Adaptive pulsatile aspiration leads to improved thrombectomy outcomes during in vivo large vessel occlusion for acute ischemic stroke

Background Mechanical thrombectomy is the standard of care for large vessel occlusion (LVO) stroke, with current aspiration systems relying predominantly on static negative pressure for clot retrieval. Adaptive pulsatile aspiration (APA; ALGO smart pump, Von Vascular, Florida, USA) represents a novel non-static approach with promising in vitro results. In this study, we evaluated its in vivo reproducibility in a preclinical model. Methods Thrombectomies were performed using moderate and firm clot analogs in a swine carotid artery LVO model. Static aspiration (Penumbra ENGINE) was compared with APA across 40 procedures (30 APA and 10 static). Primary endpoints were complete clot ingestion (CCI), first pass effect (FPE), successful revascularization (Thrombolysis in Cerebral Infarction (TICI) score ≥2B), and distal embolization. Arterial wall histology was assessed by quantitative injury and endothelial denudation scoring. Results Overall rates were 82.5% successful revascularization, 72.5% CCI, and 70% FPE. CCI was associated with zero distal embolization versus 36.4% in cases with incomplete ingestion (P=0.004). APA was associated with higher rates than static aspiration across all endpoints: revascularization (90% vs 60%), CCI (83.3% vs 40%; P=0.014), FPE (80% vs 40%; P=0.041), and distal embolization (0% vs 40%; P=0.002). In subset analysis, a smaller bore catheter with APA outperformed a larger bore catheter with static aspiration, achieving TICI 3 and CCI in 80% versus 40% of cases. Histology revealed no excess vascular injury attributable to APA. Conclusions APA demonstrated higher rates of complete clot removal, revascularization, and first pass success than static aspiration, with a favorable safety profile. These findings support further clinical evaluation of waveform modulated aspiration strategies in human trials.