Kat Dakay, DO
Mechanical thrombectomy has emerged as the standard of care for patients with large vessel occlusion; however, the optimal method of re-canalizing a large vessel occlusion is up for debate. A recent JNIS article illustrated the wide practice heterogeneity between neurointerventionalists, with no less than twelve different techniques for endovascular treatment of stroke mentioned [1]. Use vs. nonuse of a balloon guide catheter is an example of one such practice variation between different centers and neurointerventionalists.
A balloon guide catheter is a supportive catheter typically placed into the internal carotid artery (or sometimes the common carotid if there is extensive stenosis of the internal carotid) and then inflated to cause flow arrest during mechanical thrombectomy, or in some cases, contact aspiration thrombectomy [2]. The theory behind placing a balloon guide catheter to cause flow arrest, which may aid in the procedure by two mechanisms: to reduce the risk of distal clot embolization [3, 4], and to decrease the systemic arterial pressure impacting the clot to enhance the effect of stent retriever thrombectomy [5].
In this recently published study in Stroke, Zaidat et al. reported on the use of balloon guide catheter in the STRATIS registry, a multicenter prospective registry of patients who underwent mechanical thrombectomy with the Solitaire device. For purposes of the study, patients with posterior circulation large vessel occlusion were excluded as balloon guide catheter is used less frequently in these occlusions; additionally, patients who underwent a proximal carotid intervention such as angioplasty or stenting were excluded. Patients meeting inclusion criteria were grouped into three categories based on procedural technique (Figure 1): conventional guide catheter (CGC), distal access catheter (DAC), and balloon guide catheter (BGC). There were between-group differences such as a lower baseline ASPECTs in the DAC group compared to the BGC group (8.2 vs 8.3, p = 0.023), more carotid occlusions in the DAC group compared to the BGC group (p = 0.018), and less general anesthesia in the DAC group compared to the BGC group (p = 0.001).
Compared to the DAC and CGC groups, the BGC group had a higher rate of first pass effect (66.4% vs. 41.9% in the CGC and 54.9% in the DAC group), defined as successful recanalization of TICI 2c or greater after one attempt. Additionally, the BGC group had a higher rate of functional independence at 90 days compared to the DAC (61.0% vs. 51.8%; p = 0.027) and CGC (61.0% vs. 41.8%, p = 0.007) groups. On multivariate analysis adjusting for age, baseline NIHSS, ASPECTs, location of occlusion, IA or IV tPA, general anesthesia, and time to groin puncture, BGC was an independent predictor of mRS 0-2 at 90 days (p = 0.031).
This study suggests that balloon guide catheter use has additive benefit in patients receiving mechanical thrombectomy; however, there are some limitations — the primary one being that there were baseline differences between the BGC and non-BGC groups, introducing the potential for confounding bias. However, the data presented in the STRATIS registry are similar to recently published data from the Trevo registry where BGC use was associated with lower mortality and favorable 90-day outcome [6], although this study was also subject to similar limitations with baseline between-group differences: the BGC group being slightly younger with a lower NIHSS, higher IV tPA use, lower prevalence of hypertension, and a higher incidence of atrial fibrillation. A meta-analysis including data from over 2000 patients similarly found a higher incidence of first pass recanalization, favorable 90-day outcome, lower number of passes, and lower total procedural time in patients who received mechanical thrombectomy with a BGC vs. without a BGC [7].
Factors that may contribute to the effect of BGC on outcomes include the reduction of embolization to distal territories by achieving flow arrest, and enhancement of the thrombectomy technique by decreasing arterial pressure impacting the clot. The former mechanism has been demonstrated by Mokin et al. in an in-vitro model of middle cerebral artery occlusion, demonstrating a lower embolization rate with BGC compared to control [8]. Additionally, decreasing clot impaction may be one of the factors leading to a higher first pass effect; higher first pass effect means less thrombectomy attempts occur, which may reduce the risk of procedural complications such as vessel dissection or perforation [4]. Achieving first pass effect may also lead to faster recanalization and re-establishment of blood flow, impacting outcome. Concerns about use of a BGC include the need for a larger groin sheath, and its potential to cause groin complications, as well as the tolerance to temporary flow arrest [9]. However, successful deployment of balloon guide catheter via transradial access has been reported [10], illustrating the feasibility of combining this technique with radial access, which has lower major access site complications as compared to femoral access. This article adds to the growing body of literature suggesting a benefit to balloon guide catheter use in patients undergoing mechanical thrombectomy, although there are some inherent limitations in registry data given the baseline differences between groups. A randomized controlled trial may help further evaluate the benefit of BGC in patients with anterior circulation large vessel occlusion.
References:
1. Mehta T, Male S, Quinn C, Kallmes DF, Siddiqui AH, Turk A, et al. Institutional and provider variations for mechanical thrombectomy in the treatment of acute ischemic stroke: A survey analysis. J Neurointerv Surg. 2019
2. Kang DH, Kim BM, Heo JH, Nam HS, Kim YD, Hwang YH, et al. Effect of balloon guide catheter utilization on contact aspiration thrombectomy. J Neurosurg. 2018:1-7
3. Lee DH, Sung JH, Kim SU, Yi HJ, Hong JT, Lee SW. Effective use of balloon guide catheters in reducing incidence of mechanical thrombectomy related distal embolization. Acta Neurochir (Wien). 2017;159:1671-1677
4. Oh JS, Yoon SM, Shim JJ, Doh JW, Bae HG, Lee KS. Efficacy of balloon-guiding catheter for mechanical thrombectomy in patients with anterior circulation ischemic stroke. J Korean Neurosurg Soc. 2017;60:155-164
5. Baek JH, Kim BM, Kang DH, Heo JH, Nam HS, Kim YD, et al. Balloon guide catheter is beneficial in endovascular treatment regardless of mechanical recanalization modality. Stroke. 2019:STROKEAHA118024723
6. Nguyen TN, Castonguay AC, Nogueira RG, Haussen DC, English JD, Satti SR, et al. Effect of balloon guide catheter on clinical outcomes and reperfusion in trevo thrombectomy. J Neurointerv Surg. 2019
7. Brinjikji W, Starke RM, Murad MH, Fiorella D, Pereira VM, Goyal M, et al. Impact of balloon guide catheter on technical and clinical outcomes: A systematic review and meta-analysis. J Neurointerv Surg. 2018;10:335-339
8. Mokin M, Setlur Nagesh SV, Ionita CN, Mocco J, Siddiqui AH. Stent retriever thrombectomy with the cover accessory device versus proximal protection with a balloon guide catheter: In vitro stroke model comparison. J Neurointerv Surg. 2016;8:413-417
9. Ahn JH, Cho SS, Kim SE, Kim HC, Jeon JP. The effects of balloon-guide catheters on outcomes after mechanical thrombectomy in acute ischemic strokes : A meta-analysis. J Korean Neurosurg Soc. 2019
10. Maus V, Styczen H, Psychogios MN. Intracranial mechanical thrombectomy using a proximal balloon guide catheter via a transradial access. Interv Neuroradiol. 2019:1591019919844850
