Abstract 002: Examining Pulling Force Using Combined Stentreiver and Aspiration Technique in a Medium Vessel Thrombectomy Model
Authors: Molaie Amir M. , Sakuta Kenichi , Fukuda Keiko , Imahori Taichiro , Suzuki Kentaro , Tateshima Satoshi , Kaneko Naoki 
Published: March 2024

Introduction
With the advent of smaller stent retrievers (SR) and aspiration catheters (AC) capable of accessing more distal locations, distal and medium vessel occlusions (DMVO) are emerging as promising targets for endovascular thrombectomy (EVT). However, considering the vulnerability of distal vessels to injury, it is imperative to understand the safety of various frontline techniques in these challenging scenarios. Using a vascular flow model, we sought to investigate the optimal size, strategy, and positioning of a stent retriever and aspiration catheter to minimize the pulling force exerted on the M2 vasculature.

Methods
We used a silicone vascular flow model with moderate tortuosity that replicated the left‐sided anterior circulation, including middle cerebral artery (MCA) branches in the M2 territory. An 8 French Cook Shuttle guide sheath was inserted coaxially with a Catalyst 7‐132 cm aspiration catheter and TrevoTrak 21 microcatheter. To measure pulling force, an Imada force gauge DST‐1A was placed at the M2 and a DST‐11A at the proximal end of the microcatheter. The Solitaire 4x20 mm Solitaire stent‐retriever was pulled at 4 mm/sec with the AC in the proximal cavernous carotid segment (NoAsp), proximal M1 (M1P), and distal M1 (M1D), a total of 8 times per AC position, using the ingestion technique. The pinching technique was also examined using the 4x20mm stent.

Results
The average pulling force measured on M2 using the 4x20mm stent was 169.1mN with the AC docked in the proximal NoAsp position, 26.5mN with the AC at M1P, and 23.0mN at M1D (p<0.0001). The difference in pulling force between M1P and M1D was not significant (p=0.472). The average pulling force exerted on M2 from pinching the 4x20mm stent with the AC at M1D, rather than ingestion of the stent at M1D, was 62.9mN. Average pulling force was noted to decrease from the first to the last run in most cases, with an average drop of 26.4% at the fourth run.

Conclusion
ADAPT and stent‐retrieval have recently been shown to be comparable in DMVO (1), however some studies have suggested a combined approach may reduce bleeding complications compared to stent‐retrieval alone (2). In our in‐vitro model, we demonstrated that positioning the AC in M1 (M1D or M1P) reduced the pulling force exerted by the stent‐retriever on M2 compared with AC placement in the cavernous carotid (NoAsp). The pulling force exerted from pinching the 4x20mm stent with the AC at M1D was higher than with the ingestion technique, for which the explanation is uncertain, but may be due to the additional friction in the M1 segment. Taken together, these findings suggest a combined approach decreases frictional pulling force during stent‐retrieval and is safer than SR alone. We also note that the pulling force of each stent decreased after its third usage, in line with the manufacturer’s instructions for use, which suggest no more than 3 retrievals per stent (3). Future experiments will compare a wider range of techniques using stents of varying sizes to better clarify factors associated with decreased pulling force in EVT.