Evolution of Thrombectomy Approaches, Philosophy, and Devices for Acute Stroke

Abstract

Prior to 2015, intravenous administration of tissue plasminogen activator (tPA) was the only FDA-approved treatment modality for acute ischemic stroke, although many patients who did not meet the criteria for intravenous tPA were offered intra-arterial therapy. Rapid advances in devices and approaches have propelled the evolution of thrombectomy over the past decade from rudimentary mechanical disruption, followed by intra-arterial thrombolytic infusions to increasingly effective thrombectomy devices. We now have level IA evidence supporting mechanical thrombectomy for the treatment of acute ischemic stroke in patients with a large vessel occlusion. We review the critical advancements in thrombectomy technique that have evolved and the key anatomic and technical challenges they address, from first-generation Merci retrieval systems to second-generation Penumbra aspiration systems and third-generation stent retrievers, as well as nuances of their uses to maximize their effectiveness. We also highlight more recent advances that offer patients hope for more expedient vessel recanalization.