Local Intra-arterial Thrombolysis during Mechanical Thrombectomy for Refractory Large-Vessel Occlusion: Adjunctive Chemical Enhancer of Thrombectomy

Article Figures & Data

Download figure
Open in new tab
Download powerpoint
FIG 1.
Flow chart of patient selection. EVT indicates endovascular treatment.
Download figure
Open in new tab
Download powerpoint
FIG 2.
Comparison of successful reperfusion rates according to the total number of passes between the 2 groups.
Download figure
Open in new tab
Download powerpoint
FIG 3.
A, A-63-year-old male patient with acute stroke due to left MCA proximal M2 occlusion (arrow). B, Left ICA angiogram obtained after SR thrombectomy (twice) and CA thrombectomy (twice) (not shown) still shows complete occlusion at the left MCA M2 segment. C, Intra-arterial urokinase (40,000 IU) is injected through a 0.021-inch microcatheter from the distal-to-proximal portion of the thrombus. D, After completion of urokinase administration, additional SR thrombectomy followed (not shown). The angiographic morphology of the thrombus is changed, and minimal recanalization is achieved (arrow). E and F, After 1 more attempt of SR thrombectomy, complete recanalization is achieved.

Table 1:

Baseline characteristics between the 2 groups^{^a}

	Total (n = 114)	UK Group (MT+UK+MT) (n = 45)	Non-UK Group (MT+MT) (n = 69)	P Value
Age^{^b}	75 (65–81)	74 (63–81)	75 (65–82)	.615
Male	56 (49.1)	21 (46.7)	35 (50.7)	.672
Risk factor
Hypertension	59 (51.8)	23 (51.1)	36 (52.2)	.912
Diabetes	27 (23.7)	12 (26.7)	15 (21.7)	.545
Dyslipidemia	20 (17.5)	10 (22.2)	10 (14.5)	.289
Smoking	15 (13.2)	7 (15.6)	8 (11.6)	.541
Coronary artery disease	9 (7.9)	3 (6.7)	6 (8.7)	1.000
Atrial fibrillation	72 (63.2)	26 (57.8)	46 (66.7)	.336
TOAST
LAA	0 (0.0)	0 (0.0)	0 (0.0)
CA	77 (67.5)	29 (64.4)	48 (69.6)	.568
SUD	19 (16.7)	6 (13.3)	13 (18.8)	.441
Cancer-related stroke	17 (14.9)	9 (20.0)	8 (11.6)	.218
IV tPA	29 (25.4)	9 (20.0)	20 (29.0)	.282
Admission NIHSS^{^b}	15 (12–18)	15 (10–18)	15 (12–19)	.080
Baseline ASPECTS^{^b}	8 (7–9)	8 (7–9)	8 (7–9)	.328
Occlusion site				.182
ICA	42 (36.8)	12 (26.7)	30 (43.5)
M1	45 (39.5)	20 (44.4)	25 (36.2)
M2	27 (23.7)	13 (28.9)	14 (20.3)

Note:—TOAST indicates Trial of Org 10172 in Acute Stroke Treatment³¹; LAA, large-artery atherosclerosis; CA, cardioembolism; SUD, stroke of undetermined etiology.
↵a Values in parentheses represent the number of patients (%).
↵b Data are median and numbers in parentheses are IQR.

Table 2:

Procedural characteristics in the UK group

Table 3:

Procedural and clinical outcomes between the 2 groups^{^a}

	Total (n = 114)	UK Group (MT+UK+MT) (n = 45)	Non-UK Group (MT+MT) (n = 69)	P Value
Onset to puncture time (min)^{^b}	158 (110–413)	182 (122–412)	149 (102–420)	.561
Procedure time^{^b}	62 (42–93)	54 (39–88)	69 (49–113)	.137
Onset to reperfusion time^{^b}	253 (169–491)	254 (195–481)	231 (164–503)	.561
First-line technique				.533
SR	72 (63.2)	31 (68.9)	41 (59.4)
CA	29 (25.4)	9 (20.0)	20 (29.0)
Combined technique	13 (11.4)	5 (11.1)	8 (11.6)
Rescue therapy	78 (68.4)	27 (60.0)	51 (73.9)	.118
Switch to SR	24 (21.1)	9 (20.0)	15 (21.7)
Switch to CA	23 (20.2)	8 (17.8)	15 (21.7)
Switch to SR+CA	34 (29.8)	10 (22.2)	24 (34.8)
Total No. of passes^{^b}	5 (5–6)	6 (5–6)	6 (6–7)	.289
4–5 Passes	49 (43.0)	22 (48.9)	27 (39.1)	.304
6–7 Passes	46 (40.4)	17 (37.8)	29 (42.0)	.651
≥8 Passes	19 (16.7)	6 (13.3)	13 (18.8)	.441
Other adjuvant treatments	22 (19.3)	7 (15.6)	15 (21.7)	.414
Final reperfusion status
2b–3	81 (71.1)	37 (82.2)	44 (63.8)	.034
3	28 (24.6)	16 (35.6)	12 (17.4)	.044
mRS at 90 days^{^b}	3 (2–5)	3 (1–4)	3 (2–5)	.352
mRS 0–2 at 90 days	41 (36.0)	17 (37.8)	24 (34.8)	.745
Mortality at 90 days	16 (14.0)	7 (15.6)	9 (13.0)	.706
Vessel perforation	2 (1.8)	1 (2.2)	1 (1.4)	1.000
Dissection	5 (4.4)	1 (2.2)	4 (5.8)	.647
ICH	15 (13.2)	5 (11.1)	10 (14.5)	.602
SAH	7 (6.1)	2 (4.4)	5 (7.2)	.702
HI1 or HI2	20 (17.5)	7 (15.6)	13 (18.8)	.652
PH1 or PH2	8 (7.0)	2 (4.4)	6 (8.7)	.476

Table 4:

Multivariable analysis of successful reperfusion in patients with multiple passes (≥4) of mechanical thrombectomy

	Successful Reperfusion (mTICI 2b/3)
	Adjusted OR (95% CI)	P Value
Age	1.018 (0.971–1.066)	.463
IV tPA	0.773 (0.240–2.485)	.665
Baseline NIHSS	0.986 (0.881–1.104)	.806
ICA occlusion	1.287 (0.405–4.091)	.669
Onset to puncture time	0.999 (0.997–1.001)	.385
Procedure time	0.980 (0.962–0.998)	.026
Rescue therapy	0.816 (0.252–2.961)	.816
No. of passes	0.778 (0.538–1.125)	.182
Distal embolism	0.828 (0.248–2.765)	.759
Intra-arterial urokinase	3.682 (1.156–11.730)	.027