neurointervention Review Neurointervention 2022;17:70-77 https://doi.org/10.5469/neuroint.2022.00255 REACT Aspiration Catheters: Clinical Experience and Technical Considerations Jiahui Li, MEng1,2, Marc Ribo, MD, PhD1,2 1 Stroke Unit, Department of Neurology, Vall d’Hebron University Hospital, Barcelona, Spain 2 Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain Aspiration catheters are widely used in mechanical thrombectomy procedures to treat acute Correspondence to: ischemic stroke due to large vessel occlusion. The key performance requirements for aspiration Jiahui Li, MEng Stroke Unit, Department of Neurolo- catheters are ease of navigation and effective aspiration. In this work, we review the clinical ex- gy, Vall d’Hebron University Hospital, perience and in vitro studies of REACT aspiration catheters (Medtronic, Minneapolis, MN, USA). Passeig de la Vall d’Hebron, Barcelona In vitro experiments showed that REACT catheters exhibit solid performance in navigation and 119-129, Spain aspiration. Previous studies reported that the recanalization capacity of the aspiration catheters Tel: +34692839610 can be influenced by the devices’ inner diameter and tip distensibility, the catheter-to-vessel E-mail: jiahui.li@vhir.org diameter ratio, the negative pressure delivered by the vacuum generator, the cyclical aspiration Received: May 25, 2022 mode, the proximal flow arrest, and the angle of interaction between catheter and clot. REACT Revised: June 8, 2022 catheters can be navigated through the vasculature without any support from a microcatheter/ Accepted: June 8, 2022 microwire in favorable anatomical configurations. In challenging situations, mostly encoun- tered when crossing the ophthalmic segment of the internal carotid artery, the use of the sten- triever anchoring technique or delivery assist catheter can facilitate the navigation. Three clini- cal studies reporting on 299 patients who underwent mechanical thrombectomy with REACT catheters were included in this review. Successful recanalization (modified treatment in cerebral ischemia score 2b–3) was achieved in 89–96% of cases, no procedural complications related to REACT catheters were reported, and functional independence (modified Rankin Scale 0–2) at 90-days was 24–36%. In vitro experimental evaluations and clinical studies support the safety and effectiveness of the REACT catheters. Key Words: Catheter; Thrombectomy; Mechanical aspiration; Stroke INTRODUCTION Aspiration catheters, also known as Copyright © 2022 Korean Society of Interventional Neuroradiology intermediate or distal access catheters, This is an Open Access article distributed under the terms of Mechanical thrombectomy has been are frequently used in mechanical the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which established as the standard treatment thrombectomy procedures to perform permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is for acute ischemic stroke due to large direct contact aspiration (a direct aspi- properly cited. vessel occlusion.1-4 Over the last decade, ration first pass technique, ADAPT) or a a variety of new devices and techniques combined technique with a stentriever. have been developed to reduce the In both technical approaches, aspiration recanalization time and improve clinical catheters are navigated through the pISSN 2093-9043 outcomes.5,6 vascular anatomy to reach the occlusion eISSN 2233-6273 70 www.neurointervention.org Li J et al. REACT Aspiration Catheters: Clinical Experience and Technical Considerations site. The proximal end of the catheter is then connected to a adjustment of catheter flexibility, and the hydrophilic coat- syringe or aspiration pump that generates negative pressure ing on the polymer jacket can increase the lubricity of the to engage or ingest the thrombus. Therefore, the key perfor- device, ie, reduce the friction between catheter and vessel mance requirements for distal access catheters are ease of walls, during navigation. navigation and effective aspiration. The aspiration performance of distal access catheters can The main components of navigability are trackability, be evaluated by aspiration flow rate when the catheter tip which is the ability to advance over a rail to reach the target is not in contact or immediately proximal to the clot, or as- site, and pushability, which is the ability to transmit a push piration force when the thrombus is occluding the catheter force from the proximal to the distal end of the device. More- tip. In either case, the aspiration capacity increases with the over, since the vascular anatomy can be highly tortuous, the catheter’s inner diameter and the vacuum generator’s power. catheter shaft should be resistant to kink when crossing tight Furthermore, previous studies reported that maximizing the turns. Device manufacturers achieve these characteristics by catheter-to-vessel diameter ratio allowed to achieve higher adjusting the design of the 4 elements that constitute the reperfusion rates,7 as the presence of the catheter in the tar- catheters: inner liner, reinforcement, outer jacket, and hydro- get vessel induced a local flow arrest.8 Thus, there is an up- philic coating (Fig. 1). In broad terms, to enhance the track- ward tendency in the use of larger-bore aspiration catheters. ability, the liner needs to be made of a low-frictional material REACT 68 and REACT 71 (Medtronic, Minneapolis, MN, USA) such as polytetrafluoroethylene, commonly known as Teflon are large-bore aspiration catheters that feature a PTFE liner, (PTFE); to improve the pushability, the reinforcement requires nitinol reinforcement with a hybrid configuration combined a braided structure that favors force transmission along the coil and braid, flexible polymer jacket, and hydrophilic coat- catheter shaft; and to increase the kink and ovalization resis- ing on the devices’ distal end. In this work, we review the tance, the reinforcement needs a coil structure that provides clinical experience and in vitro studies of REACT catheters, flexibility and hoop strength. Additionally, the outer jacket and discuss technical tips to optimize mechanical thrombec- made of polymers of variable composition allows further tomy procedures. 1 CLINICAL EXPERIENCE Liner Radiopaque markerband Three clinical studies reporting on 299 patients who under- went mechanical thrombectomy with REACT catheters were included in this review.9-11 Demographics, procedural data, 2 Reinforcement and outcomes are presented in Table 1. Study variables in- clude median age, sex, occlusion site, procedural technique, Coil device, mean/median number of passes, mean/median + Braid procedural time, successful recanalization according to mod- 3 ified treatment in cerebral ischemia score (mTICI 2b–3, >50% Outer polymer jacket + reperfusion of the target vessel) after the first pass, complete 4 Hydrophilic coating recanalization (mTICI 2c–3) within a single attempt (first-pass effect [FPE]), overall procedural success (mTICI 2b–3 and 2c–3), Fig. 1. Four elements constitute the catheters, from innermost to rate of complications, and functional outcome according to outmost layer: (1) liner, (2) reinforcement, (3) polymer jacket, and (4) hy- modified Rankin Scale (mRS 0–2) at 90 days. drophilic coating. REACT aspiration catheters are constituted by a PTFE Requena et al.9 presented a prospective study includ- liner with low-frictional properties; hybrid (combined coil and braid) nitinol reinforcement that provides pushability, torqueability, flexibil- ing 102 consecutive adult patients. Stent-retriever assisted ity, and resistance to kinking and ovalization; an outer jacket made of vacuum-locked extraction (SAVE) (simultaneous retrieval polymer blends with varying stiffnesses along the catheter shaft; and a of stentriever and distal access catheter under continuous hydrophilic coating on the distal segment that diminishes the friction between the device and vascular walls. PTFE, polytetrafluoroethylene, aspiration) or Solumbra (re-sheathing of stentriever under commonly known as Teflon. continuous aspiration without retracting the catheter) tech- https://doi.org/10.5469/neuroint.2022.00255 71 neurointervention  Vol. 17, No. 2, July 2022 niques were performed using REACT catheters (REACT 68 of passes was 2 (1–3). No procedural complications related to or REACT 71) in combination with different stentrievers. For REACT catheters were reported. Functional independence the distal access, the interventionalists utilized the stentriever (mRS 0–2) at 90 days was 36%. anchoring technique. This navigation approach consists in, Raymond et al.10 attempted the sofia non-wire advance- first, placing a long 6F sheath in the internal carotid artery ment technike (SNAKE) technique, i.e., navigation without re- or vertebral artery through a percutaneous transfemoral or quiring microcatheter or microwire support, in 47 thrombec- transradial access. Next, a REACT catheter and a 0.021 inch tomies performed with REACT 68. The unsupported catheter microcatheter with a 0.014 inch microwire are introduced successfully reached the proximal interface of the clot in 21% into the coaxial system. The microcatheter is then tracked of attempts. Microcatheter or wire support was required in further over the microwire to cross the occlusion site. Last- 56% of cases and the stentriever anchoring technique was ly, the stentriever is deployed over the clot and used as an employed in 23% of cases. This retrospective observational anchor to apply tension over the wire and navigate the aspi- study reported that successful recanalization (mTICI 2b–3) ration catheter over the rail to the proximal interface of the using either ADAPT or aspiration combined with a stentriev- thrombus. In this study, successful recanalization (mTICI 2b–3) er was achieved in 95.7% of patients. The median procedural was achieved in 89% of patients with a complete recanaliza- time from arterial puncture to recanalization was 22 (16.5–43) tion (mTICI 2c–3) rate of 65%. Successful recanalization was minutes, and the median number of passes was 2 (1–3). No achieved in a single pass in 54% of patients and FPE in 36%. procedural complications related to REACT 68 were encoun- The median procedural time from arterial puncture to reca- tered. Functional independence (mRS 0–2) at 90 days was nalization was 40 (26–53) minutes, and the median number 23.5%. Table 1. Clinical studies using REACT catheters Reference Demographics and procedural data 10 Raymond et al. (2020) Gross et al.11 (2021) Requena et al.9 (2022) Number of patients 47 150 102 Median age 67 71 78 Sex, female 16 (34) 68 (45) 51 (50) Occlusion location Tandem 5 (11) 22 (15) 15 (15) Anterior 42 (89) 130 (87) 96 (94) Posterior 5 (11) 20 (13) 6 (6) Technique Aspiration/combined Aspiration/combined Combined technique technique technique Device REACT 68 47 (100) NA 23 (22) REACT 71 NA 150 (100) 79 (78) Mean/median number of passes 2 2.2 2 Mean/median procedural time (min) 22 25 40 FPE (mTICI 2b–3) NR 76 (51) 55 (54) FPE (mTICI 2c–3) NR 39 (26) 37 (36) Successful recanalization (mTICI 2b-3) 45 (96) 142 (95) 91 (89) Complete recanalization (mTICI 2c–3) NR 59 (39) 66 (65) Complications 2 (4) 7 (5) 4 (4) 90-days mRS 0–2 24% 34% 36% Values are presented as number only or number (%). NA, not available; NR, not reported; FPE, first pass effect; mTICI, modified treatment in cerebral ischemia; mRS, modified Rankin Scale. 72 www.neurointervention.org Li J et al. REACT Aspiration Catheters: Clinical Experience and Technical Considerations Gross et al.11 reported 150 thrombectomies performed catheter is dictated by the Poiseuille’s law, Equation 1: with REACT 71. The interventionalists delivered the aspiration πPD4 Q= catheter to the occlusion site over a 0.025 or 0.027 inch mi- 128μl crocatheter, or using the stentriever anchoring technique. In Where Q=aspiration flow rate, P=negative pressure gen- this prospective study, successful recanalization (mTICI 2b–3) erated by syringe or aspiration pump, D=catheter’s inner using either ADAPT or a combined technique was achieved diameter, µ=blood viscosity, and l=catheter length. However, in 95% of patients with a complete recanalization (mTICI to maximize the effectiveness of aspiration12 and to avoid 2c–3) rate of 39%. Successful recanalization was achieved in arterial collapse that may lead to vasospasm,13 previous stud- a single pass in 51% of patients and FPE in 26%. The mean ies remarked on the importance of positioning the catheter procedure duration was 35 minutes, and the mean number tip en face to the clot before initiating aspiration. In this case, of total passes was 2.2. No procedural complications related where the clot is corked into the catheter tip and there is no to REACT 71 were reported. Functional independence (mRS backflow (Q=0) through the device, the aspiration force is 0–2) at 90 days was 34%. governed by Equation 2: πD2 F=P × 4 In Vitro Assessment of REACT Where F=aspiration force, P=negative pressure generated Catheters’ Performance by syringe or aspiration pump, and D=catheter’s inner diam- eter. In line with the theoretical equations, technical in vitro Aspiration evaluations by several authors suggest that the aspiration On theoretical grounds, the aspiration performance of a performance (both in terms of force and flow rate) of distal Table 2. Comparison of the build elements and key performance metrics among various commercially available aspiration catheters Device Parameters REACT 68 ACE 68 Sofia Plus REACT 71 JET 7 Build elements* Liner PTFE PTFE PTFE+polyolefin PTFE+polyolefin PTFE Reinforcement NiTi SS+NiTi SS NiTi SS+NiTi Coil+braid Coil Coil+braid Coil+braid Coil Polymer jacket PEBA, Polyurethane, PEBA, Polyurethane, PEBA, Polyurethane, Polyurethane, PEBA, polyamide polyamide polyamide polyolefin, polyamide polyamide Coating Hydrophilic Hydrophilic Hydrophilic Hydrophilic Hydrophilic 21,22 Aspiration Labeled ID (in) 0.068 0.068 0.070 0.071 0.072 Effective ID (in) † 0.081 0.079 0.083 0.089 0.083 Mean flow rate (mL/s) NR NR 5.93 6.06 6.29 † Mean tip force (mN) 373.65 338.10 392.21 455.43 396.75 Navigability23 ‡ SNAKE (mN) 732.70 893.19 313.85 499.28 577.31 Microcatheter (mN) 392.52 1111.29 285.89 299.08 388.59 SR anchoring (mN) 264.34 543.02 195.20 147.77 257.94 PTFE, polytetrafluoroethylene, commonly known as Teflon; NiTi, nitinol; SS, stainless steel; PEBA, polyether block amide, commonly known as Pebax; ID, inner diameter; NR, not reported; SNAKE, sofia non-wire advancement technike; SR, stent retriever; FDA, food and drug administration. *Data retrieved from FDA 510(k) database. The exact compositions of the polymer blends and hydrophilic coatings were not disclosed. † Maximum effective inner diameter and mean tip force result from catheter tip distension due to the interaction with a stiff clot. ‡Mean track forces required to cross the ophthalmic segment of the carotid siphon using different navigation techniques: SNAKE technique (unsupported catheter navigation), microcatheter supported navigation, and the stentriever anchoring technique. https://doi.org/10.5469/neuroint.2022.00255 73 neurointervention  Vol. 17, No. 2, July 2022 access catheters is highly dependent on the labeled inner force to navigate through a sinusoidal vascular anatomy diameter specified by device manufacturers.8,14-19 However, made of glass. this rationale is only applicable when the thrombus is softer Similarly, a recent in vitro study23 compared the SNAKE than the catheter tip and only the clot experiences strain (e.g., navigation approach versus the concomitant coaxial use of erythrocyte-rich thrombus).20 In reality, the distal edge above microwire/microcatheter and the stentriever anchoring tech- the radiopaque marker band of the catheters is the softest nique. This study utilized a glass-made model that repro- part of the device, commonly constituted by the liner and/or duced a simplified version of the vascular anatomy from the the polymeric jacket layer. During aspiration thrombectomy, right common carotid artery to the M1 segment of the mid- firm clots (e.g., fibrin/platelet-rich thrombus),20 that cannot dle cerebral artery. In comparison to the SNAKE technique, be completely ingested due to their size and stiffness, may track forces were reduced by about 63% and 77% when be capable of inducing catheter tip expansion, which implies using microcatheter/microwire and the stentriever anchor- that the inner diameter during aspiration can differ from the ing technique, respectively. This may have been due to the labeled one. presence of the microcatheter/stentriever rail that aligned A recent in vitro study21 refers to the capability of inner the catheters’ trajectory with the vessel centerline, which diameter expansion as catheter tip distensibility. This work minimized the occurrence rate of ledge effect, ie, the inabili- differentiates labeled inner diameter from effective inner ty to advance the distal access catheter past the ophthalmic diameter, which takes into consideration the influence of segment of the carotid siphon because of the engagement clot biomechanics on the catheter tip. The experiments between the catheter tip and ophthalmic artery origin.24 This measured the aspiration forces of commercially available work showed up to 79% variability in catheters’ navigation catheters and showed that, when aspirating firm clots, all de- performance. Among all devices evaluated, when traversing vices presented a certain degree of tip distensibility (15–25% the ophthalmic segment, REACT 71 was one of the catheters expansion of inner diameter) that allowed them to deliver that exhibited smoother navigation with microcatheter/ aspiration forces 60–99% higher than theoretical forces ac- microwire and stentriever anchoring techniques. This was cording to Equation 2. Among all devices evaluated, REACT probably due to the hybrid coil and braid reinforcement 71 presented the highest tip distensibility, largest effective in- made of nitinol wires in the REACT catheters’ design, the ner diameter and, consequently, the highest aspiration force braid structure enhanced the pushability, the coil provided despite not being the largest-bore catheter included in the kink and ovalization resistance, and nitinol wires added flexi- study. Comparison of aspiration performance among various bility and durability to the device. Comparison of navigability catheters is summarized in Table 2. among various aspiration catheters is summarized in Table 2. Navigability In benchtop testing platforms, the proximal end of the DISCUSSION aspiration catheter is attached to a motorized force sensor that advances the device at a constant velocity to navigate The ultimate goal of mechanical thrombectomy is the it through a preset trajectory. Motor-driven dynamometers achievement of complete reperfusion in a single attempt, substitute operators’ force discrimination ability and allow for which has been reported as a strong predictor of better a more objective, consistent, and reproducible assessment of clinical outcomes. Nevertheless, FPE was reported to have devices’ navigability. Track forces required to traverse tortu- occurred at a rate of 25–40% of cases in clinical studies. To ous paths are recorded as the quantitative metric of naviga- increase the chances for FPE, it is essential to identify and bility. As higher forces exerted against the vascular walls may optimize those parameters affecting the performance of cause endothelial damage, lower track forces are deemed as different thrombectomy devices. In this article, we reviewed an indicator of better navigability. the key performance requirements for aspiration catheters. An experimental evaluation assessed the navigability of Aspiration catheters’ inner diameter, thrombus stiffness various aspiration catheters when advancing over a micro- and catheter tip distensibility, and catheter-to-vessel diame- catheter/microwire support system.22 This study reported ter ratio are variables that can influence the aspiration perfor- that REACT 71 was one of the devices that required less track mance of the devices. Other procedural-related factors that 74 www.neurointervention.org Li J et al. REACT Aspiration Catheters: Clinical Experience and Technical Considerations can vary the recanalization capacity of aspiration catheters The ledge effect has been reported as a predictor of un- are: successful recanalization.33 In vitro and clinical studies have • The negative pressure generated by the aspiration shown that the stentriever anchoring technique was an pump/syringe: both aspiration flow rate and force de- effective alternative when the SNAKE technique or microca- pend on the vacuum pressure. Commercially available theter/microwire support system failed to deliver aspiration pumps do not necessarily generate more vacuum pres- catheters past the ophthalmic segment of the carotid siphon. sure than syringes. Under flow restriction conditions (clot The effectiveness of the stentriever anchoring technique completely occluding the catheter tip), 60 cc syringes can be attributed to the “rail” effect of applying tension on showed slightly higher vacuum pressure than aspiration the wire after deploying the stentriever. The pulling force to pumps, probably due to resistive components in the generate tension should not exceed the radial force of the pumps’ system, such as the silicone tubing and on-off stentriever over the vascular wall, otherwise, the stentriever switch; under partial backflow conditions (incomplete would be dislodged. Then, when the tensioned stentriever apposition of the catheter tip against clot), syringes out- wire acts as a rail, the trajectory of the aspiration catheter is performed pumps until the entire syringe was filled with driven to the inner curve of the ophthalmic segment, which fluid, after that, the syringes’ suction power dropped to reduces the occurrence rate of the ledge effect. zero while the pumps’ remained constant due to the However, the stentriever anchoring technique implies greater volume of the canister.25 crossing the occlusion site with the microcatheter/microwire, • Static versus cyclical aspiration mode: the constant pres- which may induce thrombus fragmentation and distal em- sure delivered by conventional aspiration syringes and bolization. To minimize the interaction with the thrombus, pumps is referred to as the static or continuous uniform an emergent device class named delivery assist catheter has aspiration. Increasing aspiration cycle frequency (pressure been evaluated as an alternative to existing approaches.24,34 oscillations per second, Hz) can improve the efficacy of The operating principle behind the delivery assist catheter clot removal,26 as cyclical aspiration may be able to in- is the reduction of space between the microcatheter and duce larger strain on the clots.27 Clinical studies reported aspiration catheter. Previous studies have shown that a 0.035 that cyclical aspiration, also known as pulsatile or inter- inch rather than 0.027 inch microcatheter reduces the fre- mittent aspiration, could be more effective than continu- quency of the ledge effect.35 In other words, delivery assist ous uniform aspiration to achieve FPE.28,29 catheters are larger-caliber microcatheters that function as • The utilization of balloon guide catheter: the combined a more robust rail to keep aspiration catheters from 0.068 effect of proximal flow arrest and distal aspiration can inch to 0.072 inch away from the ophthalmic artery origin. reduce the number of passes, time from puncture to re- A recent in vitro study24 reported that TENZING 7 (Route 92 canalization, and periprocedural embolization.30,31 Three Medical, San Mateo, CA, USA), a delivery assist catheter, was force components act on a lodged thrombus and hinder capable of delivering aspiration catheters to the proximal clot removal: the impaction force exerted by the system- M1 in half the time required for the microcatheter/microwire ic pressure on the proximal face of the clot, the adhesion support system. The use of delivery assist catheters could force, and the friction force between the thrombus and be complementary to further reduce procedural times and vessel wall.32 Kang et al.30 suggested that the use of bal- refine ADAPT. loon guide catheters mitigates the impaction force, and thus, diminishes the aspiration/retrieval force required for clot extraction. CONCLUSION • The interaction between clot and catheter: as reported by Bernava et al.,12 “the angle of interaction between the aspi- In vitro studies support the effectiveness of REACT catheters, ration catheter and the clot of ≥125.5° was significantly as- as both catheters exhibited solid performance in aspiration sociated with successful clot removal” and the rate of FPE and navigability evaluations. Clinical studies using REACT was higher when the angle was approximately 180°. This aspiration catheters reported high rates of successful reca- finding highlights the importance of positioning the cath- nalization in patients with acute ischemic stroke due to large eter tip against the proximal interface of the thrombus. vessel occlusion. The rates of procedural success and recanal- https://doi.org/10.5469/neuroint.2022.00255 75 neurointervention  Vol. 17, No. 2, July 2022 ization at the first attempt, along with the null incidence of ysis of individual patient data from five randomised trials. Lan- complications related to REACT catheters, demonstrate the cet 2016;387:1723-1731 safety and effectiveness of the devices. 4. Nogueira RG, Frei D, Kirmani JF, Zaidat O, Lopes D, Turk AS 3rd, et al.; Penumbra Separator 3D Investigators. Safety and efficacy Fund of a 3-dimensional stent retriever with aspiration-based throm- None. bectomy vs aspiration-based thrombectomy alone in acute ischemic stroke intervention: a randomized clinical trial. JAMA Ethics Statement Neurol 2018;75:304-311 Not applicable. The consent for publication is not required as 5. Spiotta AM, Chaudry MI, Hui FK, Turner RD, Kellogg RT, Turk AS. this article does not include any images or information that Evolution of thrombectomy approaches and devices for acute may identify the person. stroke: a technical review. J Neurointerv Surg 2015;7:2-7 6. Bhogal P, Andersson T, Maus V, Mpotsaris A, Yeo L. Mechanical Conflicts of Interest thrombectomy-a brief review of a revolutionary new treatment Marc Ribo reports ownership of Anaconda Biomed, and for thromboembolic stroke. Clin Neuroradiol 2018;28:313-326 Methinks shares, personal fees from Medtronic, Apta Targets, 7. Kyselyova AA, Fiehler J, Leischner H, Flottmann F, Buhk JH, Stryker, Cerenovus, Philips, and Balt. Jiahui Li has no conflicts Frölich AM. Vessel diameter and catheter-to-vessel ratio to disclose. affect the success rate of clot aspiration. J Neurointerv Surg 2021;13:605-608 Author Contributions 8. Nogueira RG, Ryan D, Mullins L, Thornton J, Fitzgerald S. Maxi- Concept and design: JL. Analysis and interpretation: JL. Data mizing the catheter-to-vessel size optimizes distal flow control collection: JL. Writing the article: JL. Critical revision of the resulting in improved revascularization in vitro for aspiration article: MR. Final approval of the article: JL and MR. Overall thrombectomy. J Neurointerv Surg 2022;14:184-188 responsibility: JL. 9. Requena M, Piñana C, Olive-Gadea M, Hernández D, Boned S, De Dios M, et al. Combined technique as first approach in me- ORCID chanical thrombectomy: efficacy and safety of REACT catheter Jiahui Li: https://orcid.org/0000-0003-4278-8222 combined with stent retriever. [published online ahead of print Marc Ribo: https://orcid.org/0000-0001-9242-043X May 2, 2022] Interv Neuroradiol 2022 10. Raymond SB, Nasir-Moin M, Koch MJ, Rabinov JD, Leslie-Mazwi T, Patel AB. 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