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David J. Padalino and Eric M. Deshaies

Rapid revascularization of tandem extracranial and intracranial acute thromboembolic occlusions can be challenging and can delay restoration of blood flow to the cerebral circulation. Taking advantage of collateral pathways in the circle of Willis for thrombectomy can reduce the occlusion-to-revascularization time significantly, thereby protecting brain tissue from ischemic injury. The authors report using the trans–anterior communicating artery (ACoA) approach by using the Penumbra microcatheter to rapidly restore blood flow to the middle cerebral artery (MCA) territory prior to treating the ipsilateral internal carotid artery (ICA) occlusion. Two patients with acute onset of tandem ipsilateral ICA and MCA occlusions and a competent ACoA underwent rapid revascularization of the MCA using a trans-ACoA approach for pharmaceutical and mechanical thrombolysis with the 0.026-in Penumbra microcatheter. Subsequently, once blood flow was reestablished in the MCA territory via cross-filling from the contralateral ICA, the proximally occluded ICA dissection was revascularized with a stent. Both patients had rapid revascularization of the MCA territory (both Thrombolysis in Myocardial Infarction Grade 3) with the trans-ACoA approach (19 and 36 minutes) followed by treatment of the ipsilateral proximal ICA occlusion. This prevented prolonged MCA ischemia time (72 and 47 minutes for ICA revascularization time saved) that would have otherwise occurred if the dissections were treated prior to revascularization of the MCA. Both patients had improved NIH Stroke Scale scores after the procedure. No adverse events from crossing the ACoA with the Penumbra microcatheter were encountered during the revascularization procedure. The trans-ACoA approach with the Penumbra microcatheter for rapid revascularization of an acutely thrombosed MCA in the setting of a simultaneous ipsilateral proximal ICA occlusion is feasible in patients with a competent ACoA. This technique can significantly minimize ischemic injury by reducing the occlusion-to-revascularization time and allow for MCA perfusion via collateral circulation while treating a proximal occlusion. To the best of the authors' knowledge, this is the first reported trans-ACoA approach with the Penumbra microcatheter and the first to report the utilization of the collateral intracranial circulation to reduce occlusion-to-revascularization time.

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Eric M. Deshaies, Amit Singla, Mark R. Villwock, David J. Padalino, Sameer Sharma and Amar Swarnkar


There is limited information regarding patient outcomes following interventions for stroke during the window for endovascular therapy. Studies have suggested that recently approved stent retrievers are safer and more effective than earlier-generation thrombectomy devices. The authors compared cases in which the Solitaire-FR device was used to those in which a MERCI or Penumbra device was used.


This study is a single-center retrospective review of 102 consecutive cases of acute stroke in which patients were treated with mechanical thrombectomy devices between 2007 and 2013. Multivariate models, adjusted for confounding factors, were used to investigate functional independence (modified Rankin Scale [mRS] score ≤ 2, and successful reperfusion (thrombolysis in cerebral infarction [TICI] score ≥ 2b).


Thrombectomy device had a significant impact on functional independence (mRS score ≤ 2) at discharge from the hospital (p = 0.040). Solitaire-FR treatment resulted in significantly more patients being discharged as functionally independent in comparison with MERCI treatment (p = 0.016). A multivariate model found the use of Solitaire-FR to improve the odds of good clinical outcome in comparison with prior-generation devices (OR 6.283, 95% CI 1.785–22.119, p = 0.004). Additionally, the use of Solitaire-FR significantly increased the odds of successful reperfusion (OR 3.247, 95% CI 1.160–9.090, p = 0.025).


The stent retriever Solitaire-FR significantly improved the odds of functional independence and successful revascularization of the arterial tree. New interventional technology for stroke continues to mature, but randomized trials are needed to establish the actual benefit to specific patient populations.

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Elad I. Levy, Ricardo A. Hanel, Tsz Lau, Christopher J. Koebbe, Naveh Levy, David J. Padalino, Kim Marie Malicki, Lee R. Guterman and L. Nelson Hopkins

Object. To determine the rate of hemodynamically significant recurrent carotid artery (CA) stenosis after stent-assisted angioplasty for CA occlusive disease, the authors analyzed Doppler ultrasonography data that had been prospectively collected between October 1998 and September 2002 for CA stent trials.

Methods. Patients included in the study participated in at least 6 months of follow-up review with serial Doppler studies or were found to have elevated in-stent velocities (> 300 cm/second) on postprocedure Doppler ultrasonograms. Hemodynamically significant (≥ 80%) recurrent stenosis was identified using the following Doppler criteria: peak in-stent systolic velocity at least 330 cm/second, peak in-stent diastolic velocity at least 130 cm/second, and peak internal carotid artery/common carotid artery velocity ratio at least 3.8. Follow-up studies were obtained at approximate fixed intervals of 1 day, 1 month, 6 months, and yearly. Angiography was performed in the event of recurrent symptoms, evidence of hemodynamically significant stenosis on Doppler ultrasonography, or both. Treatment was repeated because of symptoms, angiographic evidence of severe (≥ 80%) recurrent stenosis, or both of these.

Stents were implanted in 142 vessels in 138 patients (all but five patients were considered high-risk surgical candidates and 25 patients were lost to follow-up review). For the remaining 112 patients (117 vessels), the mean duration of Doppler ultrasonography follow up was 16.42 ± 10.58 months (range 4–54 months). Using one or more Doppler criteria, severe (≥ 80%) in-stent stenosis was detected in six patients (5%). Eight patients underwent repeated angiography. Six patients (three with symptoms) required repeated intervention (in four patients angioplasty alone; in one patient conventional angioplasty plus Cutting Balloon angioplasty; and in one patient stent-assisted angioplasty).

Conclusions. In a subset of primarily high-risk surgical candidates treated with stent-assisted angioplasty, the rates of hemodynamically significant restenosis were comparable to surgical restenosis rates cited in previously published works. Treatment for recurrent stenosis incurred no instance of periprocedure neurological morbidity.