32 The SAVE Technique
32.1 Case Description
32.1.1 Clinical Presentation
An 85-year-old, high functioning, male patient was last seen well at 14:00 hours. He woke up at 16:00 hours and was found to be aphasic and weak on the right. He was taken by emergency medical services (EMS) to the hospital and reached at 16:45 hours. The National Institutes of Health Stroke Scale (NIHSS) score was 21 upon arrival. The patient was alert but globally aphasic. His pupils were equal and reactive. There was forced gaze deviation to the left, and mild right upper motor neuron facial asymmetry. Also, there was right hemiplegia, and extensor plantar response on the right. Asymmetric response to sensory stimuli on the right compared to left was observed. He was unable to test for visual fields and was afflicted with ataxia.
32.1.2 Imaging Workup and Investigations
Noncontrast CT (NCCT): Showed ASPECTS score of 7 with loss of gray-white differentiation over left insula, caudate, and lentiform nucleus (Fig. 32.1).
CTA: Revealed left proximal M1 occlusion.
CT perfusion (CTP): Demonstrated perfusion mismatch 4 mL core, and 181 mL penumbra with 45.3 mismatch ratio.
Fig. 32.1 CT scan of the head. (a) Nonenhanced CT showing loss of the left insult ribbon and indistinct left caudate and lentiform nucleus (ASPECTS 7). (b) CTA demonstrates left M1 occlusion. (c) Late-phase CTA demonstrates good collaterals. (d) RAPID perfusion images depicting small core and large penumbra.
32.1.3 Diagnosis
Acute stroke due to left M1 occlusion.
32.1.4 Management
6 mg tissue plasminogen activator (tPA) bolus was given at 17:04 hours, as no contradiction was identified, followed by 56 mg of tPA infusion.
Was taken to angiography suite for endovascular thrombectomy (EVT) promptly, while tPA infusion was run after obtaining consent.
32.1.5 Endovascular Treatment
Materials
8-Fr short vascular access sheath.
8-Fr FlowGate balloon guide catheter (BGC).
6-Fr Berenstein tip guide assist FlowGate Slip-Cath.
Terumo guidewire.
AXS Catalyst 6 Distal Access Catheter (aspiration catheter).
Synchro-14 guidewire.
Trevo XP ProVue microcatheter and 4 mm × 30 mm stentriever.
Technique
The procedure was performed under conscious sedation while anesthesia present in the room.
Right common femoral artery (CFA) puncture with placement of an 8-Fr short vascular access sheath into the CFA.
An 8-Fr FlowGate BGC placed in the left common carotid artery (CCA) coaxially over a slip-cath with the aid of Terumo guidewire.
Control anteroposterior and lateral angiographic runs confirmed persistent M1 occlusion (Fig. 32.2a).
The Trevo XP ProVue microcatheter and the AXS Catalyst 6 Distal Access Catheter were prepped and connected to the continuous flushing system.
The Trevo XP ProVue microcatheter was navigated into the left middle cerebral artery (MCA) with the aid of Synchro-14 guidewire bypassing the clot.
Microinjection confirmed the location of the Trevo microcatheter with no perforation (Fig. 32.2b).
A Trevo 4 mm × 30 mm stentriever was deployed into the left M2 superior division, with the proximal third of the stent engaging the thrombus.
The FlowGate BGC was inflated.
The AXS Catalyst 6 Distal Access Catheter was advanced to wedge the clot, while being connected to the Stryker aspiration pump with the suction turned on (Fig. 32.2c).
A penumbra aspiration tubing was primed and connected to the pump and the guide catheter
After 90 seconds of flow arrest, both the Trevo stent and the AXS Catalyst 6 were pulled gradually with both aspiration pumps turned on.
Final angiographic runs demonstrated optimal distal perfusion (thrombolysis in cerebral infarction [TICI]: 3; Fig. 32.2d).
Fig. 32.2 Thrombectomy procedure. (a) Left ICA injection showing persistent occlusion of the left M1. (b) Microinjection through the Trevo XP ProVue microcatheter confirming position distal to the occlusion with no perforation. (c) The Trevo 4 mm × 30 mm stentriever was deployed distally into the M2 with the proximal third over the occlusion, and the AXS Catalyst 6 aspiration catheter was advanced while the aspiration pump is active to wedge the clot. (d) TICI 3 reperfusion of the left MCA territory.
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