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neurintsurg-​2017-​013256).
1
Department of Radiology,
Interventional Neuroradiology
Division, Stanford University
Hospital, Stanford, California,
USA
2
Neurointerventional Surgery,
California Pacific Medical
Center, San Francisco, California,
USA
3
Department of Neurosurgery,
Stanford University Hospital,
Stanford, California, USA
Correspondence to
Dr Jeremy J Heit, Department of
Radiology, Neuroimaging and
Neurointervention, Stanford
University Hospital, 300 Pasteur Results  263 Patients (181 females, 69%) who
Drive, S0047 Stanford, CA
94305, USA; ​jheit@​stanford.​edu
Received 12 June 2017
Revised 3 July 2017
Accepted 6 July 2017
To cite: Heit JJ, Wong JHY,
Mofaff AM, et al.
J NeuroIntervent Surg
Published Online First: [please
include Day Month Year].
doi:10.1136/
neurintsurg-2017-013256
Original research
Sofia intermediate catheter and the SNAKE
technique: safety and efficacy of the Sofia catheter
without guidewire or microcatheter construct
Jeremy J Heit,1 Johnny HY Wong,1 Adrienne M Mofaff,1 Nicholas A Telischak,2
Robert L Dodd,3 Michael P Marks,1 Huy M Do1
ABSTRACT
Background  Neurointerventional surgeries (NIS)
a soft-tipped, flexible, braided single lumen intermediate
catheter designed for NIS. Sofia advancement from the
cervical to the intracranial circulation without a luminal
guidewire or microcatheter construct has not been
described.
Objective  To evaluate the efficacy and safety of the
new Sofia Non-wire Advancement techniKE (SNAKE) for
advancement of the Sofia into the cerebral circulation.
Methods  Consecutive patients who underwent
NIS using Sofia were identified. Patient information,
SNAKE use, and patient outcome were determined
from electronic medical records. Sofia advancement
to the cavernous internal carotid artery or the V2/V3
segment junction of the vertebral artery was the primary
outcome measure. Secondary outcomes included arterial
vasospasm and arterial dissection.
underwent a total of 305 NIS using Sofia were identified.
SNAKE (SNAKE+) was used in 187 procedures (61%).
Two hundred and ninety-three procedures (96%) were
technically successful, which included 184 SNAKE+ NIS
and 109 SNAKE− NIS. Primary outcome was achieved
in all SNAKE+ procedures, but not in five SNAKE−
procedures (2%). No arterial dissections were identified
among 305 interventions. In the intracranial circulation,
a single SNAKE+ patient (0.5%) had non-flow limiting
arterial vasospasm involving the petrous internal carotid.
Three SNAKE+ patients (1.6%) and one SNAKE− patient
(0.8%) demonstrated external carotid artery branch
artery vasospasm during dural arteriovenous fistula or
facial arteriovenous malformation treatment.
Conclusion  SNAKE is a safe and effective technique for
Sofia advancement. Sofia is a highly effective and safe
intermediate catheter for a variety of NIS.
Introduction
Neurointerventional surgeries (NIS) treat a wide
range of cerebrovascular pathology that includes
cerebral aneurysms, arteriovenous malformations,
dural arteriovenous fistulae, ischemic stroke, and
intracranial atherosclerotic disease among other
pathologies. Intermediate catheters provide addi-
tional support to endovascular constructs to facil-
itate NIS.1–5 While some have found that interme-
diate catheters increase the safety of NIS,3 others
have found similar complication rates between NIS
Heit JJ, et al. J NeuroIntervent Surg 2017;0:1–6. doi:10.1136/neurintsurg-2017-013256
New devices
performed with and without intermediate cathe-
ters.2
A variety of methods are used to advance inter-
mediate catheters into the proximal cerebral circu-
lation. For example, an intermediate catheter may
be advanced over a guidewire or over a microca-
theter construct, both of which require equipment
introduction through the intermediate catheter.
Placement of equipment into an intermediate cath-
eter has greater potential for complications, either
by introducing air into the endovascular construct
or thrombus formation within the lumen of the
intermediate catheter, by decreasing luminal dead
space.
Here we describe the Sofia Non-wire Advance-
ment techniKE (SNAKE), a new technique by
which the soft-tipped Sofia intermediate catheter
(MicroVention, Tustin, California, USA) is intro-
duced into the intracranial circulation without the
assistance of a guidewire or microcatheter construct
within the Sofia lumen. The safety and efficacy of
SNAKE is evaluated relative to conventional means
of advancing the Sofia over a guidewire or microca-
theter construct.
Materials and methods
Patient identification and inclusion
Our hospital’s Institutional review board approved
this study, which complied with the Health Insur-
ance Portability and Accountability Act. We retro-
spectively identified all patients who underwent a
NIS using the 5-French Sofia or 6-French Sofia Plus
intermediate catheter (MicroVention, Tustin, Cali-
fornia, USA) between January 1, 2014 and April 1,
2017 at our neurovascular referral center from a
prospectively collected neurointerventional data-
base. Patient data were obtained from the electronic
medical record.
Procedural technique
All procedures were performed using a Siemens
Artis Zee biplane system in a dedicated neuroan-
giography suite. Procedures were performed under
monitored anesthesia care or general anesthesia.
Neurophysiologic monitoring was used for all
procedures except for tumor embolizations and
stroke interventions.
Neurointerventional procedures were
performed after catheterizing the common
femoral artery with a 6-French shuttle SL sheath
   1
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New devices
(Cook Medical, Bloomington, Indiana, USA) or an 8-French
Table 1  Sofia SNAKE and complications
Brite Tip sheath (Cordis, Milpitas, California, USA). Intrave-
nous heparin was administered to achieve an activated clotting All SNAKE (−) SNAKE (+)
time of 250–300 s after arterial access was obtained. Cerebral Total procedures 305 (100%) 119 (39%) 187 (61%)
digital subtraction angiography (DSA) was performed with a Total patients 263 (100%) 105 (40%) 158 (60%)
5-French Berenstein II catheter (Cook Medical, Bloomington, Female 181 (69%) 111 (61%) 70 (39%)
Indiana, USA) positioned in the common carotid artery, Age
internal carotid artery (ICA) or the vertebral artery. The  Average age (years) 59 57 61*
Berenstein catheter was then replaced with a 5- or 6-French  Age range (years) 47–74 46–73 51–76
Sofia catheter, which was advanced into the supraclinoid ICA, Pathology treated
M1 segment of the middle cerebral artery, V4 segment of the  Ischemic stroke 80 (26%) 30 (38%) 50 (62%)
vertebral artery, or basilar artery for the subsequent NIS. All
 Cerebral aneurysm 92 (30%) 49 (53%) 43 (47%)
sheaths, Berenstein catheters, Sofia catheters, and microcath-
 Cerebral vasospasm 30 (10%) 7 (23%) 23 (77%)
eters were connected to a continuous heparinized saline flush
 Cerebral AVM 44 (14%) 9 (20%) 35 (80%)
with a Tuohy Borst adapator.
 Facial AVM 7 (2%) 1 (14%) 6 (86%)
 Dural arteriovenous fistula 29 (10%) 14 (48%) 15 (52%)
Sofia Non-wire Advancement techniKE (SNAKE)  Carotid-cavernous fistula 6 (2%) 1 (17%) 5 (83%)
There are four neurointerventionalists in our practice, which  Intracranial atherosclerotic
includes two physicians who used SNAKE in every procedure disease 10 (3%) 3 (30%) 7 (70%)
during the time period evaluation and two physicians who did  Tumor 6 (2%) 3 (50%) 3 (50%)
not use SNAKE. The distal end of the Sofia catheter is extremely  Operative internal carotid
soft and pliable, which led us to test whether the Sofia could be artery injury 1 (0.3%) 1 (100%) 0 (0%)
safely advanced into the cerebral circulation without a guiding *p=0.1, Student’s t test.
wire, microcatheter, or microcatheter and microwire construct AVM, arteriovenous malformation.
within it (SNAKE). SNAKE was performed by introducing the
5-French Sofia or 6-French Sofia Plus into the shuttle sheath Results
positioned in the distal common carotid artery, proximal Two hundred and sixty-three patients (181 females, 69%) who
cervical ICA, subclavian artery, or V1 segment of the verte- underwent a total of 305 interventions using the Sofia catheter
bral artery. Under continuous roadmap guidance, the Sofia was were identified within the study period. Mean patient age was
then advanced through the shuttle into the ICA or vertebral 59 years (IQR 47–74). Cerebral aneurysm embolization (92
artery with no additional equipment within the Sofia lumen. procedures, 30%), acute stroke intervention (80 procedures,
Sofia advancement using SNAKE was stopped when moderate 26%), and cerebral arteriovenous malformation embolization
buckling of the Sofia was observed or any significant resistance (44 procedures, 14%) were the most commonly performed
was felt by the neurointerventionalist. If more distal naviga- interventions (table 1). The 5-French Sofia was used for the
tion of the Sofia was necessary, the SNAKE was terminated majority of procedures (219 procedures, 72%) compared with
and a microcatheter and microwire were then introduced into the 6-French Sofia (86 procedures, 28%) (table 1). However,
the Sofia and advanced more distally. The Sofia was then navi- the 6-French Sofia (69 procedures, 75%) was more commonly
gated over the microwire and microcatheter to the desired used for cerebral aneurysm treatment, which was frequently
position in the intracranial circulation. performed using a balloon microcatheter (30 procedures; 33%)
or stent (12 procedures, 13%) assistance.
Imaging and outcome analysis SNAKE was used in 186 procedures (SNAKE+ group), which
All DSA images from NIS in the study were reviewed by two included 148 procedures with the 5-French Sofia (79%) and 38
neurointerventional radiologists with 4 and 20 years of experi- procedures with the 6-French Sofia Plus (20%). By contrast,
ence. The primary outcome measure was defined as successful conventional Sofia advancement with a guidewire or microcath-
advancement of Sofia to at least the posterior genu of the eter construct (SNAKE− group) was used in 119 patients, which
cavernous ICA in the anterior circulation or to at least the V2/ included 71 procedures with the 5-French Sofia (60%) and 48
V3 segment junction of the vertebral artery in the posterior procedures with the 6-French Sofia Plus (40%). Ischemic stroke
circulation. The secondary outcome measure was complica- treatment (50 procedures), cerebral aneurysm embolization (43
tions that included angiographic evidence of arterial dissection procedures), and cerebral AVM embolization (35 procedures)
or vasospasm following Sofia introduction. The procedure were the most commonly performed NIS that used SNAKE
reports for all studies were reviewed for mention of dissection (table 1). The slight differences in NIS performed between the
or vasospasm. The reports were also reviewed for the use of SNAKE+ and SNAKE− groups reflected variations in physi-
intraprocedural nitroglycerin, which was considered a proxy cian practice pattern rather than a preference for SNAKE when
for non-imaged vasospasm. treating certain types of pathology.
Two hundred and ninety-three procedures (96%) in this study
were technically successful, which included 109 procedures in
Statistical analysis the SNAKE− group (92%) and 184 procedures in the SNAKE+
Statistical analysis was performed using XLSTAT (Addinsoft, group (98%). In the anterior circulation, SNAKE was used to
New York, USA). Χ2 Analysis was used for discontinuous advance the Sofia to at least the posterior genu of the cavernous
variables, and Student’s t test for continuous variables. The ICA (figures 1 and 2 and online supplementary videos 1 and
expected procedural success rate was 95% for the effective- 2) and as distal as the M1 segment of the ICA in all NIS. In
ness analysis. A p value of 0.05 was considered statistically the posterior circulation, SNAKE advanced the Sofia to at least
significant. the distal V2 segment of the vertebral artery and as distal as the
2 Heit JJ, et al. J NeuroIntervent Surg 2017;0:1–6. doi:10.1136/neurintsurg-2017-013256
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Figure 1  Elderly patient with an acute ischemic stroke due to occlusion of the M1 segment of the left middle cerebral artery (MCA). (A) Diffusion-
weighted imaging shows a small acute infarction in the left caudate and lentiform nucleus (arrow). (B) Axial maximum intensity projection
image from MR angiography shows occlusion of the M1 segment of the left MCA (arrow). (C) Perfusion-weighted imaging identifies a large
penumbra (arrow) on the time-to-maximum maps. (D) Lateral roadmap image following injection of the left common carotid artery demonstrates
multiple acute turns within the left internal carotid artery (ICA; dashed arrows). This vessel was traversed with a 5-French Sofia using SNAKE (see
online supplementary video 1). (E) Anteroposterior view after left ICA injection demonstrates occlusion of the M1 segment of the left MCA (arrow). (F)
Complete reperfusion of the left MCA (arrow) is present after combined suction and mechanical thrombectomy.

basilar artery (figure 3 and online supplementary video 3) in all Discussion

NIS. SNAKE was used to advance Sofia through 360 degree loops
in the cervical common carotid artery and ICA without diffi-
culty (online  supplementary video 2). In the SNAKE−  group,
Sofia could not be advanced to at least the posterior genu of the
cavernous ICA in four patients and to the V2/V3 junction in one
patient owing to excessive vascular tortuosity. A stable endovas-
cular construct that could safely facilitate embolization could not
be established in these five SNAKE− procedures, which  were
all  aborted. Four procedures in the SNAKE− group and three
in the SNAKE+ group were aborted owing to unfavorable
anatomy for endovascular aneurysm embolization or lack of a
suitable embolization target. Although SNAKE was more likely
to be associated with procedural success (p=0.02), this differ-
ence most likely reflects patient anatomic differences rather than
the use of this technique.
Complications related to Sofia and SNAKE use were
extremely uncommon. No arterial dissections were identified
among 305 interventions. Non-flow limiting arterial vaso-
spasm involving the petrous ICA secondary to a 6-French Sofia
was identified in a single SNAKE+ patient, and no other Sofia
related vasospasm instances were identified in the anterior or
posterior circulations in either group (table 2). One SNAKE−
patient and three SNAKE+ patients demonstrated external
carotid artery branch artery vasospasm after placement of
a 5-French Sofia for treatment of dural arteriovenous fistula
or facial arteriovenous malformations. None of the instances
of vasospasm was symptomatic, procedurally significant, or
clinically significant. There was no significant difference in the
complication rate between the SNAKE− and SNAKE+ groups
(p=0.5).
Heit JJ, et al. J NeuroIntervent Surg 2017;0:1–6. doi:10.1136/neurintsurg-2017-013256
Cerebrovascular diseases, such as aneurysms, AVMs, ischemic
stroke, and dural arteriovenous fistulae, are increasingly treated
by endovascular approaches.6 The technological advancements
in guide catheters, intermediate catheters, microcatheters, and
other neurointerventional equipment contribute to the ability
to treat these complex lesions. Intermediate catheters have
emerged as an important technological advance that facilitate
more efficient treatment of cerebrovascular disease.2 They
provide flexibility to the neurointeventionalist, who can adapt
the stability, support, and length of the endovascular construct
to his or her needs.1–3 In addition, intermediate catheters may
reduce procedure time and likely reduce the risk of arterial
dissection given the ability to re-access the cerebral circu-
lation by traversing fewer vascular segments multiple times
and improving the stability of support of the endovascular
construct.3 Despite these purported advantages of intermediate
catheters, NIS complication rates are similar to historical proce-
dures without intermediate catheters.2
The Sofia (Soft torqueable catheter Optimized For Intracranial
Access; MicroVention, Tustin, California, USA) is an interme-
diate catheter approved for intracranial use. It has an extremely
soft distal tip and has been shown to be an effective tool for isch-
emic stroke treatment and stent-assisted aneurysm coiling,4 7–10
although its effectiveness for other NIS has not been reported.
Early in our experience with Sofia, we discovered that Sofia’s
soft distal tip allowed this intermediate catheter to be advanced
into the intracranial circulation without a guidewire, microcath-
eter, or other luminal device (SNAKE). In this study, we describe
SNAKE as an effective and safe technique for Sofia advancement
during NIS. In addition, this study is the largest series to evaluate
3
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New devices
Figure 2  Elderly patient with subarachnoid hemorrhage due to
rupture of a recurrent left posterior communicating artery aneurysm
after prior coil embolization. The aneurysm was re-treated by balloon-
assisted coiling. (A) Non-contrast head CT shows diffuse subarachnoid
hemorrhage (SAH) throughout the basal cisterns (arrow). (B)
Roadmap image following injection of the left common carotid artery
demonstrates a 360 degree loop in the proximal common carotid
artery (arrow). This vessel was traversed with a 6-French Sofia Plus
using SNAKE (see online supplementary video 2). (C) Lateral DSA
image following injection of the cervical left internal carotid artery
demonstrates a broad-based posterior communicating artery aneurysm
(arrow) that is the cause of the patient’s SAH. (D) The posterior
communicating artery aneurysm no longer fills following balloon-
assisted coil embolization (arrow).
the technical success and complication rates related to the Sofia
intermediate catheter across a variety of NIS.
SNAKE was rapid and highly effective in introducing both the
5-French and 6-French Sofia into the intracranial circulation.
The Sofia was advanced to the posterior genu of the cavernous
ICA or the V3 segment of the vertebral artery without any resis-
tance or difficulty in all cases. In one stroke intervention, the
Sofia was advanced using SNAKE to a clot interface in the M1
segment of the middle cerebral artery, which facilitated rapid
revascularization in this patient.
The main advantage of SNAKE is more rapid access to the
intracranial circulation without having to introduce a guidewire
or microcatheter construct. Routinely in our practice, one oper-
ator advances the Sofia into the intracranial circulation using
SNAKE, while a second operator prepares the microcatheter and
microwire for the planned NIS on the back table. Thus, SNAKE
allows the procedure to proceed efficiently, which provides
benefit to all NIS in the reduction of in-dwelling catheter times
and in particular, for stroke interventions. We did not compare
procedure times between the SNAKE− and SNAKE+ groups
because our non-randomized study design, but a future study
might assess time as an outcome measure.
A second potential advantage of SNAKE is a reduction in the
distance of intracranial artery that must be traversed by a micro-
catheter and microwire, which may reduce the risk of arterial
dissection and vasospasm.
4 Heit JJ, et al. J NeuroIntervent Surg 2017;0:1–6. doi:10.1136/neurintsurg-2017-013256
A third advantage of SNAKE is a possible reduction in the
number of times equipment is introduced into the Sofia. Guide-
wire and microcatheter placement within an intermediate cath-
eter introduces the possibility of air entering the closed system.
Furthermore, equipment placement within an intermediate cath-
eter increases the likelihood of thrombus formation within the
construct due to increased foreign material surface area that may
contact blood, blood stasis within the intermediate catheter due
to interruption of heparinized saline flush, and reduced luminal
dead space. Although SNAKE does not reduce these variables
throughout the duration of the procedure, it does minimize the
risk of one step of the procedure, which may increase the safety
of the procedure.
Lastly, our results raise the possibility of reduced equipment
costs in NIS if the need for guidewires, microcatheters, and/or
microwires can be eliminated. Although most procedures will
still require these pieces of equipment, one can imagine how a
stroke intervention performed using an aspiration thrombec-
tomy approach might not require this equipment if Sofia can be
advanced to the thrombus interface using SNAKE.
Sofia was a highly effective as an intermediate catheter in
our study, and 96% of the 305 NIS were technically successful.
Sofia performed well in both the SNAKE− and SNAKE+
groups, and the minor differences in procedural success
between these groups reflected patient anatomic variations
rather than technical differences in the procedure. Sofia was
successfully navigated through significant vascular tortuosity
and into the desired position in the intracranial circulation in
all but five procedures. It is difficult to compare the effec-
tiveness of Sofia with prior studies of intermediate catheters
because technical success was either not described or was
described for stroke interventions only.1–4 8 9 11 12 However,
we have found that Sofia’s trackability into the intracranial
circulation is excellent, and the technical success of this study
compares favorably with prior studies of Sofia for stroke inter-
vention.4 12
Both Sofia and SNAKE had an excellent safety profile, and
no instances of arterial dissection, flow limiting vasospasm, or
other complications were seen in our study. This safety profile
is superior to older generation intermediate catheters.2 The
external carotid artery braches were more prone to vasospasm
than the vasculature of the anterior and posterior circulations
(four patients versus one patient), which likely reflects the
anecdotal propensity of the external carotid artery branches
for vasospasm during angiography.
Sofia intermediate catheters have a couple of disadvantages.
First, although the softness of the distal tip allows for SNAKE, it
is less supportive than stiffer intermediate catheters. This slight
decrease in support results in a need for more frequent relax-
ation and addition of tension in the endovascular construct.
While the authors of this study have become accustomed to
interacting more with Sofia relative to other intermediate cath-
eters to adjust for this difference, others may find this property
is a limitation in their practice. Next, the slightly larger outer
diameter of the 6-French Sofia (0.0825 in) may lead to incom-
patibility with some endovascular constructs, particularly those
used for ischemic stroke treatment. We routinely placed the
6-French Sofia (Sofia Plus) through a 6-French shuttle sheath
(Cook Medical) without difficulty, but neurointerventionalists
should note equipment sizes to ensure endovascular construct
compatibility with the larger Sofia Plus. We expect that future
generations of the Sofia may deal with these shortcomings.
The study has several limitations. First, this is a non-ran-
domized study for comparison of the SNAKE− and SNAKE+
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New devices

Figure 3  Young patient with an acute ischemic stroke due to occlusion of the mid-basilar artery. (A) Diffusion-weighted imaging shows acute
infarction in the left pons (arrow). (B) Axial maximum intensity projection image from MR angiography (MRA) shows minimal flow-related signal
within the basilar artery (arrow). (C) Reconstructed MRA image in the lateral project demonstrates occlusion of the mid-basilar artery (arrow). The
patient has widely patient posterior communicating arteries (arrowhead) that supply the posterior cerebral arteries (dashed arrow). (D) Lateral
roadmap image following injection of the left vertebral artery demonstrates multiple acute turns within this vessel (dashed arrows). This vessel was
traversed with a 5-French Sofia using SNAKE (see online supplementary video 3). (E) Lateral view after left vertebral artery injection demonstrates
occlusion of the mid-basilar artery (arrow). (F) Complete reperfusion of the basilar artery (arrow) is present after combined suction and mechanical
thrombectomy.

groups, which might have introduced operator bias. This Conclusions

study design introduces the possibility of other variables that
influence the technical success and safety outcome measures.
Additionally, the size of our cohorts, self-reported results,
and inclusion of patients from a single neurovascular referral
center might have biased our results. These shortcomings
could be overcome through a larger, randomized trial. Lastly,
we describe SNAKE as a technique for advancement of the
Sofia intermediate catheter. We have not applied this tech-
nique routinely to other intermediate catheters, but such a
study could certainly be performed. We would advocate that
the application of SNAKE to other catheters be undertaken
with caution as intermediate catheters have varying degrees of
softness, which may affect the risk of vessel dissection during
non-wire advancement.
The Sofia Non-wire Advancement techniKE (SNAKE) is a safe
and effective technique for Sofia advancement into the intracra-
nial circulation. Sofia is a highly effective and safe intermediate
catheter during a variety of NIS.
Contributors  All authors made substantial contributions to the conception and
design of the study, acquisition of data, or analysis and interpretation of data.
Funding  This research received no specific grant from any funding agency in the
public, commercial or not-for-profit sectors.
Competing interests  JJH and HMD are consultants for MicroVention, Inc.
Ethics approval  Institutional review board.
Provenance and peer review  Not commissioned; externally peer reviewed.
Data sharing statement  Published and unpublished data may be shared for
additional publications pending the authors’ agreement to a research collaboration
when appropriate.

Table 2  Complications due to sofia and SNAKE © Article author(s) (or their employer(s) unless otherwise stated in the text of the
article) 2017. All rights reserved. No commercial use is permitted unless otherwise
Complica- Sofia Sofia expressly granted.
tions Sofia (All) (5-Fr) (6-Fr) SNAKE (−) SNAKE (+)
Vessel
dissection 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) References
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6 Heit JJ, et al. J NeuroIntervent Surg 2017;0:1–6. doi:10.1136/neurintsurg-2017-013256

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Sofia intermediate catheter and the SNAKE

technique: safety and efficacy of the Sofia
catheter without guidewire or microcatheter
construct
Jeremy J Heit, Johnny HY Wong, Adrienne M Mofaff, Nicholas A
Telischak, Robert L Dodd, Michael P Marks and Huy M Do

J NeuroIntervent Surg published online August 2, 2017

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