Enhancing thrombectomy outcomes with Adaptive Pulsatile Aspiration (APA): the role of complete clot ingestion in reducing thrombectomy time and distal embolization

BACKGROUND: Complete clot ingestion (CCI) is defined as full ingestion of the clot into the catheter or pump canister without any external clot remnants at the catheter tip. The aim of this study was to demonstrate that using the CCI metric in vitro, partially ingested ('corked') clots pose a higher risk of distal emboli given distal emboli may exist in the setting of Thrombolysis In Cerebral Infarction 3 (TICI 3) revascularization. METHODS: Thrombectomies using an in vitro synthetic clot analog were conducted across six catheters using the novel ALGO Smart Pump with Adaptive Pulsatile Aspiration (APA) (Von Vascular Inc, Sunrise, FL) and compared against the Penumbra static Engine Pump (Alameda, CA). RESULTS: A total of 360 aspiration thrombectomies were completed with an overall CCI rate of 56.9%. Cases achieving CCI were significantly faster (P<0.001) and those with successful CCI had no instances of distal embolization, whereas cases with incomplete clot ingestion ('corking') showed a 5.2% rate of distal embolization (P<0.001). The overall rate of first pass effect was comparable between two systems. ALGO's APA mode achieved a significantly higher rate of CCI compared with the Penumbra Engine Pump's continuous aspiration (77.2% vs 36.7%, P<0.001), as well as shorter mean aspiration (43.7 s vs 73.2 s, P<0.001). Additionally, these trends were also reflected across all individually tested catheter types between the pump systems. CONCLUSIONS: Our findings demonstrate that CCI is a feasible and valuable metric for assessing thrombectomy efficacy in vitro, resulting in more favorable CCI outcomes with the ALGO system compared with the Penumbra system.