Is a pressure bag with fluid in a long sheath recommended for mechanical thrombectomy in adults with acute ischemic stroke and a history of cardiovascular disease or hypertension?

Use of Pressure Bag with Fluid in Long Sheath for Mechanical Thrombectomy

The available guidelines and evidence do not address the specific technical question of attaching a pressure bag with fluid to a long sheath during mechanical thrombectomy. This procedural detail is not discussed in major stroke guidelines from the American Heart Association/American Stroke Association, European Stroke Organisation, or American College of Chest Physicians 1.

What the Guidelines Actually Address

The current evidence-based recommendations focus on:

Patient Selection and Timing

• Mechanical thrombectomy with stent retrievers is strongly recommended for patients meeting specific criteria: prestroke mRS 0-1, ICA or M1 occlusion, age ≥18 years, NIHSS ≥6, ASPECTS ≥6, and treatment initiated within 6 hours of symptom onset 1.
• Extended time windows (6-24 hours) are supported for carefully selected patients meeting DAWN or DEFUSE-3 criteria 1.

Device and Technique Considerations

• Stent retrievers are the preferred devices based on randomized trial evidence (MR CLEAN, SWIFT PRIME, EXTEND-IA, ESCAPE, REVASCAT, THRACE) 1.
• Guidelines do not mandate specific requirements for proximal balloon guide catheters, large-bore distal-access catheters, or cervical guide catheters 1.
• Combined stent-aspiration techniques have been described in retrospective series, with potential benefits including flow reversal and prevention of distal embolization 1.

Blood Pressure Management During Thrombectomy

• In patients undergoing mechanical thrombectomy (with or without IV thrombolysis), blood pressure should be lowered to <180/105 mmHg prior to thrombectomy and maintained over the next 24 hours 1.
• This is the only guideline-level recommendation regarding hemodynamic management during the thrombectomy procedure itself 1.

Clinical Context and Technical Practice

While not addressed in formal guidelines, the question of pressure bag use relates to:

• Maintaining sheath patency during the procedure
• Preventing thrombus formation within the catheter system
• Ensuring continuous flush of the access system

What We Know About Procedural Technique

• Contemporary thrombectomy techniques emphasize rapid recanalization with stent retrievers or aspiration systems 2, 3.
• Procedural complications occur in 6-13% of patients, including device malfunctions and thromboembolic events 4.
• The focus in published literature is on device selection and thrombectomy technique rather than sheath management 2, 3, 5.

Practical Considerations

In the absence of guideline-level evidence, standard endovascular practice principles apply:

• Continuous heparinized saline flush through sheaths is standard practice in neurointerventional procedures to prevent thrombus formation 6.
• The decision to use a pressure bag versus manual flush depends on institutional protocols and operator preference, as this technical detail has not been studied in randomized trials.
• The critical priority is avoiding any delay to groin puncture and recanalization, as time to treatment directly impacts outcomes 1, 4.

Key Procedural Priorities

• Do not delay catheter angiography while evaluating response to IV thrombolysis 1, 4.
• Bridging thrombolysis (IV tPA followed by thrombectomy) achieves better functional outcomes than direct thrombectomy alone, with higher successful recanalization rates 4.
• Focus should remain on rapid, effective recanalization using evidence-based devices rather than ancillary technical details 1.