Mechanical thrombectomy for acute ischemic stroke performed without continuous saline flushes and using moderate sedation: The TOOFAST technique

Abstract

Background

Rapid reperfusion is an important predictor of neurologic recovery in acute ischemic stroke due to large vessel occlusion (AIS-LVO) treated with mechanical thrombectomy (MT). We present a single-institution retrospective observational study of the ThrOmbectomy withOut Flushes or AnestheSia Teams (TOOFAST) technique, which eliminates continuous heparinized saline flushes and employs conscious sedation (CS) to streamline MT preparation.

Methods

Retrospective review of prospectively collected data for AIS-LVO patients at our comprehensive stroke center from January 1, 2020, to December 31, 2023. Patients were >18 years with premorbid modified Rankin Scale (mRS) <3. Cases were performed under CS without continuous pressurized heparinized saline flushes or anesthesiologist involvement. Cases were categorized as presenting to the emergency department or from inpatient units (in-house), outside hospital transfers, or those undergoing hyperacute MRI.

Results

Among 947 total cases, 638 were analyzed. 374 (58.6%) were in-house activations, 205 (32.1%) were transfers, and 59 (9.2%) underwent hyperacute MRI. Median presenting National Institutes of Health Stroke Scale (NIHSS) was 15 (interquartile range (IQR) 9–20) and 34.7% of patients received intravenous thrombolysis. Median arrival-to-access and NIR-to-access times for in-house activations were 67 (IQR 56–80) and 39 (IQR 29–48) minutes, respectively. Embolization to new territory occurred in 11 (1.7%) patients while vascular perforation occurred in 9 (1.4%). Median NIHSS shift from admission to discharge was −9 (IQR −15 to −5). At 90 days, 46.5% (106/228) remained mRS <3.

Conclusions

The TOOFAST technique may result in rapid access times with a profile of safety, procedural parameters, and neurologic outcomes comparable to published trial standards.