True first-pass effect in basilar artery occlusions: First-pass complete reperfusion improves clinical outcome in stroke thrombectomy patients

Background and Purpose: In the settings of thrombectomy, the first-pass effect (FPE), defined by a complete recanalization after one pass with no rescue therapy, has been shown to be associated with an improved outcome. As this phenomenon has been predominantly described in anterior circulation strokes, we aimed to study the prevalence, outcomes, and predictors of FPE in patients with a basilar artery occlusion. Methods: From a prospective multicentric registry, we collected the data of all consecutive basilar artery occlusion patients who underwent thrombectomy and compared the outcomes of patients who achieved FPE and those who did not. We also compared FPE patients with those who achieved a complete recanalization with >1 pass. Finally, a multivariate analysis was performed to determine the predictors of FPE. Results: Data from 280 patients were analyzed in our study, including 84 of 280 patients (30%) with an atheromatous etiology. An FPE was achieved in 93 patients (33.2%), with a significantly higher proportion of good outcomes (modified Rankin Scale score 0-2 at 3 months) and lower mortality than non-FPE patients. An FPE was also associated with improved outcomes compared with patients who went on to have full recanalization with >1 pass. Contact aspiration as first-line strategy was a strong predictor of FPE, whereas baseline antiplatelets and atheromatous etiology were negative predictors. Conclusions: In our study, an FPE was achieved in approximately one-third of patients with a basilar artery occlusion and was associated with improved outcomes. More research is needed to improve devices and techniques to increase the incidence of FPE. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03776877.

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First pass effect in patients with large vessel occlusion strokes undergoing neurothrombectomy: insights from the Trevo Retriever Registry

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-016952 ◽

2021 ◽

pp. neurintsurg-2020-016952

Author(s):

Ashutosh P Jadhav ◽

Shashvat M Desai ◽

Ronald F Budzik ◽

Rishi Gupta ◽

Blaise Baxter ◽

...

Keyword(s):

Atrial Fibrillation ◽

Basilar Artery ◽

Artery Occlusion ◽

Large Vessel ◽

Basilar Artery Occlusion ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Single Pass ◽

First Pass Effect ◽

First Pass

BackgroundFirst pass effect (FPE), defined as near-total/total reperfusion of the territory (modified Thrombolysis in Cerebral Infarction (mTICI) 2c/3) of the occluded artery after a single thrombectomy attempt (single pass), has been associated with superior safety and efficacy outcomes than in patients not experiencing FPE.ObjectiveTo characterize the clinical features, incidence, and predictors of FPE in the anterior and posterior circulation among patients enrolled in the Trevo Registry.MethodsData were analyzed from the Trevo Retriever Registry. Univariate and multivariable analyses were used to assess the relationship of patient (demographics, clinical, occlusion location, collateral grade, Alberta Stroke Program Early CT Score (ASPECTS)) and device/technique characteristics with FPE (mTICI 2c/3 after single pass).ResultsFPE was achieved in 27.8% (378/1358) of patients undergoing anterior large vessel occlusion (LVO) thrombectomy. Multivariable regression analysis identified American Society of Interventional and Therapeutic Neuroradiology (ASITN) levels 2–4, higher ASPECTS, and presence of atrial fibrillation as independent predictors of FPE in anterior LVO thrombectomy. Rates of modified Rankin Scale (mRS) score 0–2 at 90 days were higher (63.9% vs 53.5%, p<0.0006), and 90-day mortality (11.4% vs 12.8%, p=0.49) was comparable in the FPE group and non-FPE group. Rate of FPE was 23.8% (19/80) among basilar artery occlusion strokes, and outcomes were similar between FPE and non-FPE groups (mRS score 0–2, 47.4% vs 52.5%, p=0.70; mortality 26.3% vs 18.0%, p=0.43). Notably, there were no difference in outcomes in FPE versus non-FPE mTICI 2c/3 patients.ConclusionTwenty-eight percent of patients undergoing anterior LVO thrombectomy and 24% of patients undergoing basilar artery occlusion thrombectomy experience FPE. Independent predictors of FPE in anterior circulation LVO thrombectomy include higher ASITN levels, higher ASPECTS, and the presence of atrial fibrillation.

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Identifying the predictors of first-pass effect and its influence on clinical outcome in the setting of endovascular thrombectomy for acute ischemic stroke: Results from a multicentric prospective registry

International Journal of Stroke ◽

10.1177/1747493020923051 ◽

2020 ◽

pp. 174749302092305 ◽

Cited By ~ 1

Author(s):

Federico Di Maria ◽

Maéva Kyheng ◽

Arturo Consoli ◽

Jean-Philippe Desilles ◽

Benjamin Gory ◽

...

Keyword(s):

Ischemic Stroke ◽

Clinical Outcome ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Modified Rankin Scale ◽

Lower Systolic Blood Pressure ◽

Excellent Outcome ◽

First Pass Effect ◽

First Pass ◽

Thrombectomy Device

Background The first-pass effect, defined as a complete or near-complete recanalization after one pass (first-pass effect) of a mechanical thrombectomy device, has been related to better clinical outcome than good recanalization after more than one pass in acute ischemic stroke. We searched for predictors of first-pass effect by analyzing the results within a large prospective multicentric registry. Methods We included patients treated by mechanical thrombectomy for isolated anterior intracranial occlusions. A multi-variate logistic regression analysis was carried out to search for predictors of first-pass effect. We also analyzed the percentage of patients with 90-day modified Rankin Scale score 0 to 2, excellent outcome (90-day modified Rankin Scale 0 to 1), 24-h NIHSS change, and 90-day all-cause mortality. Results Among the 1832 patients included, clinical outcome at 90 days was significantly better in first-pass effect patients (50.6% vs. 38.9% in patients without first-pass effect), with a center-adjusted OR associated with first-pass effect of 1.74 (95%CI, 1.24 to 1.77). Older age, a lower systolic blood pressure, an MCA-M1 occlusion, higher DWI-ASPECTS at admission, mechanical thrombectomy under local anesthesia, and combined first-line device strategy were independent predictors of first-pass effect. Conclusions In this study, a strategy combining thrombectomy and thrombo-aspiration was more effective than other strategies in achieving first-pass effect. In addition, we confirm that clinical outcome was better in patients with first-pass effect compared to non-first-pass effect patients.

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Significance of angiographic clot meniscus sign in mechanical thrombectomy of basilar artery stroke

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2019-015321 ◽

2019 ◽

Vol 12 (5) ◽

pp. 477-482

Author(s):

Sung Hyun Baik ◽

Joon Whi Kim ◽

Byung Moon Kim ◽

Dong Joon Kim

Keyword(s):

Basilar Artery ◽

Mechanical Thrombectomy ◽

Side Wall ◽

Artery Occlusion ◽

Basilar Artery Occlusion ◽

Procedure Time ◽

First Pass Effect ◽

First Pass ◽

Number Of Passes ◽

The Relationship

IntroductionThe relationship between the occlusive clot morphology and the efficacy of mechanical thrombectomy (MT) in basilar artery occlusion (BAO) is not well known. Our aim was to evaluate the clinical significance of the clot meniscus sign in patients with acute BAO.Methods89 patients with acute BAO who underwent MT were retrospectively analyzed. The clot meniscus sign was defined as meniscoid/tram-track like antegrade side-wall contrast opacification of the thrombus. Patients were assigned to two groups based on the presence of the clot meniscus sign. The treatment and clinical outcomes were compared.ResultsThe clot meniscus sign was diagnosed in 62.9% (53/89) of the patients. The meniscus sign (+) group showed a shorter procedure time (55 vs 85 min; p=0.045), higher rate of successful recanalization (89.3% vs 63.6%, p=0.004), higher incidence of first pass effect (32.1% vs 6.1%, p=0.004), and lower number of passes (2 vs 3; p=0.042) when compared with the meniscus sign (−) group. The procedure time (OR 0.972, 95% CI 0.962 to 0.992; p=0.003) and clot meniscus sign (OR 7.920, 95% CI 1.769 to 35.452; p=0.007) were independent predictors of successful recanalization.ConclusionThe clot meniscus sign is related to high first pass effect and short procedure time and is a reliable predictor of successful recanalization in patients with acute BAO.

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True first-pass effect in basilar artery occlusions: first-pass complete reperfusion improves clinical outcome in stroke thrombectomy patients

10.21203/rs.3.rs-15959/v1 ◽

2020 ◽

Author(s):

Nuran Abdullayev ◽

Volker Maus ◽

Daniel Behme ◽

Utako B Barnikol ◽

Seraphine Kutschke ◽

...

Keyword(s):

Ischemic Stroke ◽

Basilar Artery ◽

Symptom Onset ◽

Posterior Circulation ◽

Favorable Outcome ◽

Basilar Artery Occlusion ◽

Stroke Severity ◽

Single Pass ◽

First Pass Effect ◽

First Pass

Abstract Background Complete reperfusion (mTICI 3) in anterior circulation ischemic stroke patients after a single mechanical thrombectomy (MT) pass has been identified as a predictor of favorable outcome (modified Rankin Score 0-2) and defined as true first-pass effect recently. This effect has not yet been demonstrated in posterior circulation ischemic stroke. We hypothesized a true first-pass effect for the subgroup of acute basilar artery occlusions (BAO). Methods Consecutive patients with acute thromboembolic occlusions in the posterior circulation, treated between 2010 and 2017, were screened and all BAO patients with complete angiographic reperfusion and known symptom onset included for unmatched and matched analysis after adjustment for multiple confounding factors (demographics, time intervals, stroke severity, posterior circulation Alberta Stroke Program early computed tomography Score and comorbidity. The primary objective was outcome at 90 days between matched cohorts of single pass vs. multi pass complete reperfusion patients. Results 90 MTs in BAO were analyzed, yielding 56 patients with known symptom onset, in whom we achieved complete reperfusion (mTICI 3), depending on whether complete reperfusion was achieved after a single pass (n=28) or multiple passes (n=28). Multivariable analysis of 56 non-matched patients revealed a significant association between first-pass complete reperfusion and favorable outcome (p<0.01). In matched cohorts (n=7 vs. n=7), favorable outcome was only seen if complete reperfusion was achieved after a single pass (86% vs. 0%). Conclusion Single pass complete reperfusion in acute basilar artery occlusion is an independent predictor of favorable outcome. Achieving complete reperfusion after multiple passes might impair favorable patient recovery.

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Correction to: Good Clinical Outcome Decreases With Number of Retrieval Attempts in Stroke Thrombectomy: Beyond the First-Pass Effect

Stroke ◽

10.1161/str.0000000000000371 ◽

2021 ◽

Vol 52 (4) ◽

Keyword(s):

Clinical Outcome ◽

Good Clinical Outcome ◽

First Pass Effect ◽

First Pass

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Abstract WP40: Balloon Guide Catheter Utilization With Continuous Aspiration Prior to Intracranial Vascular Embolectomy (BGC-CAPTIVE) Associated With Greater Recanalization

Stroke ◽

10.1161/str.51.suppl_1.wp40 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Weiyi Le ◽

Mahesh V Jayaraman ◽

Grayson L Baird ◽

Brian C Mac Grory ◽

Tina M Burton ◽

...

Keyword(s):

Clinical Outcome ◽

Post Treatment ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

First Pass Effect ◽

Guide Catheter ◽

First Pass

Background: Among thrombectomy techniques, Continuous Aspiration Prior to Intracranial Vascular Embolectomy (CAPTIVE) is associated with higher rates of recanalization. Initially, CAPTIVE was performed without a balloon guide catheter (BGC). We aimed to determine the association between BGC usage with final recanalization as well as first pass effect in patients with anterior circulation emergent large vessel occlusion. Methods: We retrospectively reviewed consecutive patients with ICA and M1 occlusions treated with thrombectomy using CAPTIVE over a 45-month period. Post-treatment angiograms were scored by an experienced neurointerventionalist who was blinded to BGC usage and clinical outcome. For both BGC and non-BGC groups, we compared degree of recanalization (using the mTICI 2c scale), first-pass successful recanalization (mTICI 2c/3), and time to recanalization. We examined these results for all patients as well as based on clot location (ICA vs. M1). Results: 357 patients met criteria (median age: 73, median NIHSS: 17) for whom BGC was used in 37/70 (53%) with ICA and 116/287 (40%) with M1 occlusion. Odds of successful reperfusion increased 2.4-fold and odds of complete reperfusion increased 3-fold using BGC (both p<.01). Odds of successful first-pass recanalization (mTICI 2c/3) increased 5-fold for ICA occlusions (p=.004) and 1.7-fold for M1 (p=.03) (See Figure). Recanalization time with BGC for ICA occlusions was faster (22 vs. 36 min, p=.02) but there was no difference in time for M1 occlusions (24 vs. 26 min). Conclusions: BGC usage with the CAPTIVE technique is associated with higher recanalization rates, markedly higher first pass effect (mTICI 2c/3) for both ICA and M1 occlusions, and faster recanalization for ICA occlusions.

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Beyond the first pass: revascularization remains critical in stroke thrombectomy

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2019-014773 ◽

2019 ◽

Vol 11 (11) ◽

pp. 1095-1099 ◽

Cited By ~ 13

Author(s):

Gaurav Jindal ◽

Helio De Paula Carvalho ◽

Aaron Wessell ◽

Elizabeth Le ◽

Varun Naragum ◽

...

Keyword(s):

Clinical Outcome ◽

Functional Outcomes ◽

Good Clinical Outcome ◽

Vessel Occlusion ◽

First Pass Effect ◽

Significant Difference ◽

First Pass ◽

Scale Scores ◽

The One ◽

Number Of Passes

BackgroundThe first pass effect has been recently reported as a predictor of good clinical outcome after stroke thrombectomy. We evaluate the first pass effect on outcome and the influence of revascularization in these and other patients.MethodsWe performed a retrospective analysis of a prospectively maintained database on anterior cerebral circulation stroke thrombectomy cases from April 2012 to April 2018. Data compiled included patient demographics, presenting National Institutes of Health Stroke Scale score, vessel occlusion site, thrombectomy procedural details, and 90 day modified Rankin Scale scores.Results205 patients were included. The numbers of patients who underwent one, two, three, four, five, and six passes were 69, 70, 55, 9, 1, and 1, respectively. Successful revascularization was achieved in 87%, 83%, and 64% of patients in the one, two, and 3 or more passes groups, respectively (p=0.002). Good functional outcome was inversely correlated with number of passes when comparing the one, two, and three or more passes groups (54%, 43%, 29%; P=0.014). In patients with full revascularization, there was no significant difference in good functional outcomes between the one, two, and three or more passes groups (64%, 65%, 50%; P=0.432). Number of passes was not an independent negative predictor of good clinical outcome (OR 1.66, 95% CI 0.82 to 3.39; P=0.165).ConclusionsFirst pass thrombectomy patients have better functional outcomes compared with beyond-first pass patients. This effect is related at least in part to a higher rate of revascularization in one pass patients. Revascularization beyond the first pass should continue to be the goal of stroke thrombectomy.

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First pass effect with contact aspiration and stent retrievers in the Aspiration versus Stent Retriever (ASTER) trial

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2019-015215 ◽

2019 ◽

Vol 12 (4) ◽

pp. 386-391 ◽

Cited By ~ 19

Author(s):

Célina Ducroux ◽

Michel Piotin ◽

Benjamin Gory ◽

Julien Labreuche ◽

Raphael Blanc ◽

...

Keyword(s):

Clinical Outcome ◽

Rescue Therapy ◽

Hemorrhagic Transformation ◽

Stent Retriever ◽

Complete Revascularization ◽

Unique Identifier ◽

First Pass Effect ◽

Significant Difference ◽

First Pass ◽

Stent Retrievers

BackgroundThe ‘first pass effect’ (FPE), which was originally described with stent retrievers, designates a (near-)complete revascularization obtained after a single device pass with no rescue therapy, and is associated with improved clinical outcome and decreased mortality.ObjectiveWe report the rate and benefits of FPE in the Aspiration versus Stent Retriever (ASTER) trial.Materials and methodsASTER is a randomized trial comparing angiographic revascularization with the stent retriever (SR) and contact aspiration (CA) thrombectomy techniques, assessed by an external core laboratory using the modified Thrombolysis in Cerebral Infarction (mTICI) scale. Rates of FPE (defined by mTICI 2c/3 after a single pass with no rescue therapy) were compared between patients treated with SR and CA techniques. Outcomes were compared between FPE-SR and FPE-CA patients, and between FPE and non-FPE patients.ResultsFPE was achieved in 97/336 patients (28.9%), with no significant difference between SR and CA (respectively 53/169 patients (31.3%) vs 44/167 patients (26.3%), adjusted RR for CA versus SR 0.84, 95% CI 0.54 to 1.31; p=0.44). After prespecified adjustment for allocated arm and randomization stratification factors, FPE in patients was associated with a significantly improved clinical outcome and a decreased mortality, and a significantly lower rate of hemorrhagic transformation and procedural complications than in non-FPE patients.ConclusionIn the ASTER trial, similar rates of FPE were achieved with SR and CA, and FPE was associated with a significantly improved outcome. New techniques and devices to improve the rate of FPE are warranted.Trial registration numberUnique identifier: NCT02523261.

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