1. The use of large bore sheaths in patients who underwent mechanical thrombectomy for acute ischemic stroke was associated with low rates of groin complications (<1%) even with tissue Plasminogen Activator administration.
Evidence Rating: 4 (Below Average)
Study Rundown: Balloon guided catheters (BGC) may be associated with superior clinical outcomes when compared to standard guide catheters in cerebral arterial thrombectomy. However, interventionalists have been hesitant to use BGCs due to a hypothetically increased risk of complications given its larger sheath size at 7-9 French (Fr). This single center study retrospectively investigated the groin complication rates of patients who underwent thrombectomy with BGCs using large 8 or 9 Fr femoral catheters. Overall, the use of these large bore sheaths resulted in a 0.4-0.8% groin complication rate in 472 patients over 9 years, with 55.1% of patients having received tissue Plasminogen Activator (t-PA) prior to mechanical thrombectomy. This study is important in establishing the relative safety of endovascular therapy in acute ischemic stroke, especially given the relatively large rates of femoral venous access for vascular devices. The main limitation in this study was its case series design, with no control data to compare complication rates, and with low enrollment of patients on chronic antiplatelet or anticoagulant agents. Future studies should try to expand the patient population pool by using a multi-center study design that might allow for better subgroup analysis.
In-Depth [case series]: A single center study identified a total of 472 patients (mean age 70±16, 50% female) between 2005 – 2014 who had undergone endovascular therapy for acute ischemic stroke with an 8 or 9 french venous sheath or BGC. Radiological reports for groin ultrasound or CT imaging of the abdomen/pelvis within 30 days post-procedure were used to assess for post-procedure complications. Definite complications were defined as groin hematoma, retroperitoneal hematoma, or femoral artery pseudoaneurysm. Possible complications were defined as blood transfusion within 72 hours of procedure without clear indication. Overall, 260 patients (55.1%) had preprocedural tissue Plasminogen Activator administered as part of standard stroke treatment, and 462 (97.9%) underwent intervention with a vascular closure device. The vast majority of patients were treated using the Angioseal VIP closure device (93.9%, n = 443) with a minority treated using either the Perclose, Starclose, Vasoseal, or Mynx devices, and 2.1% (n = 10) receiving manual compression only. Additionally, 87.3% of enrolled patients were anticoagulation naïve, while 12.5% (n = 59) were on warfarin, 0.2% (n = 1) on rivaroxaban, and 2.1% (n = 10) on dual antiplatelet therapy. There was an overall definite groin complication rate of 0.4% (n = 2) and a possible groin complication of 0.8% (n = 4). Both of the definite complications were groin hematomas.
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