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En los últimos años se ha demostrado la efectividad y el beneficio de la extracción del trombo, que ocluye un vaso grande cerebral, trombectomía mecánica por acceso endovascular. El beneficio es tal que en la edición del 10 de Febrero del 2023 del "The New England Journal of Medicine" se publican dos ensayos clínicos que fueron detenidos antes de completar el número total de pacientes, dado el beneficio encontrado de la trombectomía mecánica, en comparación con el tratamiento médico exclusivo. En Chile no contamos con una cobertura nacional para que la población pueda acceder a este tratamiento. Proponemos una alternativa de implementación progresiva de este tratamiento, dada la extensión de la ventana terapéutica demostrada recientemente.

Purpose PROMISE study aimed to observe the safety and effectiveness of Penumbra System (PS) with ACE68 and ACE64 Reperfusion Catheters in patients with acute ischemic stroke (AIS) from large vessel occlusion (LVO), treated with ADAPT (A Direct Aspiration First Pass Technique) as front-line treatment. Materials and methods This was a prospective, single-arm, multicenter study across 20 European centers. Inclusion criteria were anterior circulation LVO within 6 hours of ictus; NIHSS≥2; CT-ASPECTS ≥6; or MR-ASPECTS ≥5. Primary endpoints included success in angiographic revascularization (mTICI 2b-3), and clinical independence (mRS 0–2) at 90 days. Secondary endpoints included safety events, functional improvement at 7–10 days, procedural metrics and quality of life. mTICI scores and safety endpoints were adjudicated by core laboratory and clinical events committee, respectively. Results A total of 204 patients were enrolled. Median age was 74 [IQR 65–80]. Primary occlusion vessels were 17.2% (35/204) patients with ICA occlusion, 3.9% (8/204) with Carotid T, 60.8% (124/204) with M1% and 18.1% (37/204) with M2. Median baseline CT ASPECT score was 9 [IQR 8–10]. Median baseline and 7–10 day NIHSS scores were 16 [IQR 11–20] and 3 [IQR 1–8], respectively. A reduction of ≤10 points or 7–10 days NIHSS of 0–1 was reported in 67.9% (127/187) patients. Prior to endovascular procedure, IV rtPA was administered in 61.8% (126/204) patients. After PS treatment, 70.3% (142/202) patients achieved mTICI 2b/3. Final revascularization (mTICI 2b/3) was achieved in 93.1% (188/202). Revascularization to mTICI 2 c/3 was achieved 63.9% (129/202). Median time from stroke to revascularization (mTICI 2b/3) was 245.5 min [IQR 192–305]. Median time from puncture to revascularization (mTICI 2b/3) was 31 min [IQR 20–53]. Day-90 mRS of 0–2 was achieved in 61.0% (122/200). In the subgroup analysis by occlusion location, final revascularization (mTICI 2b/3) in the ICA/Carotid T was 95.2% (40/42) and 90 day mRS of 0–2 was achieved in 64.3% (27/42), final revascularization (mTICI 2b/3) in the MCA M1 was 92.7% (114/123) and 90 day mRS of 0–2 was achieved in 57.0% (69/121) and the final revascularization (mTICI 2b/3) in the MCA M2 was 91.9% (34/37) and 90 day mRS of 0–2 was achieved in 70.3% (26/37). There was no significant difference in the safety rates by treatment location. Safety rates were favorable (sICH=2.9%; ENT=1.5%). 90 day morbidity, defined as mRS score (3–5), was observed in 31.5% (63/200). 90 day all cause-mortality was observed in 7.5% (15/200). Device and procedure-related SAEs were reported in 2.0% (4/204) and 4.9% (10/204), respectively. No deaths were device-related. Conclusion PROMISE study demonstrated safety and efficacy with latest generation of PS Reperfusion Catheters (ACE68/64) in patients with acute ischemic stroke from large vessel occlusion, using ADAPT as front-line treatment. Disclosures P. Navia: 2; C; Penumbra Inc. P. Schramm: 2; C; Penumbra Inc. R. Papa: None. J. Parra: None. A. Weitz: None. W. Weber: None. J. Fiehler: None. P. Michel: None. V. Pereira: None. T. Krings: None. L. Pierot: None. J. Gralla: None. P. Santalucia: None. T. Lo: None.

Introduction: Safe and complete recanalization is important to reduce clot burden and determines functional prognosis of patients with cerebral infarction from large vessel occlusions (LVO). The aim of PROMISE is to evaluate the safe and effective use of the aspiration-based Penumbra System with the latest generation of ACE Reperfusion Catheters in a real world population with acute ischemic stroke from anterior circulation LVO, treated with the ADAPT technique in routine practice. Methods: The prospective, single-arm, multicenter PROMISE registry evaluated the Penumbra System with ACE64 and ACE68 catheters across 20 European centers. Criteria for inclusion include presentation of anterior circulation LVO within 6 hours of ictus, NIHSS ≥ 2, ASPECTS ≥ 6 and wherein intervention was proceeded with ADAPT as frontline. Primary endpoints include angiographic revascularization to TICI 2b-3, and clinical independence (mRS 0-2) at 90 days. Secondary endpoints include safety events, functional improvement at 7-10 days, procedural metrics and quality of life. Results: A total of 202 patients were enrolled for evaluation of this interim analysis. Table I details patient history and baseline characteristics. Prior to endovascular procedure, IV rtPA was administered in 61.9% of patients. A final revascularization mTICI 2b-3 was achieved in 96.5% (194/201), per investigator assessment. Of these, mTICI 3 was achieved in 68.2% (137/201). Mortality was observed in 15 of the 141 (10.6%) patients at this interim analysis. Patient follow-up data collection, including clinical outcome, will be completed by the end of 2017. Core lab adjudicated results will be available at time of presentation. Conclusion: Interim analysis of the PROMISE registry demonstrated safe and effective utility of the Penumbra System with the novel ACE64 and ACE68 Reperfusion Catheters using ADAPT as frontline treatment. All follow up visits and final results will be presented at the ISC conference.

BACKGROUND: The REVASCAT trial and other studies have shown that the neurovascular thrombectomy improves outcomes at 90 days post stroke. However, whether the observed benefit is sustained in the long term remains unknown. We report the results of the prespecified 12-month analysis of the REVASCAT trial. METHODS: Patients with acute ischaemic stroke who could be treated within 8 h of symptom onset were randomly assigned to medical therapy (including intravenous alteplase when eligible) and neurovascular thrombectomy with Solitaire FR or medical therapy alone. The main secondary outcome measure at 1 year follow-up was disability, measured using the modified Rankin Scale (mRS), ranging from 0 (no symptoms) to 6 (death) with categories 5 (severe disability) and 6 (death) collapsed into one category (severe disability or death), analysed as the distribution of the mRS. Additional prespecified secondary outcome measures included health-related quality of life measured with the EuroQol five dimensions questionnaire (EQ-5D) utility index (ranging from -0.3 to 1, higher values indicate better quality of life), the rate of functional independence (mRS 0-2), and cognitive function measured with the Trail Making Test (reported elsewhere). Treatment allocation was open label but endpoints at 12 months were assessed by masked investigators. The trial was registered at ClinicalTrials.gov, number NCT01692379. FINDINGS: From Nov 24, 2012, to Dec 12, 2014, 206 patients were randomly assigned to medical therapy plus endovascular treatment (n=103) or medical treatment alone (n=103), at four centres in Catalonia, Spain. At 12 months post randomisation, based on 205 of 206 outcomes available at 12 months, thrombectomy reduced disability over the range of the mRS (common adjusted odds ratio [aOR] 1.80, 95% CI 1.09-2.99), and improved functional independence (mRS=0-2; 45 [44%] of 103 patients vs 31 [30%] of 103 patients; aOR 1.86, 95% CI 1.01-3.44). Health-related quality of life was superior in the thrombectomy group (mean EQ-5D utility index score, 0.46 [SD 0.38] in the thrombectomy group vs 0.33 [0.33] in the control group, difference 0.12 [95% CI 0.03-0.22]; p=0.01). 1-year mortality was 23% (24 of 103 patients) in the thrombectomy group versus 24% (25 of 103 patients) in the control group. INTERPRETATION: At 12 months follow-up, neurovascular thrombectomy reduced post-stroke disability and improved health-related quality of life, indicating sustained benefit. These findings have important clinical and public health implications for evaluating the cost-effectiveness of the intervention in the long term. FUNDING: Fundacio Ictus Malaltia Vascular through an unrestricted grant from Medtronic.

The endovascular technique is the gold standard treatment in dural arteriovenous fistulas. Due to the limited number of series published it is difficult to create rigid guidelines in terms of the best endovascular treatment approach. Treatment must be tailored to each particular case, but it is important to keep in mind that the possibility of treating a type V dAVF by the transvenous approach should not be discarded. In selected cases the transvenous approach may be helpful to increase the chance of success in the endovascular treatment of type V dAVF. We describe a patient in whom the first arterial treatment failed to achieve occlusion of the fistulous point with the glue. Clinical symptoms improved due to the diminished flow at the fistula after the first embolization but as soon as collateral arteries were recruited by the fistula, spinal cord venous drainage impairment led to symptoms recurrence. Transvenous access allowed us to close the fistula completely in one only session with a complete disappearance of the pathologically inverted perimedullary venous flow.