Thrombectomy Techniques: Remote Aspiration

While recent major trials have demonstrated the efficacy of thrombectomy for the treatment of emergent large vessel occlusion (ELVO), major technical aspects of the endovascular procedure used to achieve revascularization vary significantly. Balloon-guide catheters (BGCs) were initially brought into use as a means of temporarily arresting antegrade flow to improve the ability of the operator to extract clot from the intracranial vessels. In addition, BGCs limit embolization to new territories (ENT), as during the clot extraction, portions of the thrombus may break off and travel distally, potentially resulting in re-occlusion of the target artery or occlusion of previously unaffected vessels. For proximal internal carotid (and sometimes middle cerebral) artery occlusions, BGCs can serve as a standalone mechanism for thrombectomy when coupled with aspiration. This concept of “remote aspiration,” in which the inflated BGC arrests flow and then direct aspiration of the BGC functions to reverse flow, is a technically straightforward technique, which, when effective, results in prompt and efficient revascularization without the need of and potential risks associated with distal intracranial catheter manipulation.