WSC 2022 | Renewed interest in intra-arterial thrombolysis to optimize mechanical thrombectomy
Adnan Qureshi, MD, University of Missouri-Columbia, School of Medicine, Columbia, Missouri, discusses the growing interest in the use of intra-arterial thrombolysis. Data suggests that there are two groups of patients following mechanical thrombectomy (MT): one group has no recanalization and the other group has successful opening of the occluded vessel, yet abnormal tissue perfusion remains due to occlusion at a microvascular level which increases the risk of ischemia. Considering this, some researchers propose that intra-arterial thrombolysis should be combined with mechanical thrombectomy. There is some initial evidence to support that this practice would be more effective than mechanical thrombectomy alone, however more data is required to ascertain this. More data is also needed to determine which patients would be most suited to a combination of intra-arterial thrombolysis and MT: those with no recanalization after thrombectomy or those with suboptimal perfusion following recanalization. This interview took place at the World Stroke Congress 2022 in Singapore.
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Transcript (edited for clarity)
Interestingly, there is a renewed interest in intra-arterial thrombolysis. Obviously, when endovascular treatment for acute ischemic stroke was first initiated, it initiated with intra-arterial thrombolysis, meaning it was simply putting in a microcatheter and injecting thrombolytic medication into the clot. Then as the devices for mechanical thrombectomy became more and more effective, intravenous thrombolysis kind of became… Some people actually used to give intravenous thrombolysis...
Interestingly, there is a renewed interest in intra-arterial thrombolysis. Obviously, when endovascular treatment for acute ischemic stroke was first initiated, it initiated with intra-arterial thrombolysis, meaning it was simply putting in a microcatheter and injecting thrombolytic medication into the clot. Then as the devices for mechanical thrombectomy became more and more effective, intravenous thrombolysis kind of became… Some people actually used to give intravenous thrombolysis. Some actually just relied on using the devices alone.
But now there is actually new data coming in that when patients actually get mechanical thrombectomy, there’s two groups of patients. One actually have no recanalization despite multiple efforts with mechanical thrombectomy. Then the second group, they actually opened the occluded blood vessel with mechanical thrombectomy, but nonetheless, the tissue perfusion is not normal. There is occlusion at microvascular and small vessel level, which obviously, mechanical thrombectomy cannot do anything further. But nonetheless, that is actually preventing the tissue from receiving the proper oxygen or appropriate blood supply, so the tissue still is at risk for ischemia.
Now the thought process is that maybe we should combine them together. So we do the mechanical thrombectomy, and we also do intra-arterial thrombolysis at parts of the procedure. Obviously, there is some initial data to support that yes, that practice would actually be superior to mechanical thrombectomy alone. More data is required. I think it’s also required that which patients intra-arterial thrombolysis is the most benefit. These patients who have no recanalization after mechanical thrombectomy, and then intra-arterial thrombolysis will actually assist in recanalization? Or these patients who have recanalization on mechanical thrombectomy, but the results are suboptimal, and there is still a risk of tissue ischemia because the micro vessel and small vessels have not recanalized? Then how do you make that judgment that the tissue perfusion is adequate or not, based on a classic angiogram, which may not be sensitive enough to detect these abnormalities?
I think that’s where the field is heading. I think that the question about intravenous thrombolysis prior to mechanical thrombectomy still remains an open question. I think that mechanical thrombectomy, and a lot of people are using the term optimization, that we have to optimize mechanical thrombectomy. And if optimization means administering intra-arterial thrombolytics to achieve the best tissue perfusion, then essentially, we have to incorporate that as part of mechanical thrombectomy.
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