Mechanical thrombectomy is a method of endovascular treatment of blockages in arteries, e.g. a stroke. This procedure is another, after coronary angioplasty, example of minimally invasive, endovascular techniques, which have recently been widely developed in medicine. Find out what thrombectomy is, whether it is an appropriate treatment for all people with stroke, and where it is performed.

Mechanical thrombectomyis an endovascular procedure that removes the blockage from the cerebral artery. Since the introduction of this method on a larger scale, a completely new period of treatment of strokes has begun, thanks to which we have the opportunity to help people in whom standard treatment - thrombolysis, is ineffective or contraindicated, and the stroke is extremely severe. However, it should be remembered that the key is to call for help quickly when the first symptoms of a stroke appear:

  • numbness in one hand
  • mouth corner drooping
  • speech disorder

This is due to the fact that thrombectomy also has its limitations - time. The sooner help is provided, the greater the chances of successful treatment, regardless of the treatment method selected.

A stroke is a set of symptoms caused by a brain dysfunction that results from blood circulation disorders. There are two types of stroke: it may be a hemorrhagic stroke, when there is damage to a vessel and bleeding into the brain, or an ischemic stroke. In this case, the cerebral vessels are closed by an embolus and blood does not flow to specific areas of the brain, and the source of the embolism may be atrial fibrillation or carotid atherosclerosis.

The first of these - hemorrhagic events are rare, management includes non-specific therapy: fluid treatment, patient monitoring, appropriate pharmacological treatment and sometimes neurosurgery. In the case of ischemic stroke, the treatment options are broader and more specific.

The standard of care in such a case in Poland is currently thrombolysis, i.e. dissolving the embolism with thrombolytic drugs - anticoagulants "thinning the blood".

Thrombectomy, i.e. mechanical removal of the blockage, is used when pharmacological treatment is ineffective or if it iscontraindicated.

The effectiveness of each method depends primarily on the time of its implementation, which is why it is so important to promptly proceed in the event of stroke symptoms. To ensure maximum effectiveness, the procedure should be performed within a few hours from the beginning of the symptoms. It is worth remembering that the typical symptoms of a stroke are: speech disorders, facial asymmetry, imbalance or weakening of the muscles on one side of the body. In the event of any of them, it is necessary to immediately call for medical assistance.

Hospitals performing thrombectomy

Mechanical thrombectomy is performed in highly specialized centers for several reasons. First: before performing the procedure, it is necessary to conduct thorough imaging diagnostics - tomography or MRI, not only of the cerebral vessels, but also of the aorta and arteries of the neck. This allows, first of all, to properly qualify the patient so that the procedure is effective and safe. Imaging tests are also very helpful in planning the procedure and selecting the appropriate equipment by the operator.

The procedure itself is performed in a neuroradiology room with access to X-ray radiation and the possibility of performing angiography during the procedure, it is the basic imaging technique used during thrombectomy.

Patients after such surgery require appropriate care, therefore the thrombectomy center should include, outside the neuroradiology room: a neurological ward with a stroke profile, an intensive care ward and a neurosurgery ward.

Of course, the team caring for the patient is no less important, all its members play a key role: doctors preparing the patient for the procedure, radiologists assessing imaging tests, and finally performing the procedure - most often interventional radiologists, as well as technicians and nurses who ensure appropriate conditions for the procedure to be performed.

In 2022, there were 25 centers offering thrombectomy in Poland. Let us hope that this number will increase and that a large-scale surgical treatment of strokes will be possible, as was the case with the treatment of heart attacks, when many hemodynamics laboratories were quickly organized, which significantly contributed to the effectiveness of the treatment of ischemic heart disease. . Unfortunately, the organizational requirements and the necessity to have adequate back-up facilities can be difficult to obtain in many cases.

From December 1, 2022, a pilot project of the Ministry of He alth has begun, in which it will take on seven institutions carrying outmechanical thrombectomy as part of the ER, these are:

  • Upper Silesian Medical Center in Katowice
  • Provincial Clinical Hospital No. 2 in Rzeszów
  • Independent Public Specialist Hospital of the West in Grodzisk Mazowiecki
  • Independent Public Clinical Hospital No. 4 in Lublin
  • University Hospital in Krakow
  • University Clinical Center in Gdańsk
  • Military Medical Institute in Warsaw

Who has thrombectomy?

The possibility of performing the procedure results from many conditions, and the time of its performance is crucial, which is why making the decision to use this method is so difficult. Choosing the best treatment option is based on many factors, including:

  • time from beginning of symptoms
  • current treatment of stroke
  • place of vessel closure - location of the blockage
  • stroke severity
  • comorbidities

Considering all the risks and benefits allows you to decide for whom the procedure will be safe and effective.

Thrombectomy - technique of the procedure

As mentioned, thrombectomy is performed in the neuroradiology lab. Preparation for the procedure includes shaving and disinfecting the skin in the area of ​​vascular access.

The procedure is performed under local or general anesthesia (general anesthesia), depending on the operator's preferences, both methods have their strengths and weaknesses.

The procedure begins with puncture of the femoral artery in the groin. Then, long catheters are inserted, running against the bloodstream, successively through the iliac arteries, the aorta to the carotid, internal carotid arteries, and then to the cerebral arteries, or from the aorta to the subclavian and vertebral arteries.

The procedure is performed under the control of scopies, i.e. a series of X-ray images displayed on the screen during treatments, the simultaneous administration of a contrast agent allows you to locate a thrombus - a place of limited blood flow.

Then, small baskets are inserted through the catheters, with the help of which the clot is taken and drawn out. After the procedure, the puncture site is compressed.

The very idea of ​​the procedure is not complicated, but in order to be performed effectively and safely, it requires not only a large amount of equipment (thrombectomes, catheters, balloon catheters, pumps), but also patience and precision, which is why these procedures are long-lasting.

Treatment after thrombectomy

Adequate treatment after surgery allows not only to improve he alth, but also to prevent similar episodes in the future. Aboveall it is necessary to determine the cause of a stroke, for this purpose, diagnostics of the cardiovascular system is undertaken, e.g.

  • heart rate assessment
  • echocardiographic examination
  • ultrasound of the carotid arteries
  • laboratory tests

This is to detect and treat the cause or at least to prevent any subsequent episodes. The procedure depends on the triggering factor and includes:

  • In the case of atrial fibrillation, thrombus may form in the left atrium, which may form an embolus and cause a stroke. The treatment is prophylaxis: administering anticoagulants that inhibit this process
  • in the case of carotid atherosclerosis, cholesterol deposits, drugs are used to reduce its amount and inhibit the activity of platelets, and sometimes also surgical treatment

Adequate treatment of all diseases is equally important, including e.g. systemic diseases (e.g. rheumatoid arthritis), diabetes or hypercoagulability.

Rehabilitation plays a key role in post-stroke recovery.

Complications of thrombectomy

Thrombectomy is a procedure on the delicate vessels of the brain, damage to which can have very serious consequences. As with any procedure, thrombectomy is associated with the risk of complications, they result from several aspects:

  • vascular access
  • administering a contrast agent
  • damage to the vessel with the embolism

Complications are rare and most often do not affect the effects of treatment, they include:

  • vessel puncture and intracranial hemorrhage
  • aortic damage
  • zapory
  • damage to the femoral artery
  • allergic reactions to contrast

It is, among others, due to the risk of complications, it is necessary to have adequate facilities - including neurosurgery, to implement immediate help if necessary.

Thrombectomy not only in the treatment of stroke

Another condition where this technique can be used is pulmonary embolism. The principle of the procedure is similar, the difference is the place where it is performed. In this case, the femoral vein is punctured, then a pulmonary artery catheter is inserted through the iliac, inferior vena cava, right atrium and right ventricle.

Due to the size of the vessels and the extent of the lesions, it is often not possible to remove the blockage with a basket, as is the case in small cerebral arteries.

During pulmonary thrombectomy, the material is fragmented and removed in parts. This treatment is performedusually in the hemodynamics laboratory, and the operator is usually an invasive cardiologist.

About the authorBow. Maciej GrymuzaA graduate of the Faculty of Medicine at the Medical University of K. Marcinkowski in Poznań. He graduated from university with an over good result. Currently, he is a doctor in the field of cardiology and a doctoral student. He is particularly interested in invasive cardiology and implantable devices (stimulators).

Category:

Cardiology