Mechanical Thrombectomy for Distal Occlusions: Efficacy, Functional and Safety Outcomes: Insight from the STAR collaboration

Background: Mechanical thrombectomy (MT) is the standard of care for acute ischemic stroke due to large vessel occlusions. There is strong evidence supporting the benefit of MT in proximal anterior circulation vessel occlusions and basilar occlusions. However, data regarding the efficacy and safety of MT in distal occlusions is scarce. In this study, we aim to report the efficacy, functional and safety outcomes of MT for distal occlusions. Methods: This a retrospective study from 14 comprehensive stroke centers across 4 countries. For the purpose of this study, distal occlusion was defined as MCA occlusion distal to M2 (M3-4 segments), any segments of ACA and any segments of PCA. Patients with concomitant proximal occlusions were excluded from this study. Results: Of 2826 patients, 111 patients were included in this study (mean (SD) age: 69 (13), 51% of patients were female, and 52% received tPA). Median onset to groin time was 241 (IQR, 136 minutes), median NIHSS on admission was 11 (IQR, 8), and median ASPECTS was 10 (IQR, 1). The procedure was done using ADAPT, stent retriever, and Solumbra techniques in 58%, 17% and 15% of patients respectively. Successful revascularization (mTICI 2b-3) and complete revascularization (mTICI 3) were achieved in 78% and 35% of our cohort, respectively. Median procedure time (puncture to revascularization or end of the procedure) was 29 minutes (IQR 42 minutes) and the median number of attempts was 1 (IQR=2). Five percent of patients suffered procedural complications Hemorrhagic complications occurred in 11% of patients of whom only 4% were PH2 hemorrhage. At the last follow up, mRS 0-2 was achieved in 53% of patients. Conclusion: Up to our knowledge, this represents the largest study to the date investigating the safety and efficacy of MT in distal occlusions treatment. MT was safe and achieved a high rate of successful revascularization with an acceptable safety profile.

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Abstract TP12: The Trend of Successful First Pass in M2 Segment Stroke Thrombectomy- Insights From the STAR Collaboration

Stroke ◽

10.1161/str.51.suppl_1.tp12 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Eyad Almallouhi ◽

Sami Al kasab ◽

Ali Alawieh ◽

Reda M Chalhoub ◽

Marios Psychogios ◽

...

Keyword(s):

Mechanical Thrombectomy ◽

Independent Predictor ◽

Star Collaboration ◽

Stroke Patients ◽

First Pass ◽

Thrombectomy Device ◽

Intravenous Alteplase ◽

Multicenter Registry ◽

Over Time ◽

Iv Tpa

Introduction: Stroke thrombectomy devices and the experience of neurointerventionists have improved significantly over the last few years making targeting distal occlusions such as of the M2 segment of the middle cerebral artery more feasible. We aimed to study the trend in the successful first pass (SFP) of M2 occlusions over time using the data from a contemporary multicenter registry. Methods: We reviewed the data from the Stroke Thrombectomy and Aneurysm Registry (STAR), which included data from 11 thrombectomy-capable stroke centers to identify stroke patients who underwent mechanical thrombectomy of M2 segment occlusion. SFP was defined by achieving modified Thrombolysis in Cerebral Infarction (mTICI) score≥2b with a single thrombectomy device pass. We analyzed the linear trendline of the rate of SFP over time. Then, we used a logistic regression model to assess predictors of SFP of M2 segment occlusion. Results: We included 401 patients who underwent stroke thrombectomy of M2 occlusion; median age was 71 (IQR 60-80), 212 (52.9%) were females, 174 (43.4%) were white, National Institute of Health stroke scale (NIHSS) was 14 (IQR 8-19), Alberta Stroke Program Early CT (ASPECT) score on presentation was 9 (IQR 7-10) and onset wot groin time was 287 (IQR 181-454). SFP was achieved in 118 (29.4%) patients (linear trendline over time is in Figure 1). Presenting after 2014 was an independent predictor of SFP (OR 1.9, 95% CI 1.1-3.2, P=0.019) after controlling for age, sex, NIHSS on presentation, intravenous alteplase (IV-tPA), and onset to groin time. Conclusion: SFP rate of M2 segment occlusion has increased after 2014 likely secondary the improvement in stroke thrombectomy devices and neurointerventionists experience.

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Impact of Retriever Passes on Efficacy and Safety Outcomes of Acute Ischemic Stroke Treated with Mechanical Thrombectomy

CardioVascular and Interventional Radiology ◽

10.1007/s00270-018-2022-0 ◽

2018 ◽

Vol 41 (12) ◽

pp. 1909-1916 ◽

Cited By ~ 3

Author(s):

Yongjie Bai ◽

◽

Jie Pu ◽

Huaiming Wang ◽

Dong Yang ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Efficacy And Safety ◽

Safety Outcomes

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Abstract P11: Clinical Utility of Aspects in Late Window Stroke Thrombectomy Patients: Insights From Star

Stroke ◽

10.1161/str.52.suppl_1.p11 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Guilherme B Porto ◽

Zachary Hubbard ◽

Sami Al Kasab ◽

Eyad Almallouhi ◽

Robert Starke ◽

...

Keyword(s):

Ct Scan ◽

Symptom Onset ◽

Mechanical Thrombectomy ◽

Multivariable Analysis ◽

Star Collaboration ◽

Outcome Data ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Aspiration Thrombectomy

Introduction: Recent trials have proven safety and efficacy of mechanical thrombectomy for patients presenting with emergent large vessel occlusion beyond 6 hours of symptom onset. While evidence supports using baseline CT scan to evaluate the candidacy for mechanical thrombectomy for patients presenting in the early window, late window trials have used advanced imaging such as CT and MR perfusion. We aim to assess outcomes of MT stratified by admission Alberta Stroke Program Early CT Score (ASPECTS). Methods: We used data from the prospectively maintained registries of 28 stroke centers in the Stroke Thrombectomy and Aneurysm (STAR) collaboration. Demographics, comorbidities, LVO site, ASPECTS, MT technique, radiographic and clinical outcome data were collected. Patients with M1 or ICA occlusion were included in these analyses. Multivariable analysis was performed using a generalized linear model with logit link to assess for variables associated with favorable outcomes. Results: 3356 patients in the STAR database were reviewed and 347 (10.3%) of those underwent MT in the late window (table). Median age was 69, 189 (54.5%) were female, and 181 (52.2%) were white. 295 patients ASPECTS ≥6. In this group, 200 (68.8%) had M1 occlusion, and the remaining had ICA occlusion. Aspiration thrombectomy was used in 139 (47.1%) of patients. Successful reperfusion was achieved (mTICI≥2b) in 264 (76.1%). sICH was observed in 15 (5.1%). Excellent functional outcome (mRS 0-2) was observed in 124 (42%) patients. ASPECTS score was independently associated with favorable outcomes (aOR 1.2, 95% CI 1.1-1.4, P=0.006). Conclusion: Excellent outcomes are observed in patients with good ASPECT score presenting in the late window irrespective of perfusion criteria. Admission CT scan could be used to triage patients presenting with emergent large vessel occlusion beyond 6 hours of symptom onset.

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Benefit from mechanical thrombectomy in acute ischemic stroke with fast and slow progression

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2019-015064 ◽

2019 ◽

Vol 12 (2) ◽

pp. 132-135 ◽

Cited By ~ 1

Author(s):

Arturo Renú Jornet ◽

Xabier Urra ◽

Carlos Laredo ◽

Carmen Montejo ◽

Salvatore Rudilosso ◽

...

Keyword(s):

Medical Treatment ◽

Functional Status ◽

Mechanical Thrombectomy ◽

Infarct Volume ◽

Progression Rate ◽

Ischemic Lesion ◽

Slow Progressors ◽

Best Medical Treatment ◽

Safety Outcomes ◽

Modifying Effect

ObjectiveThe rate of progression of the ischemic lesion is variable in patients with stroke. We tested the hypothesis that the tissue saving effect of mechanical thrombectomy (MT) is greater in fast progressors.MethodsA single-center cohort of consecutive patients (n=242) with occlusions of the terminal internal carotid or M1 segment of the middle cerebral artery treated with MT (n=195) or best medical treatment (n=47), known time from onset, and full imaging (baseline CT perfusion and follow-up MRI) available was studied. The estimated infarct progression rate (eIPR) was calculated at baseline and patients were categorized as fast/slow progressors according to the median eIPR of 4.8 mL/hour. The primary outcome measure was the interaction between eIPR category and MT on infarct growth. The secondary outcomes assessed the effect of MT on final infarct volume and functional status in relation to the eIPR category. The safety outcomes were mortality and symptomatic intracranial hemorrhage.ResultsThe eIPR category had a modifying effect (Pi=0.017) of MT on infarct growth that was significantly reduced with MT only in fast progressors (median (IQR) 3.8 mL (−11–55) vs 41 mL (11–107) with medical treatment; p=0.009, adjusted p=0.045). There was also a significant interaction on final infarct volume (Pi=0.005), with a greater reduction after MT in fast progressors. The functional status improved with MT both in fast and slow progressors, with no significant modifying effect of eIPR category (Pi=0.201). There were also no significant interactions on safety outcomes.ConclusionMT in stroke patients with large vessel occlusion limits infarct growth more significantly in fast progressors.

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Abstract P469: Device-Related Dimensions and Their Effect on First Pass Success and Safety Outcomes After Mechanical Thrombectomy: Is Longer Safer?

Stroke ◽

10.1161/str.52.suppl_1.p469 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Mahmoud Dibas ◽

Sohum Desai ◽

WONDWOSSEN TEKLE ◽

Sherief Ghozy ◽

Adam A Dmytriw ◽

...

Keyword(s):

Mechanical Thrombectomy ◽

Mass Effect ◽

Mortality Rates ◽

Hemorrhagic Transformation ◽

Symptomatic Intracerebral Hemorrhage ◽

First Pass ◽

Safety Outcomes ◽

The Mean ◽

Comprehensive Stroke Center ◽

Stroke Center

Introduction: Mechanical thrombectomy (MT) results in a marked improvement in outcomes of acute ischemic stroke (AIS) patients. First pass effect (FPE), which is defined as the achievement of complete recanalization (mTICI 3) from a single pass, appears to be associated with higher rates of good outcome. We seek to determine if dimensions of stentreivers such as length and diameter have influence on FPE, and other safety outcomes including hemorrhagic transformation, symptomatic intracerebral hemorrhage (sICH), masseffect, and mortality. Methodology: Patients who underwent MT between 2012 and 2020 were identified from a prospectively maintained database at a comprehensive stroke center. Then, these patients were stratified based on dimensions of stentrievers into: "4x20", "4x40", "6x30", and “6x40". Stentrievers used during the study period included Trevo and Solitare. Results: This study included 320 AIS patients. The mean (SD) age of the included patients was 70.7 (13.5), and 54.1% of them were males. 79 (24.7%) of the stentrievers were 4x20, 47 (14.7%) were 4x40, 66 (20.6%) were 6x30, while 128 (40%) were 6x40. There was no difference among the four stentreivers in FPE rates (64.6% vs 68.1%, 66.7%, 67.2%, p=0.98), hemorrhagic transformation (10.1% vs 14.9%, 12.1%, 14.8%, p=0.88), mass effect (3.8% vs 6.4%, 9.1%, 11.7%, p=0.134), and mortality rates (17.7% vs 23.7%, 19.7%, 20.3%, p=0.86). Noteworthy, sICH was significantly different among the groups with the lowest rates reported for 4x40 (4.3%) and 6x40 (5.5%), followed by 4x20 (10.1%), and 6x30 (16.7%), respectively (p=0.04). Conclusions: Stentriever dimensions do not appear to significantly influence FPE rates. We found that 4x40 and 6x40 stentrievers were significantly associated with lower rates of sICH.

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Abstract TP15: A Multicenter Study Comparing Solumbra to Standard Aspiration and Stent Retriever Thrombectomy

Stroke ◽

10.1161/str.51.suppl_1.tp15 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

David J McCarthy ◽

Vasu Saini ◽

Stephanie Chen ◽

Evan Luther ◽

Dallas Sheinberg ◽

...

Keyword(s):

Linear Regression ◽

Mechanical Thrombectomy ◽

Star Collaboration ◽

Functional Independence ◽

Stent Retriever ◽

P Value ◽

Regression Analyses ◽

Procedure Time ◽

Aspiration Thrombectomy ◽

Lower Likelihood

Background: Standard mechanical thrombectomy (MT) techniques utilized include aspiration thrombectomy (ADAPT), stent retriever (SR), and a combination of both (Solumbra). Many studies compare outcomes between ADAPT and SR; however, there has yet to be a large multicenter investigation comparing ADAPT and SR to Solumbra. Methods: All patients from the participating STAR collaboration who underwent MT from 2015-2019 were included. Patients were analyzed by first MT technique utilized (ADAPT, SR, or Solumbra). Univariable and multivariable linear regression was utilized to analyze the MT technique association to number of thrombectomy attempts and procedure time. Univariable and multivariable logistic regression was utilized to determine the association between MT technique and the following outcomes: recanalization, symptomatic hemorrhage, 90-day functional independence, or 90-day mortality. P value less than 0.5 was considered significant. Results: A total of 2515 MT for stroke were identified: 1155 (46%) ADAPT, 735 (29%) SR, 625 (25%) Solumbra. Patients who received Solumbra MT were older (p<0.001), had higher IV-tPA administration rates (p<0.01), and lower onset-groin times (p<0.01). Separate multivariable linear regression analyses revealed that Solumbra technique had significantly high procedure times (OR 10.2, p<0.001) but less thrombectomy attempts (OR -0.8, p<0.001) compared to other MT techniques. There was no difference in recanalization success between techniques (ADAPT 85%, SR 84%, Solumbra 86%). Compared to Solumbra, ADAPT and SR thrombectomy had significantly lower incidence of symptomatic hemorrhage (ADAPT OR 0.32, p=0.009; SR OR 0.39, p=0.039) and ADAPT had a significantly lower likelihood of mortality (OR 0.50, p<0.001). There was no difference in 90-day functional independence (mRS≤2) rates between MT techniques. Conclusion: Compared to standard ADAPT and SR thrombectomy, the Solumbra technique for MT is a longer procedure that results in an increased likelihood of hemorrhage and 90-day mortality.

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Percutaneous mechanical thrombectomy in the treatment of acute and subacute occlusions of the peripheral arteries and bypasses

VASA ◽

10.1024/0301-1526/a000495 ◽

2016 ◽

Vol 45 (1) ◽

pp. 49-56 ◽

Cited By ~ 10

Author(s):

Frantisek Stanek ◽

Radoslava Ouhrabkova ◽

David Prochazka

Keyword(s):

Mechanical Thrombectomy ◽

Clinical Success ◽

Major Amputation ◽

Peripheral Arteries ◽

Duration Of Symptoms ◽

Efficient Treatment ◽

Percutaneous Mechanical Thrombectomy ◽

Single Centre Study ◽

Crural Arteries

Abstract. Background: The aim of this prospective single-centre study was to analyse the immediate results, failures and complications of percutaneous mechanical thrombectomy using the Rotarex catheter in the treatment of acute and subacute occlusions of peripheral arteries and bypasses, as well as to evaluate long-term outcomes of this method. Patients and methods: Patients with acute (duration of symptoms < 14 days) or subacute (duration of symptoms > 14 days and < 3 months) occlusions of peripheral arteries and bypasses were selected consecutively for treatment. The cohort consisted of 113 patients, aged 18 - 92 years (median 72 years). In all, 128 procedures were performed. Results: Angiographic success was obtained in 120 interventions (93.8 %). Reasons for failures were rethrombosis of a partially recanalised segment in six procedures, and embolism into crural arteries in one intervention - percutaneous aspiration thromboembolectomy (PAT) and/or thrombolysis were ineffective in all these cases. Breakage of the Rotarex catheter happened in one procedure. Embolisation into crural arteries as a transitory complication solvable with PAT and/or thrombolysis occurred in four cases. Rethrombosis was more frequent in bypasses than in native arteries (p = 0.0069), in patients with longer occlusions (p = 0.026) and those with poorer distal runoff (p = 0.048). Embolisation happened more often in patients with a shorter duration of symptoms (p = 0.0001). Clinical success was achieved in 82.5 %. Major amputation was performed in 10 % of cases. Cumulative patency rates were 75 % after one month, 71 % after six months, 38 % after 12 months, 33 % after 18 months and 30 % after 24, 30, 36 and 42 months. Conclusions: Rotarex thrombectomy has excellent immediate results with a low rate of failures and complications. In comparison to thrombolysis, it enables the fast and efficient treatment of acute and subacute occlusions of peripheral arteries in one session.

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