1. SOLITAIRE™ STENT USED AS A REVASCULARIZATION DEVICE IN ACUTE ISCHEMIC CEREBRAL STROKE MONTPELLIER PRELIMINARY EXPERIENCE
P. Machi, V. Costalat, C. Riquelme, I.L. Maldonado, A. Bonafé
CHU Montpellier (France)
I would like to share with you the results we recently had using the solitaire flow restoration system in acute stroke

2. Theoretical interests
Solitaire™FR (EV3)
Theoretical interests
immediate flow restoration (temporary endovascular bypass)
clot retrievier
May act as a temporary bypass allowing imedite ans sutained flow restoration after deployment on one hand and as aclot retriever on the other hand.The system was maintained open for 5 to10 ‘ and therafter pulled back into the guiding catheter

3. TREATMENT STRATEGY : IV FIBINOLYSIS ; MECHANICAL THROMBECTOMY( MTB)
3h-4h30
4h30-6h00
> 6h00
ICA-MCA Tandem
Combined
0.9mg/kg rt-Pa
MTB ?
T-Carot M1
Rescue* BA
Our institutional guidelines alows MTB to be associated with thrombolytics in a 4:30 hours time window in czses of terminal occlusion of ICA and at any time in cases of bailarartrey occlusion. cases of MCA oclusion that failed to improve after an IV fibrinolysis are treated with MTB provided that their NIHSS is superior to7.
*NIHSS > 7

4. EXCLUSION CRITERIA Imaging Exclusion Criteria
General Exclusion Criteria
pregnancy, NIHSS>30 or coma (except in case of basilar artery occlusion), Pl<50 000, ACT>200 seconds, allergy to contrast media, uncontrolled arterial hypertension , life expectancy<3 months, rapid clinical improvement, stent downstream the guiding catheter
Imaging Exclusion Criteria
no MRA or DSA arterial occlusion, cerebral tumor, cerebral hemorrhage, mass effect, diffusion lesion (DWI)> 50% of MCA territory e.g ASPECTS<5

5. PATIENTS Age: 62 years (35 -89) Arterial occlusion:
26 patients: 14 men, 12 women
Age: 62 years (35 -89)
Arterial occlusion:
9 Middle Cerebral Artery (M1-M2)
8 Terminal Carotid
9 Basilar Artery

6. TECHNICAL CONSIDERATIONS
General Anesthesia Femoral Approach Guiding catheter 6F for VA; 8F or 9F balloon guiding catheter for ICA (aspiration during system pull-back) Microcatheter at least .021 in of ID Microguidewire in Bolus of heparine IV (1000 IU after femoral puncture plus 1000 IU at the end of first hour) After procedure: no anticoagulation therapy at least for 24 hours, CT after the procedure and CT or MRI the day after.

7. Rebar 18 positionned
downstream from the trhombus
+5’
4:11

8. Solitaire deployment
Partial flow restoration
4:21+ {7’waiting}

9. Clot retrieval
Solitaire repositioning
4:47(+45’)
{7’waiting}
4;29

10. 4:55 (56’)

11. ANGIOGRAPHICAL RESULTS
TIMI classification
TIMI 0 = NO modification
TIMI 1 = contrast filling over the thrombus without reperfusion
TIMI 2 = partial reperfusion
TIMI 3 = total reperfusion
Angiographic target TIMI > 2
In 22/26 (84.7%) cases a TIMI score of 3 was obtained
In 1/26 (3.8%) cases a TIMI score of 2 was obtained
Mean revascularization time 57.1 min (19-260)
Number of pass on average 1.9 (1-5)
In 2/26 (7.6%) case Solitaire was not able to retrieve the entire thrombus

12. PATIENT 14 - 4 PASS - SOLITAIRE FR FAILURE

13. Site
Initial NIHSS/GCS
Strategy
Flow Restoration Attempt
Initial TIMI
Final TIMI
Time to Revasc
3 months NIHSS 1
L M1 20
Rescue 3
58 min 2
L M1 23
Combined
47 min 7 BA
GCS 4
MTB
50 min
Died 4
106 min 5 18
38 min 10 6
Left T 22
71 min
R M1
18 min 8
GCS 3
35 min 9
TEmbolic complication
31 min
43 min 25 11
R M1 12
42 min 16 13
20 min 14
FAILED ? 15
99 min 19
59 min

14. Site
Initial NIHSS/GCS
Strategy
Flow Restoration Attempt
Initial TIMI
Final TIMI
Time to Revasc (min)
3 months NIHSS 17 AB 20
Combiné 4 3 77 18
ACI T 23 75 19
ACM1
GCS 4
RESCUE 1 26  - 2 36 21
 ACM 22
ACI 8 10 EV
120 24
GCS 3 53 25 52  0 X
death  27 M1 82

15. PATIENT 6 - 3 SOLITAIRE FR PASSES – 71 MIN. TO RECANALIZE

16. PATIENT 12 – 2 SOLITAIRE FR PASSES – 42 MIN. TO RECANALIZE

17. PATIENT 1 - 1 SOLITAIRE FR PASSES – 58 MIN. TO RECANALIZE

18. PATIENT 4 - 4 SOLITAIRE FR PASSES – 106 MIN. TO RECANALIZE

19. COMPLICATIONS PER –PROCEDURAL THROMBOEMBOLIC EVENTS:
PICA (x2) occlusion after a successfull basilar artery revascularization during a combined procedure
ACA occlusion after a successfull T revascularization during a combined procedure
HEMORRHAGIC COMPLICATIONS:
PH1: MCA te occlusion angio for dural CC fistula
PH2: L-MCA infarct with subsequent hemorrhagic transformation
2) PH asymptomatic
ECASS(1and2) DEFINITIONS
HI: petechial infarction without space-occupying effect
HI1: small petechiae
HI2: more confluent petechiae
PH: hemorrhage (coagulum) with mass effect
PH1: <30% of the infarcted area with mild space-occupying effect
PH2: >30% of the infarcted area with significant space-occupying

20. First passage Second passage
PATIENT 8: GCS 3 ON ADMISSION, NIHSS 18 AT DICHARGE
BILATERAL PICA OCCLUSION after a basilar artery revascularization during a combined procedure
second passage
first passage
First passage
Second passage

21. After Before efore efore After
2)PATIENT 12:NHISS WORSENING FROM 10 IN ADMISSION TO 16 AT DISCHARGE ACA OCCLUSION AFTER T REVASCULARIZATION DURING A COMBINED PROCEDURE
After
Before
efore
efore
After

22. PROCEDURE RELATED COMPLICATIONS
Patient 4 :PH 2 ; NIHSS of 20 at discharge unchanged from admission

23. PATIENT 9 - 1 PASS - 31 MIN. TO RECANALIZE PH 1 ASYMPTOMATIC

24. CONCLUSIONS Short learning curve: friendly device
Relatively Safe and effective for M1, T, and BA occlusion
Rapid recanalization, often in one flow restoration recovery,
No vascular damages so far (mild spasm (2 cases), no subarachnoid hemorrhage, no vascular perforation)
Low incidence of technical failure
Acceptable (?) level of Thromboembolic complications due to clot fragmentation even with combined procedure associating Solitaire®+ IV rt-Pa {0.9mg/kg}