Double Solitaire Mechanical Thrombectomy in Acute Stroke: Effective Rescue Strategy for Refractory Artery Occlusions?

BACKGROUND AND PURPOSE:Mechanical thrombectomy by using a single stent retriever system has demonstrated high efficacy for recanalization of large-artery occlusions in acute stroke. We aimed to evaluate the feasibility, safety, and efficacy of a novel double Solitaire stent retriever technique as an escalating treatment for occlusions that are refractory to first-line single stent retriever mechanical thrombectomy.MATERIALS AND METHODS:All patients treated with the double stent retriever technique by using the Solitaire system were retrospectively selected from 2 large neurointerventional centers. Time to recanalization, angiographic (TICI) and clinical outcomes (mRS), and complications were assessed.RESULTS:Ten patients (median NIHSS score, 16; mean age, 70 years) with MCA M1 segment (n = 5) and terminal ICA (n = 5 including 2 ICA tandem) occlusions were included. Prior single stent retriever mechanical thrombectomy had been performed in 9 patients (median number of passes, 3). Median time to recanalization was 60 minutes (interquartile range, 45–87 minutes). Procedure-related complications occurred in 1 patient; overall mortality was 20%. Recanalization of the target vessel (TICI 2b/3) was achieved in 80%. Good clinical outcome (mRS 0–2) was 50%.CONCLUSIONS:In this preliminary feasibility study, the double Solitaire stent retriever technique proved to be an effective method for recanalization of anterior circulation large-artery occlusions refractory to standard stent retriever mechanical thrombectomy.

In acute ischemic stroke, recanalization of an occluded cerebral artery is strongly linked with improved clinical outcome and reduced mortality.¹ The potential of IV thrombolysis for achieving successful vessel recanalization is significantly limited by the extent of clot burden in proximal cerebral artery occlusions.² With the recent introduction of stent retrievers (SR) for mechanical thrombectomy (MT), fast, safe, and efficient large-artery recanalization treatment can be achieved, and their superiority over older MT devices has been demonstrated in randomized controlled trials.^3,4Despite considerable recanalization rates of 61%–86% (Thrombolysis in Myocardial Infarction/TICI scores of ≥2/2b),^3–5 up to 33.3% of patients are still left without sufficient recanalization after standard SR MT.⁶ In these refractory cases, different rescue treatments have been proposed with variable rates of success.^4,5,7–10 These include local intra-arterial fibrinolysis, MT with the Penumbra device (Penumbra, Alameda, California), mechanical thrombus disruption, thromboaspiration through a distal-access catheter (DAC), balloon angioplasty, and/or stent placement.Here, we describe a novel escalating strategy for MT by using 2 Solitaire SR devices (Covidien, Irvine, California), hence termed the “double Solitaire SR technique,” for proximal anterior circulation occlusions that are refractory to first-line single SR MT. In a retrospective series of patients from 2 large neurointerventional centers, we assessed the feasibility, safety, and angiographic and clinical outcomes of this technique.