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IntroductionFinancial considerations are important in acute ischemic stroke (AIS) care. Mechanical thrombectomy (MT) devices and techniques for large vessel occlusion (LVO) have evolved over time, with variability in direct and indirect costs associated with MT. This study evaluates the cost effectiveness of MT using the Monopoint system (Route 92 Medical, San Mateo, CA) compared to traditional contact aspiration (CA) and stentriever/aspiration (SA) approaches.MethodsA retrospective analysis of AIS patients treated with MT across four high-volume stroke centers was conducted. Patients with ICA terminus or M1 occlusions were categorized into Monopoint, CA, or SA groups. Direct device costs and indirect hospital costs were obtained from institutional databases. Statistical analyses included mixed-effects linear regression and multivariable modeling.ResultsAmong 148 patients (Monopoint: 74, CA: 32, SA: 42), device costs were lowest for Monopoint ($7,836 ± 4570) vs. CA ($10,089 ± 6078, p<0.001) and SA ($19,069 ± 4730, p<0.001). Indirect hospital costs followed a similar trend (Monopoint: $27,089 ± 19,899, CA: $28,883 ± 14,161, p<0.001, SA: $63,327 ± 72,440, p<0.001). The Monopoint system demonstrated higher rates of final eTICI2C/3 (85.1% vs. 62.5% CA, 71.4% SA, p<0.001) and fewer passes (1.8 vs. 2.0, p=0.001).ConclusionFirst-line MT with the Monopoint system is cost-effective, with lower direct and indirect costs compared to CA and SA approaches. These lower costs were noted despite longer hospital stays in the Monopoint group that were likely the result of higher rates of patients with large core infarcts. Cost savings were driven by procedural efficiency and higher recanalization rates. These findings highlight the economic benefits of optimized MT strategies in AIS treatment.DisclosuresJ. Kim: None. F. Settecase: 2; C; Route 92 Medical. 4; C; Route 92 Medical. W. Kim: 2; C; Route 92 Medical. 4; C; Route 92 Medical. J. English: 2; C; Route 92 Medical. 4; C; Route 92 Medical. M. Alexander: 2; C; Route 92 Medical, Medtronic, Cerenovus, Certus Critical Care. 4; C; Route 92 Medical, Certus Critical Care, Piraeus Medical.

PurposeDespite limited evidence of improved outcomes, endovascular treatment is often performed in dural venous sinus thrombosis (DVST) patients with clinical or imaging evidence of deterioration after medical therapy. Clinical trials have not shown improved outcomes using thrombolytic infusion, balloon angioplasty, or mechanical thrombectomy with stent-retrievers. We describe our first-in-human experience using a super-large bore 0.088’ inner diameter (ID) catheter, HiPoint 088, delivered using a tapered shelf-reducing catheter, Tenzing 8, through a 0.10’ BaseCamp guide sheath (Route 92, San Mateo, CA) in DVST patients.MethodsAfter local IRB approval, we retrospectively reviewed clinical, procedural and imaging data of patients who underwent endovascular therapy for DVST with the BaseCamp, HiPoint 088, and Tenzing 8 our institutions from 2021-2022.ResultsFour patients were identified, all female, average age 33±11 years. Each patient had extensive clot burden with complete thrombosis of the superior sagittal sinus (SSS), dominant transverse and sigmoid sinus and jugular bulb, as well as the deep cerebral veins. Two patents had deteriorated to coma immediately pre-procedure. One patient presented with headache progressing to bilateral CNVI palsies, papilledema and vision changes. The fourth patient presented with headache, papilledema and vision changes. All were started on heparin IV infusions. Off-label aspiration thrombectomy was performed using the Tenzing 8, HiPoint 088, Basecamp system. In two cases, the initial 6-7 passes were performed using vacuum aspiration of the Basecamp alone in the high cervical jugular vein/bulb. Subsequent passes were performed by delivering the HiPoint 088 using the Tenzing 8 into the sigmoid sinus and transverse sinus in three cases, and into the SSS in two cases. In one patient, as the HiPoint 088 could not navigate through bilaterally tortuous small caliber jugular-sigmoid sinus anatomy, a HiPoint 070-Tenzing7 were inserted through the HiPoint 088 in telescoping fashion to reach the bilateral sigmoid and transverse sinuses and torcula for 15 AT passes. In all four patients, venous outflow restoration was achieved with no complications. Good clinical outcome were seen at 90 days: 3 patients mRS 0, one with mRS 1. The average number of passes was 11±5. Average procedure time was 203 minutes.ConclusionsThe design features of Tenzing 8, HiPoint 088, and BaseCamp, and improve deliverability of a super large bore catheters into the dural venous sinuses, increased aspiration force, and resulted in efficacious venous sinus flow restoration in the setting of DVST with large thrombus burden. Further study in larger patient cohorts is warranted.Abstract E-159 Figure 1Disclosures F. Settecase: 2; C; Stryker, Route 92. W. Kim: 2; C; Stryker, Route 92. 4; C; Route 92. R. Khangura: None. J. English: 2; C; Stryker, Route 92. 4; C; Route 92.

IntroductionIntracranial atherosclerotic disease (ICAD), characterized by arterial stenoses, greatly increases risk for ischemic stroke, a leading cause of disability and mortality in the US. The BASIS trial revealed balloon angioplasty of symptomatic ICAD to be superior to aggressive medical therapy alone in reducing 30-day stroke recurrence rates. The Tenzing (Route 92 Medical, San Mateo, CA) catheter is a soft, tapered tip delivery catheter which can navigate through tortuous anatomy and guide large-bore aspiration catheters to sites of intracranial occlusion. This study describes a novel percutaneous transluminal Dotter angioplasty technique of ICAD lesions using Tenzing -Tenzingplasty - in emergent and elective patients with known symptomatic ICAD.ObjectiveThis study reviews the effectiveness and safety of the novel Tenzingplasty technique in elective and emergent treatment of ICAD lesions.MethodsIn a retrospective two-centered study, all patients who underwent Tenzingplasty for ICAD from January 2024 to March 2025 were reviewed. This study included both chronic and acute symptomatic ICAD patients, excluding patients undergoing emergent mechanical thrombectomy. Patients’ demographics, clinical course, and radiographic findings were reviewed. Two-tailed student T-test, mean difference, and confidence intervals (CI) were calculated to compare values when appropriate with a statistically significant threshold of p<0.05.ResultsThirty patients with an average age of 64.5 ± 11 years, 53% (16) male, underwent Tenzingplasty of ICAD at our institution; 18 (60%) had hypertension, 12 (40%) had hyperlipidemia, 12 (40%) had diabetes, and 6 (20%) were smokers. Eleven (37%) patients were experiencing acute symptoms from severe ICAD stenosis and 63% presented with chronic symptomatic disease latest onset within 72-hours. A total of 30 vessels were treated, 26 involving the anterior circulation (21 middle cerebral arteries, 5 internal carotid arteries) and 4 involving the posterior circulation (one vertebral and three posterior cerebral artery). A Tenzing 7 Catheter was used in all cases and was kept across the ICAD stenosis for 2-minutes. No immediate or short-term complications were noted. Twenty-four (80%) of the vessels required only one Tenzingplasty pass to keep the vessel open, 6 (20%) required two passes. The average immediate post- Tenzingplasty improvement in vessel stenosis was 32%; pre-treatment 0.8 ± 0.4 mm vs post-treatment 1.4 ± 0.4 mm (mean-difference 0.6 mm, CI=0.4–0.9, p<0.001). The average modified Rankin Scale (mRS) of all patients on discharge was 1.5 ± 1.1 with an average of 1.1 ± 0.5 points improvement post- Tenzingplasty (p=0.04). No statistical difference was noted between mRS improvements of acute and chronic symptomatic cases.ConclusionsThese findings support the feasibility and effectiveness of Tenzingplasty in treating ICAD stenoses in emergent and elective settings with no complications and good short-term outcomes. Further follow-up of these patients will determine the durability of the result achieved with Tenzingplasty.DisclosuresF. Behzadi: None. N. Gaddam: None. K. Zurcher: None. P. Sunenshine: None. F. Settecase: None. N. Mehta: None.

PurposeEarly detection of infarct volume immediately after mechanical thrombectomy may aid in prognostication and guiding post-treatment clinical management decisions. Iodine-staining of infarcted tissue may mask low-attenuation changes and virtual non-contrast (VNC) reconstruction of post-procedure dual-energy CT (DECT) may improve visualization of infarcted brain. In mTICI 3 reperfused patients, we rated infarct extent using ASPECTS on immediate post-MT mixed energy DECT and VNC, compared to follow-up single energy noncontrast CT ASPECTS . We hypothesize that VNC ASPECTS would more closely approximate follow-up CT ASPECTS than mixed energy DECT that has not been post-processed.Materials & MethodsInstitutional review board approval was obtained. Patients who underwent MT for treatment of anterior circulation ischemic stroke between January and September 2019 were consecutively reviewed. 28 patients (aged 68 ± 17 years, 16 female) with a mTICI score of 3 and without hemorrhagic transformation were included. Dual-energy CT imaging was obtained immediately post-MT and post-processed with vendor software (syngo.via, Siemens, Erlangen, Germany) to produce VNC images. ASPECTS was rated by two independent blinded assessors for the immediate post-MT DECT and VNC as well as for the follow-up conventional single energy CT at 24–48 hours. A Wilcoxon rank sum test was applied to compare the ASPECTS across DECT, VNC and follow-up CT studies. Cohen’s kappa was measured to assess inter-rater agreement.ResultsASPECTS for the DECT (rater A; median = 9 (IQR 8–9), rater B; median = 8.5 (IQR 6.75–9)) were significantly different from the follow-up at 24–48 hours for both raters (p<0.001 for both). There was no statistical difference, however, between the VNC (rater A; median = 6.5 (IQR 6–8.25), rater B; median = 6 (IQR 4–6)) and the follow-up CT (rater A; median = 7.5 (IQR 6–8), rater B; median = 6 (IQR 5–7)) for both raters (rater A; p=0.985, rater B; p=0.058). Inter-rater agreement for VNC was low (κ = -0.029) and follow-up CT (κ =-0.031) and DECT ((κ =0.235) . The caudate and lentiform nuclei were areas most commonly affected on the follow-up CT and demonstrated the greatest discrepancy between the VNC and the DECT. For rater A, VNC was 88.9% and 83.3% sensitive for caudate and lentiform infarcts, respectively, versus 22.2% and 27.8% for DECT. Similarly, for rater B, VNC was 88.2% and 90.9% sensitive for caudate and lentiform infarcts, respectively, versus 20% and 22.7% for DECT.ConclusionsImmediate post-thrombectomy DECT with VNC post-processing may more accurately visualize infarcted tissue and aid in prognostication and guiding treatment decisions despite suffering from low inter-rater agreement. Further larger scale studies are warranted.Disclosures C. Kim: None. S. Moghimi: None. A. Rohr: None. F. Settecase: 1; C; Stryker Neurovascular, Microvention. 2; C; Stryker Neurovascular. 6; C; Medtronic.

In a trial involving patients with ischemic stroke due to medium-vessel occlusion, thrombectomy within 12 hours did not lead to a better functional outcome and lower mortality at 90 days than usual care.

IntroductionDirect aspiration thrombectomy with super large-bore catheters (SLBC, 0.088’ ID) may improve first pass reperfusion, though consistent delivery to the target occlusion is difficult. We report our multicenter initial experience with a novel full length SLBC (Route 92 Medical Freeclimb 088 catheter, currently approved for neurovascular access), and its customized Tenzing 8 delivery catheter, for supraclinoid (SCICA) and middle cerebral artery M1 (M1) occlusions.MethodsWe performed a retrospective review of aspiration thrombectomy cases performed at three stroke centers from May 2022 through November 2022. All patients were treated using the Route 92 Medical Basecamp guide catheter, Freeclimb 88 catheter and Tenzing 8 delivery catheter in an off-label fashion.ResultsFourteen consecutive acute stroke patients with SCICA or M1 LVOs underwent aspiration thrombectomy using the Freeclimb 88 and its Tenzing 8 delivery catheter. The median age was 74 (45-91) and 9 were female (64%). The median presenting NIHSS score and ASPECT score were 15 (8-24) and 9 (6-10), respectively. LVO locations were 3 right SCICAs, 6 right M1s and 5 left M1s. Three patients also had tandem occlusion/near-occlusion of the cervical internal carotid artery. The Freeclimb 88 catheter was delivered to the target occlusion with the Tenzing 8 delivery catheter in 13/14 patients (93%); in one patient a stent retriever was required for delivery to the M1 occlusion. The median time from groin puncture to catheter delivery to the target occlusion was 14 minutes (7-35). First pass reperfusion (modified Thrombolysis in Cerebral Infarction score, mTICI) of 2B/2C/3 was achieved in 13/14 (93%) and of 2C/3 in 12/14 (86%) patients. Adjunctive therapy for a residual M2 occlusion was utilized in 2/14 patients. There were no adverse events or post-procedural symptomatic hemorrhages.ConclusionsOur initial experience with a novel full length SLBC (Route 92 Freeclimb 88 catheter) and its customized catheter delivery device (Tenzing 8) for aspiration thrombectomy of SCICA and M1 LVOs demonstrated successful delivery to the target occlusions in 93% of patients, with first pass mTICI 2c/3 achieved in 86%. No significant adverse events were noted.Disclosures J. English: 2; C; Route 92 Medical. 4; C; Route 92 Medical (Co-Founder and Equity Holder). J. Caldwell: None. J. Singh: None. S. Lee: None. W. Kim: 2; C; Route 92 Medical. 4; C; Route 92 Medical (Equity Holder). F. Settecase: 2; C; Route 92 Medical. A. Puri: None.

Background: On DECT, the ratio of maximum iodine concentration within parenchyma compared to the superior sagittal sinus has been shown to predict hemorrhagic transformation. We aimed to determine if this ratio also predicts the development of an infarct. Methods: 53 patients with small infarct cores (ASPECTS≥7) and good endovascular recanalization (mTICI 2b/3) were enrolled. Maximum brain parenchymal iodine concentration as per DECT relative to the superior sagittal sinus (iodine ratio) was correlated with the development of an infarct on follow up CT. Results: All patients showed contrast staining, 52 developed infarcts in the area of staining. The extent of infarction (smaller, equal or larger than area of staining) did not correlate with the iodine ratio. Conclusions: Brain parenchyma with contrast staining on post-procedure head CT almost invariably goes on to infarct, however the extent of infarct development is not predicted by the intensity of contrast staining. n=53 patients with successful recanalization of anterior circulation LVO infarct (TICI2b,3) with post procedural parenchymal iodine staining F/U infarct extent Number Hemorrhage (n) Iodine ratio on intial CT(median/range) 0: No infarct in area of staining 1 0 101(101-101)* 1: Infarct smaller than staining 8 0 138(64-341)* 2: Infarct equal to staining 14 0 140(74-259)* 3:Infarct larger than staining 30 6 120(23-1715)* 0,1:No or smaller infarct than staining 9 0 114(64-341)* 2,3 :equal or larger infarct than staining 44 6 126(23-1714)* all 53 6 123(23-1714)* There was no correlation between the degree of contrast staining on initial post procedural CT as expressed in iodine ratio and F/U infarct extent.

PurposeCraniocervical arterial sacrifice requires reliable, controlled, and stable device deployment and positioning to achieve durable occlusion while minimizing embolic risk. This retrospective case series evaluates the safety and effectiveness of the Micro Vascular Plug (MVP, Medtronic, Minneapolis, MN)) for craniocervical arterial sacrifice for various head and neck vascular pathologies.Methods and MaterialsAfter IRB approval, we retrospectively reviewed medical records of 26 patients between February 2017 to March 2023 at our institution who underwent off-label arterial sacrifice using the MVP as the first device deployed. Demographics, clinical data, procedural details, and outcomes were analyzed. Technical success was defined as successful MVP deployment.ResultsArterial sacrifice was performed in 26 arteries with 34 MVP devices (3 mm (n=9), 5 mm (n=21), 7 mm (n=4)) which were deployed using an 0.025’ lumen microcatheter for devices ≤ 5 mm. The technical success rate was 96.2%, successful arterial occlusion was 100%, and the procedure-related complication rate was 3.8%. One patient suffered a post-procedural infarct. 38.4% (10/26) of procedures were performed for adjunctive pre-operative cervical spine tumor resection, and 34.6% (9/26) for intracranial aneurysm or dissection treatment. 18 vertebral and 5 internal carotid arteries were occluded. In addition to the MVP, additional coils were placed into the parent artery for complete occlusion, with a median of 5 (range 0–12, IQR 3–7) coils required.ConclusionCraniocervical arterial sacrifice using the MVP as a distal occluder could be accomplished with precise positioning and reliable deployment, with a high technical success rate and low complication rate. This is the largest case series of its use for intra- and extracranial arterial sacrifice. Further study is warranted.Disclosures C. Kim: None. M. Marangoni: None. F. Settecase: 1; C; Microvention, Stryker. 2; C; Stryker, Route 92 Medical. 3; C; Stryker. 4; C; Route 92 Medical. 6; C; Medtronic, Route 92 Medical. A. Rohr: None. W. Guest: None. S. Mangat: None. G. Redekop: None. C. Haw: None. M. Heran: None.

IntroductionVasospasm is a morbid and often fatal complication of intracranial pathologies. Typically caused by aneurysmal subarachnoid hemorrhage (aSAH), it can also occur in association with intracranial infections. Heterogeneity exists in treatment regimens, but management usually involves intensive medical therapy. This may often require augmentation with endovascular therapy, most commonly intra-arterial calcium channel blocker infusion, with angioplasty historically reserved for refractory cases with a high risk for permanent neurological deficits. Given the high risk of iatrogenic complications with balloon angioplasty, alternative mechanical therapies have been explored. This series examines Dotter technique mechanical dilatation performed with Tenzing devices, or Tenzingplasty, of various sizes chosen to best approximate native premorbid calibers of affected arteries.MethodsAccording to IRB-approved protocols, retrospective analysis of prospectively maintained procedural databases and medical records was performed for patients undergoing Tenzingplasty at five high-volume cerebrovascular centers. Demographic and clinical features were recorded, including disease-specific features of vasospasm, details of pre-treatment management, noninvasive markers of vasospasm, technical elements of the Tenzingplasty procedure, and short-term clinical outcomes. Per-segment analysis was performed, including any treated arterial segment with narrowing >50%. The primary outcome was improvement of treated vessel narrowing to less than 50%. The primary safety outcome was any procedural complication. Secondary outcomes included absolute improvement in narrowing, post-treatment velocities on transcranial Doppler (TCD), and need for repeat endovascular therapy to be performed on a previously targeted segment. Statistical analysis was performed with the Exact test for non-continuous variables and T-tests for continuous variables. Mixed effects linear and logistic regression analysis was then performed as appropriate for multivariable analysis, excluding variables with p>0.20 in univariable tests to account for possible residual confounding.ResultsTwelve patients were treated with Tenzingplasty for vasospasm; 10 (83.3%) had aSAH, and 2 (16.7%) had meningitis. Tenzing devices were passed through 67 arterial segments. Among these, 56 (83.6%) had stenosis >50% and were included in the analysis. 73 passes were performed in total, with no procedural complications occurring after any treatment. All treated segments had improved narrowing, while 64 (95.5%) had residual narrowing <50%. 76.5% of segments interrogated with TCD following Tenzingplasty had normal velocities following treatment. Mean vessel narrowing improved from 79.9% ± 12.7 to 33.9% ± 14.2, with absolute improvement of narrowing 45.9% ± 16.6. Three (5.4%) segments required repeat endovascular therapy. In univariable and multivariable analysis, no demographic, clinical, or treatment variables were associated with any outcome measures.ConclusionTenzingplasty performed for vasospasm was safe and effective, with all vessel narrowing improving and 95.5% having <50% residual narrowing following the procedure. No procedural complications occurred in any treated segment. Improvement in post-treatment TCD velocities and low need for repeat endovascular therapy suggest durable clinical benefit.DisclosuresF. Behzadi: None. N. Mehta: None. W. Kim: 2; C; Route 92 Medical. 4; C; Route 92 Medical. F. Settecase: 2; C; Route 92 Medical. 4; C; Route 92 Medical. J. English: 2; C; Route 92 Medical, Stryker. 4; C; Route 92 Medical. J. Kim: 2; C; Route 92 Medical. 4; C; Route 92 Medical. B. Varjavand: None. T. Chaudhry: None. R. Khangura: None. N. Telischak: 2; C; Route 92 Medical. M. Alexander: 2; C; Certus Critical Care, Route 92 Medical, Medtronic, Ceronovus. 4; C; Piraeus Medical, Route 92 Medical.

Introduction/PurposePrevious large vessel occlusion (LVO) comparative thrombectomy device trials reported a substantial rate of crossover from first line aspiration thrombectomy (AT) to stent-retriever (SR) thrombectomy. Use of 0.070 inch ‘large-bore’ catheters for AT is associated with increased aspiration flow rates, first pass effect, faster recanalization, reduced procedure time and better reperfusion rates. A 0.070 inch distal inner diameter catheter, FreeClimbTM 70 (Route 92, San Mateo, CA), was recently introduced and comes packaged with a specialized delivery catheter with a tapered distal tip, Tenzing® 7 (Route 92, San Mateo, CA), which significantly reduces the ledge or space between itself and the tip of the access catheter. This is especially important with increased caliber of ‘large bore’ catheters, which have a greater tendency to catch on arterial side branches and encounter increased friction in tortuous vascular anatomy. We report our initial multicenter experience using the FreeClimb 70 delivered over the Tenzing 7 catheter in the treatment of large vessel occlusion stroke.Materials and MethodsAfter local IRB approval, we retrospectively reviewed and collected the clinical, procedural and imaging data of consecutive patients who underwent off-label AT with the FreeClimb 70 and Tenzing 7 at five institutions. The FreeClimb 70 and Tenzing 7 catheters were inserted as a unit into the guide catheter. After initial selective catheterization of the occluded vessel with Tenzing 7, the FreeClimb 70 was then advanced over the Tenzing catheter to the angiographic limit of contrast on roadmap angiography. The Tenzing was then removed and the FreeClimb 70 catheter was allowed to passively advance into the clot. Vacuum pump aspiration was then applied to the FreeClimb 70 for 2-5 minutes.ResultsFreeClimb 70 was successfully delivered over the Tenzing 7 to the target occlusion in 25/25 (100%) of cases (15 M1 segment, 5 M2, 4 ICA-terminus, and 1 basilar artery occlusions). No stent-retrievers were needed for delivery. Median time from groin puncture to first pass was 12 (IQR 8-16) minutes. In 20/25 (80%) cases, a leading microwire was not needed to advance the Tenzing 7 to the target occlusion. First pass effect (mTICI 2C or 3) was achieved in 13/25 (52%). For M1 MCA occlusions, FPE (mTICI 2C or 3) was 9/15 (60%). After a median of 1 (IQR 1-3) pass, successful reperfusion (mTICI ≥ 2B) was achieved in 24/25 (96%) cases, with complete reperfusion (2C or 3) in 22/25 (88%). After the first pass, additional clot retrieval devices were used in 10/25 (40%) cases, including SR in 2/25 (8%) cases. Median groin puncture to reperfusion time was 16 (IQR 12-28) minutes. There were no procedural complications or symptomatic intracranial hemorrhages. NIHSS at discharge decreased on average 8.5 ± 5.5 from presentation. There were three patient deaths: due to respiratory failure, oliguric renal failure, and transition to comfort care for large core infarct.ConclusionsInitial clinical experience supports the use of the FreeClimb 70 catheter with Tenzing 7 for reliable access to intracranial LVO for rapid, effective and safe reperfusion. Further study is warranted.Disclosures F. Settecase: 2; C; Stryker, Route 92. W. Kim: 2; C; Stryker, Route 92. 4; C; Route 92. J. Kim: None. T. Sivapatham: None. J. Caldwell: None. S. Lee: None. R. Hixon: None. D. Hoss: None. J. English: 2; C; Stryker, Route 92. 4; C; Route 92.