PUSH AND PUFF TECHNIQUE FOR MECHANICAL THROMBECTOMY – OUR EXPERIENCE

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:
URL:
www.sanif.co.in
Facebook:
https://www.facebook.com/strokeawarenessindia
https://www.facebook.com/vipul.gupta.35175
Twitter
https://twitter.com/drvipulgupta25
LinkedIN
https://in.linkedin.com/pub/dr-vipul-gupta/51/8a1/25a
YouTube
Channel: Stroke & Neurovascular Interventions
www.youtube.com/c/StrokeNeurovascularInterventionsfoundation
Dr Vipul Gupta

11. Thank You