Methods of managing neurovascular obstructions
Systems, methods, and devices for the treatment of acute ischemic stroke that provide immediate blood flow restoration to a vessel occluded by a clot and, after reestablishing blood flow, address the clot itself Immediate blood flow restoration advantageously can facilitate natural lysis of the clot and also can reduce or obviate the concern for distal embolization due to fragmentation of the clot. Several embodiments of the invention provide for progressive, or modular, treatment based upon the nature of the clot. For example, the progressive treatment can include immediate restoration of blood flow, in-situ clot management, and/or clot removal depending on the particular circumstances of the treatment. The in-situ clot management can include, for example, lysis, maceration, and/or removal.
1. A thrombus management method without distal embolic protection for the treatment of acute ischemic stroke, the method comprising:
identifying an occluded artery in the neurovasculature of a subject having a thrombus;
inserting a balloon guide catheter within the subject and advancing a distal end of the balloon guide catheter to an arterial location proximal to the occluded artery;
inserting a distal access catheter through the balloon guide catheter and advancing a distal end of the distal access catheter to a location within the occluded artery proximate the thrombus;
inserting a microcatheter through the distal access catheter and advancing a distal end of the microcatheter through or to the side of the thrombus;
positioning the distal end of the microcatheter 0.5 to 10 mm past a distal end of the thrombus;
inserting an expandable tip assembly comprising a self-expandable scaffold tethered to a distal end of an elongate delivery member through the microcatheter,
wherein said self-expandable scaffold comprises a generally cylindrical body comprised of a plurality of struts and bridges forming a plurality of cells,
wherein the cells are sized and shaped to impact, compress and engage thrombus material upon radial expansion of the self-expandable scaffold;
retracting the microcatheter proximally, thereby causing the self-expandable scaffold to expand at the location of the thrombus;
wherein said expansion impacts and compresses the thrombus against a wall of the occluded artery,
wherein said compression of the thrombus restores blood flow within the occluded artery,
wherein said restored blood flow facilitates natural lysis and fragmentation of at least a portion of the thrombus;
while the expandable tip assembly remains stationary, macerating the thrombus by resheathing the self-expandable scaffold and unsheathing the self-expandable scaffold, thereby facilitating mechanical lysis and fragmentation of the thrombus to release embolic particles,
capturing one or more non-lysed portions of the thrombus on the exterior surface of the self-expandable scaffold; and
removing said expandable tip assembly from the subject, thereby removing the captured non-lysed portions of the thrombus engaged by the self-expandable scaffold from the occluded artery.
2. The thrombus management method of claim 1 , wherein capturing said one or more non-lysed portions of the thrombus on the exterior surface of the self-expandable scaffold comprises resheathing and unsheathing the self-expandable scaffold by retracting and advancing the microcatheter to facilitate said capturing.
3. The thrombus management method of claim 1 , wherein the one or more non-lysed portions comprises an inner core of the thrombus.
4. The thrombus management method of claim 1 , further comprising providing local aspiration at a location proximal to the thrombus within the occluded artery through the distal access catheter.
5. The thrombus management method of claim 1 , further comprising providing proximal aspiration at a location proximal to and remote from the location of thrombus through the balloon guide catheter.
6. The thrombus management method of claim 1 , further comprising inserting a guidewire through the balloon guide catheter and advancing a distal end of the guidewire within the occluded artery and through or to the side of the thrombus.
7. The thrombus management method of claim 1 , further comprising inserting the distal access catheter, the microcatheter, and/or the expandable tip assembly over a guidewire.
8. The thrombus management method of claim 1 , wherein the occluded artery is a middle cerebral artery and wherein the distal end of the distal access catheter is inserted to a location within the middle cerebral artery or within an internal carotid artery.
9. A thrombus management method without distal embolic protection for the treatment of ischemic stroke, the method comprising:
identifying an occluded blood vessel having a thrombus;
inserting a microcatheter within a guide catheter to a location of the thrombus;
positioning a distal end of the microcatheter 0.5 to 20 mm past a distal end of the thrombus;
inserting an expandable tip assembly comprising a self-expandable scaffold permanently tethered to a distal end of a flexible, elongate delivery member through the microcatheter;
advancing the expandable tip assembly within the microcatheter to a position within the microcatheter such that, upon retraction of the microcatheter, the self-expandable scaffold will at least partially span the thrombus;
retracting the microcatheter proximally, thereby causing the self-expandable scaffold to expand across at least a segment of the length of the thrombus;
wherein said expansion radially compresses the thrombus against a wall of the blood vessel;
wherein said radial compression of the thrombus restores blood flow within the blood vessel;
wherein said restored blood flow facilitates natural lysis of at least outer layers of the thrombus;
while the expandable tip assembly remains stationary, macerating the thrombus by resheathing the self-expandable scaffold and unsheathing the self-expandable scaffold, thereby facilitating mechanical lysis and fragmentation of the thrombus to release embolic particles;
wherein the embolic particles flow in the direction of the blood flow and are not captured by any distal embolic protection member, but are instead lysed through the natural lysis process due to the restored blood flow;
engaging a remaining core portion of the thrombus after said maceration on an external surface of the self-expandable scaffold; and
extracting said remaining core portion of the thrombus from the blood vessel by removing the expandable tip assembly from the subject.
10. The thrombus management method of claim 9 , wherein engaging the remaining core portion of the thrombus and extracting the remaining core portion of the thrombus are performed by the self-expandable scaffold of the expandable tip assembly.
11. The thrombus management method of claim 9 , wherein the expandable tip assembly is a first expandable tip assembly, and wherein engaging the remaining core portion of the thrombus and extracting the remaining core portion of the thrombus are performed by a second expandable tip assembly having a second self expandable scaffold, wherein said second expandable tip assembly is inserted into the microcatheter after removing the first expandable tip assembly from the microcatheter.