Failure modes and effects analysis of mechanical thrombectomy for stroke discovered in human brains

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  • 1 Departments of Mechanical Engineering and
  • | 2 Neurosurgery, University of Michigan, Ann Arbor, Michigan;
  • | 3 Departments of Radiology and
  • | 4 Neurosurgery, Mayo Clinic, Rochester, Minnesota;
  • | 5 UC Berkeley–UCSF Graduate Program in Bioengineering, San Francisco, California; and
  • | 6 Department of Mechanical Engineering, Worcester Polytechnic Institute, Worcester, Massachusetts
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OBJECTIVE

Despite advancement of thrombectomy technologies for large-vessel occlusion (LVO) stroke and increased user experience, complete recanalization rates linger around 50%, and one-third of patients who have undergone successful recanalization still experience poor neurological outcomes. To enhance the understanding of the biomechanics and failure modes, the authors conducted an experimental analysis of the interaction of emboli/artery/devices in the first human brain test platform for LVO stroke described to date.

METHODS

In 12 fresh human brains, 105 LVOs were recreated by embolizing engineered emboli analogs and recanalization was attempted using aspiration catheters and/or stent retrievers. The complex mechanical interaction between diverse emboli (elastic, stiff, and fragment prone), arteries (anterior and posterior circulation), and thrombectomy devices were observed, analyzed, and categorized. The authors systematically evaluated the recanalization process through failure modes and effects analysis, and they identified where and how thrombectomy devices fail and the impact of device failure.

RESULTS

The first-pass effect (34%), successful (71%), and complete (60%) recanalization rates in this model were consistent with those in the literature. Failure mode analysis of 184 passes with thrombectomy devices revealed the following. 1) Devices loaded the emboli with tensile forces leading to elongation and intravascular fragmentation. 2) In the presence of anterograde flow, small fragments embolize to the microcirculation and large fragments result in recurrent vessel occlusion. 3) Multiple passes are required due to recurrent (15%) and residual (73%) occlusions, or both (12%). 4) Residual emboli remained in small branching and perforating arteries in cases of alleged complete recanalization (28%). 5) Vacuum caused arterial collapse at physiological pressures (27%). 6) Device withdrawal caused arterial traction (41%), and severe traction provoked avulsion of perforating and small branching arteries.

CONCLUSIONS

Biomechanically superior thrombectomy technologies should prevent unrestrained tensional load on emboli, minimize intraluminal embolus fragmentation and release, improve device/embolus integration, recanalize small branching and perforating arteries, prevent arterial collapse, and minimize traction.

ABBREVIATIONS

BA = basilar artery; DA = direct aspiration; EA = embolus analog; FMEA = failure modes and effects analysis; FPE = first-pass effect; ICA = internal carotid artery; LVO = large-vessel occlusion; MCA = middle cerebral artery; RELVO = Recanalization in LVO; SR+A = stent retriever + aspiration; TICI = Thrombosis in Cerebral Infarction.

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Contributor Notes

Correspondence Luis E. Savastano: Mayo Clinic, Rochester, MN. savastano.luis@mayo.edu.

INCLUDE WHEN CITING Published online June 4, 2021; DOI: 10.3171/2020.11.JNS203684.

Y.L. and D.G. contributed equally to this work.

Disclosures Dr. Savastano is the founder and a stake owner of Endovascular Engineering, Inc., which develops thrombectomy technologies. Dr. Liu serves on the Scientific Advisory Board of Endovascular Engineering, Inc. Drs. Liu, Zheng, Shih, and Savastano are inventors on international patent application no. WO2019199931A1, which was licensed to Endovascular Engineering, Inc., and they could benefit from royalties in the future.

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