willis vascular replica and a contrast-enhanced clot analog. Emboli generated during the procedure with a size >1,000 μm were collected and measured with calipers. The Coulter principle was used to characterize emboli with a size between 200 and 1,000 µm. Results: EmboTrap thrombectomy resulted in a significant reduction in the risk of large emboli (>1,000 μm) formation as compared to first-generation stent retriever thrombectomy (p = 0.031, Fisher exact test). The majority of emboli >1,000 μm (∼80%) were found in the MCA, regardless of device type. There was no significant difference between the EmboTrap and Solitaire in 200 to 1,000 μm emboli formation (p = 0.89, Mann-Whitney test). When combining all emboli in the most dangerous range (>200 μm), EmboTrap offered a size reduction of emboli (p = 0.022). Conclusion: The risk of distal embolization can be altered with improved stent retriever design. When encountering fragment-prone clots, EmboTrap thrombectomy may lower the risk of distal embolization.

1.
Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, Schonewille WJ, Vos JA, Nederkoorn PJ, Wermer MJ, van Walderveen MA, Staals J, Hofmeijer J, van Oostayen JA, Lycklama a Nijeholt GJ, Boiten J, Brouwer PA, Emmer BJ, de Bruijn SF, van Dijk LC, Kappelle LJ, Lo RH, van Dijk EJ, de Vries J, de Kort PL, van Rooij WJ, van den Berg JS, van Hasselt BA, Aerden LA, Dallinga RJ, Visser MC, Bot JC, Vroomen PC, Eshghi O, Schreuder TH, Heijboer RJ, Keizer K, Tielbeek AV, den Hertog HM, Gerrits DG, van den Berg-Vos RM, Karas GB, Steyerberg EW, Flach HZ, Marquering HA, Sprengers ME, Jenniskens SF, Beenen LF, van den Berg R, Koudstaal PJ, van Zwam WH, Roos YB, van der Lugt A, van Oostenbrugge RJ, Majoie CB, Dippel DW; MR CLEAN Investigators: A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 2015;372:11-20.
2.
Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, Yan B, Dowling RJ, Parsons MW, Oxley TJ, Wu TY, Brooks M, Simpson MA, Miteff F, Levi CR, Krause M, Harrington TJ, Faulder KC, Steinfort BS, Priglinger M, Ang T, Scroop R, Barber PA, McGuinness B, Wijeratne T, Phan TG, Chong W, Chandra RV, Bladin CF, Badve M, Rice H, de Villiers L, Ma H, Desmond PM, Donnan GA, Davis SM; EXTEND-IA Investigators: Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 2015;372:1009-1018.
3.
Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, Roy D, Jovin TG, Willinsky RA, Sapkota BL, Dowlatshahi D, Frei DF, Kamal NR, Montanera WJ, Poppe AY, Ryckborst KJ, Silver FL, Shuaib A, Tampieri D, Williams D, Bang OY, Baxter BW, Burns PA, Choe H, Heo JH, Holmstedt CA, Jankowitz B, Kelly M, Linares G, Mandzia JL, Shankar J, Sohn SI, Swartz RH, Barber PA, Coutts SB, Smith EE, Morrish WF, Weill A, Subramaniam S, Mitha AP, Wong JH, Lowerison MW, Sajobi TT, Hill MD; ESCAPE Trial Investigators: Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 2015;372:1019-1030.
4.
Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, San Roman L, Serena J, Abilleira S, Ribo M, Millan M, Urra X, Cardona P, Lopez-Cancio E, Tomasello A, Castano C, Blasco J, Aja L, Dorado L, Quesada H, Rubiera M, Hernandez-Perez M, Goyal M, Demchuk AM, von Kummer R, Gallofre M, Davalos A; REVASCAT Trial Investigators: Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 2015;372:2296-2306.
5.
Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, Albers GW, Cognard C, Cohen DJ, Hacke W, Jansen O, Jovin TG, Mattle HP, Nogueira RG, Siddiqui AH, Yavagal DR, Baxter BW, Devlin TG, Lopes DK, Reddy VK, du Mesnil de Rochemont R, Singer OC, Jahan R; SWIFT PRIME Investigators: Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 2015;372:2285-2295.
6.
Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM, Davalos A, Majoie CB, van der Lugt A, de Miquel MA, Donnan GA, Roos YB, Bonafe A, Jahan R, Diener HC, van den Berg LA, Levy EI, Berkhemer OA, Pereira VM, Rempel J, Millan M, Davis SM, Roy D, Thornton J, Roman LS, Ribo M, Beumer D, Stouch B, Brown S, Campbell BC, van Oostenbrugge RJ, Saver JL, Hill MD, Jovin TG; HERMES Collaborators: Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 2016;387:1723-1731.
7.
Campbell BC, Hill MD, Rubiera M, Menon BK, Demchuk A, Donnan GA, Roy D, Thornton J, Dorado L, Bonafe A, Levy EI, Diener HC, Hernandez-Perez M, Pereira VM, Blasco J, Quesada H, Rempel J, Jahan R, Davis SM, Stouch BC, Mitchell PJ, Jovin TG, Saver JL, Goyal M: Safety and efficacy of Solitaire stent thrombectomy: individual patient data meta-analysis of randomized trials. Stroke 2016;47:798-806.
8.
Chueh J-Y, Kühn AL, Puri AS, Wilson S, Wakhloo AK, Gounis MJ: Reduction in distal emboli with proximal flow control during mechanical thrombectomy: a quantitative in vitro study. Stroke 2013;44:1396-1401.
9.
Menon BK, Sajobi TT, Zhang Y, Rempel JL, Shuaib A, Thornton J, Williams D, Roy D, Poppe AY, Jovin TG, Sapkota B, Baxter BW, Krings T, Silver FL, Frei DF, Fanale C, Tampieri D, Teitelbaum J, Lum C, Dowlatshahi D, Eesa M, Lowerison MW, Kamal NR, Demchuk AM, Hill MD, Goyal M: Analysis of workflow and time to treatment on thrombectomy outcome in the Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE) randomized, controlled trial. Circulation 2016;133:2279-2286.
10.
Velasco A, Buerke B, Stracke CP, Berkemeyer S, Mosimann PJ, Schwindt W, Alcazar P, Cnyrim C, Niederstadt T, Chapot R, Heindel W: Comparison of a balloon guide catheter and a non-balloon guide catheter for mechanical thrombectomy. Radiology 2016;280:169-176.
11.
Nguyen TN, Malisch T, Castonguay AC, Gupta R, Sun CH, Martin CO, Holloway WE, Mueller-Kronast N, English JD, Linfante I, Dabus G, Marden FA, Bozorgchami H, Xavier A, Rai AT, Froehler MT, Badruddin A, Taqi M, Abraham MG, Janardhan V, Shaltoni H, Novakovic R, Yoo AJ, Abou-Chebl A, Chen PR, Britz GW, Kaushal R, Nanda A, Issa MA, Masoud H, Nogueira RG, Norbash AM, Zaidat OO: Balloon guide catheter improves revascularization and clinical outcomes with the Solitaire device: analysis of the North American Solitaire Acute Stroke Registry. Stroke 2013;45:141-145.
12.
Saver JL, Goyal M, van der Lugt A, Menon BK, Majoie CB, Dippel DW, Campbell BC, Nogueira RG, Demchuk AM, Tomasello A, Cardona P, Devlin TG, Frei DF, du Mesnil de Rochemont R, Berkhemer OA, Jovin TG, Siddiqui AH, van Zwam WH, Davis SM, Castano C, Sapkota BL, Fransen PS, Molina C, van Oostenbrugge RJ, Chamorro A, Lingsma H, Silver FL, Donnan GA, Shuaib A, Brown S, Stouch B, Mitchell PJ, Davalos A, Roos YB, Hill MD; HERMES Collaborators: Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: a meta-analysis. JAMA 2016;316:1279-1288.
13.
Teng D, Pannell JS, Rennert RC, Li J, Li YS, Wong VW, Chien S, Khalessi AA: Endothelial trauma from mechanical thrombectomy in acute stroke: in vitro live-cell platform with animal validation. Stroke 2015;46:1099-1106.
14.
Power S, Matouk C, Casaubon LK, Silver FL, Krings T, Mikulis DJ, Mandell DM: Vessel wall magnetic resonance imaging in acute ischemic stroke: effects of embolism and mechanical thrombectomy on the arterial wall. Stroke 2014;45:2330-2334.
15.
Renu A, Laredo C, Lopez-Rueda A, Llull L, Tudela R, San-Roman L, Urra X, Blasco J, Macho J, Oleaga L, Chamorro A, Amaro S: Vessel wall enhancement and blood-cerebrospinal fluid barrier disruption after mechanical thrombectomy in acute ischemic stroke. Stroke 2017;48:651-657.
16.
Marosfoi MG, Korin N, Gounis MJ, Uzun O, Vedantham S, Langan ET, Papa AL, Brooks OW, Johnson C, Puri AS, Bhatta D, Kanapathipillai M, Bronstein BR, Chueh JY, Ingber DE, Wakhloo AK: Shear-activated nanoparticle aggregates combined with temporary endovascular bypass to treat large vessel occlusion. Stroke 2015;46:3507-3513.
17.
Kabbasch C, Mpotsaris A, Liebig T, Soderman M, Holtmannspotter M, Cronqvist M, Thornton J, Mendes Pereira V, Andersson T: First-in-man procedural experience with the novel EmboTrap® revascularization device for the treatment of ischemic stroke - a European multicenter series. Clin Neuroradiol 2016;26:221-228.
18.
Chueh JY, Wakhloo AK, Gounis MJ: Neurovascular modeling: small-batch manufacturing of silicone vascular replicas. AJNR Am J Neuroradiol 2009;30:1159-1164.
19.
Chueh JY, Puri AS, Gounis MJ: An in vitro evaluation of distal emboli following Lazarus Cover-assisted stent retriever thrombectomy. J Neurointerv Surg 2017;9:183-187.
20.
Chueh JY, Wakhloo AK, Hendricks GH, Silva CF, Weaver JP, Gounis MJ: Mechanical characterization of thromboemboli in acute ischemic stroke and laboratory embolus analogs. AJNR Am J Neuroradiol 2011;32:1237-1244.
21.
Wiesmann M, Brockmann MA, Heringer S, Muller M, Reich A, Nikoubashman O: Active push deployment technique improves stent/vessel-wall interaction in endovascular treatment of acute stroke with stent retrievers. J Neurointerv Surg 2017;9:253-256.
22.
Asadi H, Dowling R, Yan B, Wong S, Mitchell P: Advances in endovascular treatment of acute ischaemic stroke. Intern Med J 2015;45:798-805.
23.
Pierot L, Soize S, Benaissa A, Wakhloo AK: Techniques for endovascular treatment of acute ischemic stroke: from intra-arterial fibrinolytics to stent-retrievers. Stroke 2015;46:909-914.
24.
Nogueira RG, Lutsep HL, Gupta R, Jovin TG, Albers GW, Walker GA, Liebeskind DS, Smith WS; TREVO 2 Trialists: TREVO versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trial. Lancet 2012;380:1231-1240.
25.
Saver JL, Jahan R, Levy EI, Jovin TG, Baxter B, Nogueira RG, Clark W, Budzik R, Zaidat OO; SWIFT Trialists: Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial. Lancet 2012;380:1241-1249.
26.
Gascou G, Lobotesis K, Machi P, Maldonado I, Vendrell JF, Riquelme C, Eker O, Mercier G, Mourand I, Arquizan C, Bonafe A, Costalat V: Stent retrievers in acute ischemic stroke: complications and failures during the perioperative period. AJNR Am J Neuroradiol 2014;35:734-740.
27.
Gratz PP, Jung S, Schroth G, Gralla J, Mordasini P, Hsieh K, Heldner MR, Mattle HP, Mono ML, Fischer U, Arnold M, Zubler C: Outcome of standard and high-risk patients with acute anterior circulation stroke after stent retriever thrombectomy. Stroke 2014;45:152-158.
28.
Klinger-Gratz PP, Schroth G, Gralla J, Jung S, Weisstanner C, Verma RK, Mordasini P, Kellner-Weldon F, Hsieh K, Heldner MR, Fischer U, Arnold M, Mattle HP, El-Koussy M: Protected stent retriever thrombectomy prevents iatrogenic emboli in new vascular territories. Neuroradiology 2015;57:1045-1054.
29.
Chueh JY, Kuhn AL, Puri AS, Wilson SD, Wakhloo AK, Gounis MJ: Reduction in distal emboli with proximal flow control during mechanical thrombectomy: a quantitative in vitro study. Stroke 2013;44:1396-1401.
30.
Chueh JY, Puri AS, Wakhloo AK, Gounis MJ: Risk of distal embolization with stent retriever thrombectomy and ADAPT. J Neurointerv Surg 2016;8:197-202.
31.
Kurre W, Vorlaender K, Aguilar-Perez M, Schmid E, Bazner H, Henkes H: Frequency and relevance of anterior cerebral artery embolism caused by mechanical thrombectomy of middle cerebral artery occlusion. AJNR Am J Neuroradiol 2013;34:1606-1611.
32.
McTaggart RA, Tung EL, Yaghi S, Cutting SM, Hemendinger M, Gale HI, Baird GL, Haas RA, Jayaraman MV: Continuous aspiration prior to intracranial vascular embolectomy (CAPTIVE): a technique which improves outcomes. J Neurointerv Surg 2016, Epub ahead of print.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.