This document describes the push and puff technique for mechanical thrombectomy and one physician's experience using this technique with the Solitaire stent retriever. It summarizes a case study of a 65-year-old female patient who presented with left-sided weakness and was found to have a right terminal ICA occlusion that was successfully treated with mechanical thrombectomy using the push and puff technique. The physician's early experience using this technique with the Solitaire device in 7 patients demonstrated a 100% first pass reperfusion rate and modified TICI 3 reperfusion in 85% of patients. Commonly encountered challenges after stent retrieval included vessel spasm and residual thrombus. The conclusion is that the push and puff technique appears very promising for improving outcomes

1. VIPUL GUPTA
NEUROINTERVENTION SURGERY, MEDANTA THE MEDICITY

2. Objective:
Describe technique to achieve first pass reperfusion
and relevant literature.
Case study of a patient with terminal ICA occlusion
Single center experience with relevant technical
pearls
PUSH AND PUFF TECHNIQUE FOR MECHANICAL THROMBECTOMY
–
OUR EXPERIENCE

3. Significantly better first pass reperfusion
and higher modified TICI 3 reperfusion with
Trevo device
Stent opens better and cell size larger
(shown in image)

4. Standard unsheathing
technique with TREVO stent
Push and fluff technique
- Note better expansion of stent and larger
cell size to allow for better clot entrapment

5. Solitaire (Medtronic, MN) stent has been the most
common device used in the randomized trials
 The parametric design of the Solitaire device (Medtronic,
MN) allows for maintaining cell size regardless of the vessel
size. In addition, the folding design provides greater device -
clot interaction, particularly in the stage of delivery of stent.
One may wonder if the parameteric design and consequent
unfurling of stent may offer greater possibility of engaging the
clot if push and fluff techniques is employed.
Therefore, we utilized the ‘push and fluff’ technique with
Solitaire (Medtronic, MN) device

6. Case study:
65 year old female with a history of ST elevation MI
a week ago presented with left sided weakness that
started 2.5 hours ago. She had gaze deviation to the
right, left hemispatial neglect, left hemifield loss and
left hemiplegia (NIHSS – 18).
Patient underwent multimodal imaging that
revealed right terminal ICA occlusion, good
collaterals and a large penumbra.
In view of recent MI intravenous thrombolysis was
contraindicated and patient was shifted to angio
suite for mechanical thrombectomy
A B
C D
A, B – Noncontrast CT brain – ASPECTS of 10, no
early ischemia noted; C – CBV map, no infarct
core; D – MTT, prolonged MTT suggestive of a
large area of penumbra.

7. A B C D
E F G H
A – CT angio
demonstrating right L
– type terminal ICA
occlusion; B – tapered
R ICA due to terminal
ICA occlusion; C, D –
Initial run
demonstrating
occlusion beyond the
origin of the
ophthalmic; E-
microcatheter run
after crossing the
occlusion; F- well
expanded Solitaire
stent; G, H – TICI 3
reperfusion in the
occluded territory.
Post procedure, patient made near complete recovery with a NIHSS of 4.

8. Our experience of PUSH and FLUFF technique with Solitaire device:
7 consecutive patients (2016)
3 terminal ICA occlusion; 4 M1 MCA occlusion
First pass reperfusion – 7/ 7 (100%)
Modified TICI 3 reperfusion – (6/7)85%
Modified TICI 2b reperfusion – (1/7) 15%
Picture to Puncture time : 58 minutes (median)
Puncture to reperfusion: 18 minutes (median)
Clinical – mRS 0-2 in 6/7 (85%), one patient had heparin induced bleeding
Commonly encountered problems post stent retrieval –
•Spasm in M1 MCA (spontaneously resolves in most; otherwise resolves with a
small dose of Nimodipine )
•Thrombus at site of stent delivery – resolved with adequate heparinization

9. Conclusion
•Push and Puff technique appears to be a very promising method to
improve results of mechanical thrombectomy
•Our early experience with Solitaire stent-retriever are extremely
encouraging

10. For more information on:
STROKE & NEUROVASCULAR INTERVENTIONS:
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Dr Vipul Gupta

11. Thank You