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Introduction: Aspiration mechanical thrombectomy traditionally includes use of an inner microcatheter and leading microwire to navigate an aspiration catheter (AC) to the site of occlusion. Early clinical experience suggests that a leading microwire is often not needed with the Tenzing 7 (T7, Route 92 Medical, San Mateo, CA), a soft tapered tip ledge-reducing delivery catheter. This multicenter experience aims to describe AC delivery success in single-pass thrombectomy using T7 with and without a leading microwire., Methods: A retrospective review was conducted of consecutive patients who underwent single-pass thrombectomy with T7 at six institutions between 2020 and 2022. We examined the percentage of successful AC delivery, puncture-to-revascularization time, and procedural complication rate., Results: A leading microwire with T7 was used in 19/89 (21%) of patients, and it was not used with T7 in 70/89 (79%) of patients. Successful AC delivery was similar with and without microwires (97% vs. 90%, p = 0.15). Median puncture-to-revascularization times were similar (17 min microwire vs. 16 min no-microwire, p = 0.12). No complications were associated with microwire use; one (1.4%) patient had a T7-related vasospasm resolved with verapamil during thrombectomy without a leading microwire. Differences in complication rates were not statistically significant (p = 0.46)., Conclusion: In our real-world clinical experience, leading microwire use was infrequently necessary with the T7 delivery catheter. Successful AC delivery and complication rates were similar with and without microwire use in single-pass T7 thrombectomies. Initial pass with T7 may be performed without use of leading microwire, reserving microwire use for refractory cases or known difficult-to-navigate vasculature., Competing Interests: Declaration of conflicting interestsThe authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: J. English is a consultant for Route 92 Medical and Stryker. He has equity in Route 92 Medical. F. Settecase is a consultant for Route 92 Medical and Stryker. He has received honorarium from Stryker. W. Kim is a consultant for Route 92 Medical and Stryker. He has equity in Route 92 Medical. A. Thomas is a consultant for Stryker, Medtronic, and CereVasc. T. Jovin is a consultant for Anaconda, Route 92 Medical,Viz.AI, FreeOx, Blockade Medical, and Methinks. He serves in an advisory capacity for Cerenovus and Contego Medical. He has equity in Cornidus. He receives research support from Medtronic and Stryker. R. Hanel is a consultant for Medtronic, Stryker, Cerenovous, Microvention, Balt, Phenox, Rapid Medical, and Q'Apel. He serves in an advisory capacity for MiVI, eLum, Three Rivers, Shape Medical, and Cornidus. He receives research support from National Institutes of Health, Interline Endowment, Microvention, Stryker, and CNX. He has equity in InNeuroCo, Cerebrotech, eLum, Endostream, Three Rivers Medical Inc., Scientia, RisT, BlinkTBI, and Cornidus. A. Aghaebrahim serves in an advisory capacity for iSchemaView. E. Sauvageau is a consultant for Stryker. T.N. Nguyen serves in an advisory capacity for Vesalio, National Institutes of Health, Avania, Idorsia, Brainomix, and SUMMIT Max PI. She serves as an editor, associate editor, or editorial advisory board member for the American Heart Association. She receives research support from Society of Vascular and Interventional Neurology and Boston Medical Center. All other authors have no disclosures to declare..

Introduction: Subarachnoid hyperdensity is commonly seen on postoperative computed tomography scans within 24 h after mechanical thrombectomy. The impact on patients' outcomes remains uncertain. We present a real-world experience evaluating periprocedural factors associated with the development of subarachnoid hemorrhage (SAH) and its impact on outcomes of patients with acute stroke undergoing mechanical thrombectomy., Methods: A single-center, retrospective analysis was performed between January 2016 and August 2021, including all consecutive patients who underwent thrombectomy. Our study aimed to evaluate periprocedural factors associated with subarachnoid hemorrhage within 24 h of the intervention, and the potential impact on patients' outcome., Results: Of 781 patients, 44 patients (5.63%) demonstrated pure SAH within 24 h of the intervention. Patients from the SAH group were more likely to have tandem occlusion (15.9% vs. 5.2%, p  = .003), aspiration using reperfusion pump system (81.4% vs. 66.8%, p  = .047), intraoperative complications (9.1% vs. 0.9%; p  < .001), longer puncture-to-recanalization times (45 min vs 29 min, p  = .042) and a higher median number of passes to achieve recanalization (1 vs. 3, p  = .002). There was no statistically significant difference in the long-term functional outcome between the groups., Conclusion: We suggest that dual-energy computed tomography could better distinguish between blood and pure contrast stagnation. Still, SAH was not associated with an unfavorable outcome in stroke patients undergoing thrombectomy.

Endovascular therapy became the mainstream treatment for patients with acute stroke due to emergent large vessel occlusion (LVO). With increasing number of interventions, it is not uncommon for incidental vascular pathologies to be found during mechanical thrombectomy. Overall, intracranial aneurysms can occur in up to 4% of the population, but previous studies suggest a slightly higher prevalence of intracranial aneurysms in stroke patients as they may share common risk factors. We report on three patients with acute stroke secondary to LVO undergoing mechanical thrombectomy with brain aneurysms incidentally discovered and discuss the potential implications and technical considerations of performing revascularization in these scenarios. In the first case, a patient treated with stent-retriever and aspiration developed a carotid-cavernous fistula without clinical repercussion. The second case illustrates an internal carotid artery posterior communicating segment aneurysm rupture with a massive subarachnoid hemorrhage. The third case exemplifies an unruptured middle cerebral artery bifurcation aneurysm related to an M2 occlusion managed with a different strategy, avoiding aneurysm rupture. Intraprocedural aneurysm rupture is a potential complication during mechanical thrombectomy, especially when anatomical challenges are present. Interventionalists should be aware of the potential risk and constraints in this setting in order to mitigate adverse events.

Background and Aim: Mechanical thrombectomy (MT) for large vessel occlusion often requires multiple passes to retrieve the entire thrombus load. In this multi-institutional study we sought to examine the composition of thrombus fragments retrieved with each pass during MT., Methods: Patients who required multiple passes during thrombectomy were included. Histopathological evaluation of thrombus fragments retrieved from each pass was performed using Martius Scarlet Blue staining and the composition of each thrombus component including RBC, fibrin and platelet was determined using image analysis software., Results: 154 patients underwent MT and 868 passes was performed which resulted in 263 thrombus fragments retrieval. The analysis of thrombus components per pass showed higher RBC, lower fibrin and platelet composition in the pass 1 and 2 when compared to pass 3 and passes 4 or more combined (P values <0.05). There were no significant differences between thrombus fragments retrieved in pass 1 and pass 2 in terms of RBC, WBC, fibrin, and platelet composition (P values >0.05). Similarly, when each composition of thrombus fragments retrieved in pass 3 and passes 4 or more combined were compared with each other, no significant difference was noted (P values >0.05)., Conclusion: Our findings confirm that thrombus fragments retrieved with each pass differed significantly in histological content. Fragments in the first passes were associated with lower fibrin and platelet composition compared to fragments retrieved in passes three and four or higher. Also, thrombus fragments retrieved after failed pass were associated with higher fibrin and platelet components.