Application of modified SWIM technique in mechanical thrombectomy of acute ischemic stroke

doi:10.3969/j.issn.1672-6731.2024.11.004

Abstract

Abstract:

Objective: To investigate the efficacy and safety of modified SWIM technique for mechanical thrombectomy in patients with acute ischemic stroke. Methods: Total 114 patients with acute ischemic stroke who underwent mechanical thrombectomy in The Third the People's Hospital of Bengbu from January 2021 to January 2024 were included. Modified SWIM technique (modified thrombectomy group, n=57) and conventional SWIM technique (conventional thrombectomy group, n=57) were given respectively. Vascular recanalization rate of the first thrombectomy, overall vascular recanalization rate, the number of thrombectomy, puncture-to-reperfusion time, near-term neurological deficits [National Institutes of Health Stroke Scale (NIHSS) at 14 d postoperatively] and long-term neurological prognosis [modified Rankin Scale (mRS) at 90 d postoperatively] were recorded, as well as symptomatic intracranial hemorrhage (sICH) rate and mortality. Results: The vascular recanalization rate of the first thrombectomy in modified thrombectomy group was higher than that in conventional thrombectomy group (χ²=5.054, P=0.025), the number of thrombectomy was less than (Z=2.014, P=0.044), and puncture-to-reperfusion time was shorter than (Z=2.630, P=0.009) conventional thrombectomy group. There was a statistically significant difference in NIHSS score between modified thrombectomy group and conventional thrombectomy group before and after surgery (F=5.185, P=0.025), and there was also a statistically significant difference in NIHSS score between the 2 groups at admission and 14 d after surgery (F=133.705, P=0.000). There was not an interaction between treatment factors and measurement times (F=3.148, P=0.079). The NIHSS score 14 d after surgery in modified thrombectomy group was lower than that in conventional thrombectomy group (t=2.969, P=0.004). The NIHSS score of modified thrombectomy group (t=10.286, P=0.000) and conventional thrombectomy group (t=6.428, P=0.000) were lower at 14 d after surgery than those at admission. There was a statistically significant difference in mRS score between modified thrombectomy group and conventional thrombectomy group before and after surgery (F=7.581, P=0.007), and there was also a statistically significant difference in mRS score between the 2 groups at admission and 90 d after surgery (F=277.328, P=0.000). There was an interaction between treatment factors and measurement times (F=10.471, P=0.002), and the effect of modified SWIM technique was better. Modified thrombectomy group had a better prognosis (mRS score ≤ 2) at 90 d after surgery than conventional thrombectomy group (χ²=4.267, P=0.039). There were no significant differences in the incidence of postoperative sICH rate (χ²=0.077, P=0.782) and the mortality (χ²=0.101, P=0.751) between 2 groups. Conclusions: The application of modified SWIM technique in mechanical thrombectomy has better efficacy and safety than conventional SWIM technique, and is worthy of clinical promotion.

Key words: Ischemic stroke, Thrombectomy, Stents, Prognosis

摘要：

目的: 探讨改良SWIM技术机械取栓术治疗急性缺血性卒中的有效性和安全性。方法: 纳入2021年1月至2024年1月在安徽省蚌埠市第三人民医院行血管内机械取栓术的114例急性缺血性卒中患者，分别予以改良SWIM技术（改良取栓组，57例）和常规SWIM技术（常规取栓组，57例），记录首次取栓血管再通率、总体血管再通率、取栓次数、穿刺至再灌注时间，近期神经功能缺损[术后14 d美国国立卫生研究院卒中量表（NIHSS）]和远期神经功能预后[术后90 d改良Rankin量表（mRS）]，以及症状性颅内出血发生率和病死率。结果: 改良取栓组首次取栓血管再通率高于常规取栓组（χ² = 5.054，P = 0.025），取栓次数少于（Z = 2.014，P = 0.044）、穿刺至再灌注时间短于（Z = 2.630，P = 0.009）常规取栓组。改良取栓组与常规取栓组手术前后NIHSS评分差异有统计学意义（F = 5.185，P = 0.025），两组入院时与术后14 d NIHSS评分差异亦有统计学意义（F = 133.705，P = 0.000），但处理因素与测量时间之间无交互作用（F = 3.148，P = 0.079），其中术后14 d改良取栓组NIHSS评分低于常规取栓组（t = 2.969，P = 0.004），改良取栓组（t = 10.286，P = 0.000）和常规取栓组（t = 6.428，P = 0.000）术后14 d NIHSS评分均低于入院时。改良取栓组与常规取栓组手术前后mRS评分差异有统计学意义（F = 7.581，P = 0.007），两组患者入院时与术后90 d mRS评分差异亦有统计学意义（F = 277.328，P = 0.000），且处理因素与测量时间之间存在交互作用（F = 10.471，P = 0.002），改良SWIM技术的效果更佳。改良取栓组术后90 d预后良好（mRS评分≤ 2分）率高于常规取栓组（χ² = 4.267，P = 0.039），而两组术后症状性颅内出血发生率（χ² = 0.077， P = 0.782）和病死率（χ² = 0.101，P = 0.751）差异均无统计学意义。结论: 机械取栓术中应用改良SWIM技术较常规SWIM技术具有更好的疗效且安全性相当，值得临床推广。

关键词: 缺血性卒中, 血栓切除术, 支架, 预后

Jie-men CUI, Bin YE, Xin GONG, Hong-yan ZHANG, Xuan SUN. Application of modified SWIM technique in mechanical thrombectomy of acute ischemic stroke[J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2024, 24(11): 883-893.

崔接门, 叶斌, 宫鑫, 张红艳, 孙瑄. 改良SWIM技术在急性缺血性卒中血管内机械取栓术中的应用[J]. 中国现代神经疾病杂志, 2024, 24(11): 883-893.

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URL: https://journal11.magtechjournal.com/cjcnn/EN/10.3969/j.issn.1672-6731.2024.11.004

https://journal11.magtechjournal.com/cjcnn/EN/Y2024/V24/I11/883

Figures/Tables 8

Table 1. Comparison of general data between the modified thrombectomy group and the conventional thrombectomy group

观察指标	常规取栓组（n = 57）	改良取栓组（n = 57）	统计量值	P值
性别[例（%）]			1.774	0.183
男性	30（52.63）	37（64.91）
女性	27（47.37）	20（35.09）
年龄（${\bar x}$ ± s，岁）	67.26 ± 12.92	65.81 ± 13.46	0.589	0.557
高血压[例（%）]	40（70.18）	43（75.44）	0.399	0.528
房颤[例（%）]	20（35.09）	22（38.60）	0.151	0.698
糖尿病[例（%）]	23（40.35）	24（42.11）	0.036	0.849
高脂血症[例（%）]	24（42.11）	28（49.12）	0.566	0.452
吸烟[例（%）]	23（40.35）	31（54.39）	2.252	0.133
饮酒[例（%）]	26（45.61）	25（43.86）	0.035	0.851
既往脑卒中病史 [例（%）]	35（61.40）	29（50.88）	1.283	0.257
入院时NIHSS （${\bar x}$ ± s，评分）	17.91 ± 6.75	17.00 ± 4.53	0.847	0.399
入院时mRS [M（P₂₅，P₇₅），评分]	4.00 （4.00，5.00）	4.00 （4.00，5.00）	0.458	0.796
静脉溶栓[例（%）]	15（26.32）	18（31.58）	0.384	0.536
发病至动脉穿刺时间 [M（P₂₅，P₇₅），min]	285.00 （215.00，430.00）	318.00 （213.00，439.00）	0.666	0.505

Figure 1 A 67-year-old male patient was clinically diagnosed as MCA occlusive ischemic stroke, and performed mechanical thrombectomy with conventional SWIM technique. DSA findings pre - and intra - operation and gross specimen view Preoperative anteroposterior DSA showed occlusion of the M1 segment of right MCA (arrow indicates, Panel 1a). Microguidewire and microcatheter cautiously passed through the occlusion segment and withdraw the microguidewire, microcatheter DSA roadmap showed smooth blood flow at the distal end of the occlusion, located in the true cavity (Panel 1b). During operation, the Solitaire FR thrombectomy stent was sent to the M1-M2 segment of right MCA, and the stent was released routinely. After 5 min, the intermediate catheter followed up to the proximal end of the thrombus, and under continuous negative pressure aspiration, firstly withdraw the thrombectomy stent and microcather, and then withdraw the intermediate catheter (Panel 1c). Intraoperative anteroposterior (Panel 1d) and lateral (Panel 1e) DSA showed smooth blood flow in the right MCA, and mTICI was grade 3. Gross specimen view of thrombus removal (Panel 1f).

Figure 2 Schematic diagram of PFT The unsheathed method of retracting the delivery microcatheter and meanwhile releasing the stent, the diameter of the stent is about 1.91 mm (Panel 2a). Mesh of conventional release stent (Panel 2b). Standard unsheathed technology releases the front section of the stent, so that the stent is anchored and actively pushed the stent forward to deliver microguidewire. The microcatheter automatically retreats due to tension until the stent is completely released, changing the shape of the thrombectomy stent. The diameter of the stent is about 3.34 mm, an increase of 75% (Panel 2c). After the stent is released by PFT, the mesh area increases by 51%, the diameter and the mesh area of the stent increase, which can better adhere to the wall of the blood vessel, so as to combine the thrombus more completely (Panel 2d).

Figure 3 Schematic diagram of BWT After routine stent release, the delivery microcatheter is retained, and intermediate catheter aspiration is performed while the stent is withdrawn (Panel 3a). Using the anchoring effect of the stent, the stent delivery microguidewire is retained, the microcatheter is withdrawn, and then intermediate catheter aspiration is performed while the stent is withdrawn. Only the stent delivery guide wire is retained in the intermediate catheter, which increases the lumen area of the intermediate catheter. Greater negative pressure suction force can be obtained by pumping through the intermediate catheter to improve the success rate of thrombectomy (Panel 3b).

Figure 4 A 71-year-old male patient was clinically diagnosed as left MCA occlusive ischemic stroke, and performed mechanical thrombectomy with modified SWIM technique. DSA findings pre- and intra - operation and gross specimen view Preoperative anteroposterior DSA showed occlusion of the M1 segment of left MCA (arrow indicates, Panel 4a). During surgery, the microguidewire and microcatheter were discreetly passed through the occlusion segment, withdraw the microguidewire, Solitaire FR thrombectomy stent delivered to the M1- M2 segment of left MCA, using PFT to release the stent (Panel 4b). Slowly withdraw the microcatheter after 5 min, follow up with the intermediate catheter to the proximal end of the thrombus, using BWT to recover the stent under continuous negative pressure aspiration in the intermediate catheter, then withdraw the intermediate catheter (Panel 4c). Intraoperative anteroposterior (Panel 4d) and lateral (Panel 4e) DSA showed left MCA had smooth blood flow, and mTICI was grade 3. Gross specimen view of thrombus removal (Panel 4f).

Table 2. Comparison of vascular recanalization rate, number of thrombectomy and puncture-to-reperfusion time between the modified thrombectomy group and the conventional thrombectomy group

组别	例数	首次取栓血管再通率 [例（%）]	总体血管再通率 [例（%）]
常规取栓组	57	22（38.60）	50（87.72）
改良取栓组	57	34（59.65）	52（91.23）
χ²或Z值		5.054	0.373
P值		0.025	0.542

组别	例数	取栓次数 [M（P₂₅，P₇₅），次]	穿刺至再灌注时间 [M（P₂₅，P₇₅），min]
常规取栓组	57	2.00（1.00，3.00）	60.00（40.50，82.50）
改良取栓组	57	1.00（1.00，2.00）	45.00（31.50，66.50）
χ²或Z值		2.014	2.630
P值		0.044	0.009

Table 3. Comparison of NIHSS and mRS scores before and after operation between the modified thrombectomy group and the conventional thrombectomy group (${\bar x}$ ± s, score)

组别	例数	NIHSS		mRS
组别	例数	入院时	术后14 d	入院时	术后90 d
常规取栓组	57	17.91 ± 6.75	12.11 ± 5.77	4.35 ± 0.52	2.86 ± 1.23
改良取栓组	57	17.00 ± 4.53	9.09 ± 5.07	4.33 ± 0.48	2.12 ± 1.24

Table 4. ANOVA of premeasure-postmeasure design of NIHSS and mRS scores before and after surgery between the modified thrombectomy group and the conventional thrombectomy group

变异来源	SS	df	MS	F值	P值
NIHSS
处理因素	220.070	1	220.070	5.185	0.025
测量时间	2682.123	1	2682.123	133.705	0.000
处理因素×测量时间	63.158	1	63.158	3.148	0.079
组间误差	4753.772	112	42.444
组内误差	2246.719	112	20.060
mRS
处理因素	8.110	1	8.110	7.581	0.007
测量时间	195.268	1	195.268	277.328	0.000
处理因素×测量时间	7.373	1	7.373	10.471	0.002
组间误差	119.807	112	1.070
组内误差	78.860	112	0.704

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