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.