Further Development of Combined Techniques Using Stent Retrievers, Aspiration Catheters and BGC: The PROTECT^PLUS Technique

Purpose: First pass complete (mTICI 3) reperfusion must be regarded as the ultimate goal in mechanical thrombectomy (MT) in patients suffering from an emergent large vessel occlusion (ELVO). With this in mind a technical modification of the previously published PROTECT (PRoximal balloon Occlusion TogEther with direCt Thrombus aspiration during stent retriever thrombectomy) approach, the PROTECT^PLUS technique was evaluated. Under proximal flow arrest using a balloon guide catheter (BGC), a stent retriever was only partially inserted into a large-bore aspiration catheter. This construction was subsequently retracted as a unit into the BGC with aspiration both at the aspiration catheter and at the BGC. Methods: A case-control study was performed comparing the PROTECT technique with the PROTECT^PLUS technique with respect to the technical and procedural parameters. Patients n = 165 (101 PROTECT, 64 PROTECT^PLUS) with ELVO of either the terminus of the internal carotid artery or the proximal middle cerebral artery were included. Results: Using the PROTECT^PLUS resulted in a higher rate of first pass complete reperfusions (59.4% vs. 27.7%, p < 0.001) as compared with PROTECT. The PROTECT^PLUS also led to shorter procedure times (21 min vs. 37 min, p = 0.001) and higher rates of overall complete reperfusion (73.5% vs. 49.5%, p = 0.014) compared to PROTECT. Conclusion: The PROTECT^PLUS technique is a promising technical modification to further optimize endovascular stroke treatment.