Case Study

AsprAX / Afentta 065-127cm aspiration catheter assisted in reopening acute occlusion of the left MCA

Surgeon's Profile

Chen Qingliang
The Third People’s Hospital of Henan Province

Director of the Department of Interventional Radiology, Director of the Minimally Invasive Diagnosis and Treatment Center for Cerebral Aneurysms, Chief Interventional Therapist, and Master’s Supervisor. Executive Committee Member of the Interventional Branch of the China Society of Norman Bethune’s Spirit Research and Executive Committee Member of the Clinical Pharmacy Branch of the China Society of Traditional Chinese Medicine Information. Started interventional radiology surgeries in 1996, independently completing over 8000 procedures. Specializes in interventional treatment of cerebral aneurysms, endovascular embolization for cerebral vascular malformations, intracranial stent placement, cerebral thrombus extraction, etc. Has led three provincial-level research projects and received two medical science and technology awards in Henan Province. Holds three national invention patents. Published over 30 papers in journals indexed in core databases. Editor of three professional monographs in this field.

Shen Meng
The Third People’s Hospital of Henan Province

Neurointerventional Team Leader, Attending Physician. Expert in the Cerebral Aneurysm Diagnosis and Treatment Center expert pool. Independently completed over 3000 interventional surgeries at or above the tertiary level. Specializes in neurointerventional procedures such as thrombus extraction for acute cerebral infarction, stent placement, embolization of cerebral aneurysms, and interventional treatment of cerebral vascular malformations. Received two medical science and technology awards in Henan Province. Holds one national invention patent. Published 6 papers in core journals.

Li Zhaojun
The Third People’s Hospital of Henan Province

Leader of the Comprehensive Interventional Team, Deputy Chief Physician of Interventional Therapy, Bachelor’s Degree. Expert in the Cerebral Aneurysm Diagnosis and Treatment Center expert pool. Independently completed over 2000 interventional surgeries at or above the tertiary level. Specializes in acute stroke thrombectomy, cerebral vascular stent placement, embolization therapy for cerebral aneurysms, CT-guided percutaneous biopsy and ablation therapy for small pulmonary nodules, etc. Received two medical science and technology awards in Henan Province. Holds one national invention patent. Published 10 papers in core journals.

Liang Hao
The Third People’s Hospital of Henan Province

Research Group Leader, Attending Physician, Master’s Degree graduate. Member of the Cerebral Aneurysm Diagnosis and Treatment Center expert pool. Proficient in interventional research, having led several provincial-level research projects. Independently completed over 1500 interventional surgeries at or above the tertiary level. Specializes in neurointerventional procedures such as thrombus extraction for acute cerebral infarction, stent placement, cerebral vascular stent placement, and embolization therapy for cerebral aneurysms.

Case Information

Patient male, 60 years old.

Chief complaint:

Sudden right-sided weakness with speech impairment for 1 hour.

Present illness:

The patient had no obvious cause and suddenly developed right-sided weakness with speech impairment 1 hour ago. There was no loss of consciousness. The symptoms persisted without obvious improvement, family members called emergency services (120). On-site assessment by emergency services showed: BP 172/98 mmHg; SO2 94%; blood glucose 6.9 mmol/L; ECG: Sinus bradycardia. The green channel for pre-hospital stroke care was immediately activated: blood samples were taken for testing, oxygen was administered via nasal cannula, and an intravenous line was established. The patient was quickly transported to our emergency department. Upon arrival, a head CT scan revealed no intracranial hemorrhage. Acute ischemic stroke was suspected, and intravenous thrombolysis with “alteplase 67 mg” was initiated within the time window. However, the symptoms did not improve after thrombolysis. After discussion with the family, mechanical thrombectomy was requested.

Past medical history:

The patient is healthy, denies any history of cardiovascular or cerebrovascular diseases, hypertension, or diabetes. No history of surgery or trauma.

Physical examination on admission:

Alert, but lack of fluency in speech. Muscle strength of the left limbs is grade 5, while the right limbs are grade 1. Left finger-to-nose and heel-to-shin tests are stable and accurate, but right side could not cooperate. Sensory examination is normal, and pathological reflexes are not elicited bilaterally. Scale assessments: NIHSS score: 9 points; mRS score: 4 points.

Diagnosis:
Acute ischemic stroke, location (left cerebral hemisphere), TOAST classification: (large artery atherosclerosis type);

Hypertension grade 2 (very high risk);

Cardiac arrhythmia: Sinus bradycardia.

Preoperative Imaging

Head CT scan: Grey-white matter structures appear normal in all sections, no abnormalities in cerebral sulci, midline structures are in the centre, and no abnormalities in bone structures observed.
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DSA imaging: The right ICA system and vertebrobasilar artery system show no definite abnormalities, with forward blood flow graded as 3.
DSA imaging: Left MCA, M1 segment, shows intraluminal filling defect, with forward blood flow graded as 2

Preoperative Analysis

  1. The onset of the patient’s condition is acute, symptoms are severe, and the diagnosis is clear – left MCA M1 distal occlusion. Thrombolysis has shown suboptimal results, so rapid intervention is crucial.
  2. Elderly patient with poor vascular conditions, leading to a high risk of bleeding and recurrent infarction. Therefore, it is preferable to use a simple aspiration method to remove the thrombus, minimizing damage to the vessel wall.
  3. The occlusion is located at the distal end of the left MCA, with a long travel distance for the thrombectomy procedure. The left ICA has a tortuous segment, and the catheter needs to navigate through significant bends, making it difficult for standard thrombectomy catheters to pass through.
  4. Based on experience, Hemo’s AsprAX / Afentta aspiration catheter has strong capabilities to navigate through tortuous vessels, making it suitable for the needs of this patient.

Surgical Procedure

The 8F guiding catheter tip reached the C1 segment, and the microcatheter and microwire guided Hemo’s AsprAX / Afentta 065-127cm aspiration catheter smoothly to the proximal end of the thrombus in the left MCA. The thrombus was successfully aspirated in one attempt.
After thrombus removal, angiography showed: the left MCA had a smooth vascular wall, with unobstructed blood flow graded as 3.
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Postoperative Condition

After complete awakening from anesthesia, the patient’s examination showed: clear consciousness, good mental state, clear and fluent speech, and normal performance on advanced cognitive tasks. Muscle strength of the left and right limbs was graded as 5. Finger-to-nose and heel-to-shin tests were accurate and stable, and sensory examination was normal. Babinski and Oppenheim signs were negative bilaterally. Neck resistance was absent, and Kernig and Brudzinski signs were negative. Scale assessments: NIHSS: 0 points, mRS: 0 points, ADL: 95 points, ESSEN: 2 points. The patient was transferred to the observation room.

CT imaging 5 hours post-surgery: No abnormal changes observed in various sections, and no signs of hemorrhage or edema.
6 hours postoperative MRI imaging: No definite abnormal signs observed in brain tissue on various sequences, and MRA shows patent blood vessels.

Condition Upon Discharge

The patient recovered and was discharged after one week of hospitalization. Assessment at the time of discharge:

  1. NIHSS: 0 points, mRS: 0 points, ADL: 95 points, ESSEN: 2 points;
  2. Discharged based on medical advice;
  3. Etiological classification: TOAST classification: Large artery atherosclerosis (LAA);
  4. Follow-up on changes in medical condition.

Case Summary

  1. Case Characteristics: The patient presented with acute onset and severe symptoms. Despite receiving timely intravenous thrombolysis, DSA showed incomplete recanalization of the left MCA, highlighting the significant clinical value of timely thrombus extraction.
  2. Assessment Points: Within the time window of symptom onset, CT ruled out intracranial hemorrhage timely, indicating large vessel occlusion, requiring timely DSA cerebral angiography and thrombus retrieval.
  3. Surgical Highlights: The tortuous nature of the left ICA siphon segment posed challenges. Limited high positioning of the 8F guiding catheter (at the C1 segment) and the long distance required for the aspiration catheter to reach the occlusion site added to the difficulty of achieving timely and accurate positioning.
  4. Instrument Selection Considerations: Hemo’s AsprAX /  Afentta aspiration catheter features a flexible tip, minimizing vascular wall injury. When encountering highly tortuous vessels, the coaxial alignment of microguidewires and microcatheters facilitates navigation. The large bore tip increases thrombus contact area, enhancing aspiration efficiency and playing a crucial role in achieving rapid recanalization.

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