Comparing different thrombectomy techniques in five large-volume centers: a ‘real world’ observational study

Background and purposeThrombectomy has become the standard of care for acute ischaemic stroke due to large vessel occlusion. Aim of this study was to compare the radiological outcomes and time metrics of the various thrombectomy techniques.MethodsIn this retrospective, multicenter study we analysed the data of 450 patients with occlusion of the anterior circulation, treated in five high-volume center from 2013 to 2016. The treatment techniques were divided in three categories: first-pass use of a large-bore aspiration-catheter; first-pass use of a stent-retriever; and primary combined approach (PCA) of an aspiration-catheter and stent-retriever. Primary endpoints were successful reperfusion and groin to reperfusion time. Secondary endpoints were the number of attempts and occurrence of emboli in new territory (ENT). The primary analysis was based on the intention to treat groups (ITT).ResultsThe ITT-analysis showed significantly higher reperfusion rates, with 86% of successful reperfusion in the PCA-group compared with 73% in the aspiration group and 65% in the stent-retriever group. There was no significant difference in groin to reperfusion time regarding the used technique. The secondary analysis showed an impact of the technique on the number of attempts and the occurrence of ENTs. Lowest ENT rates and attempts were reported with the combined approach.ConclusionsThe combined first-pass deployment of a stent-retriever and an aspiration-catheter was the most effective technique for reperfusion of anterior circulation large vessel occlusion. Our results correlate with the latest single-centrere studies, reporting very high reperfusion rates with PCA variations.

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Endovascular therapy in patients with large vessel occlusion due to cardioembolism versus large-artery atherosclerosis

Therapeutic Advances in Neurological Disorders ◽

10.1177/1756286421999017 ◽

2021 ◽

Vol 14 ◽

pp. 175628642199901

Author(s):

Meredeth Zotter ◽

Eike I. Piechowiak ◽

Rupashani Balasubramaniam ◽

Rascha Von Martial ◽

Kotryna Genceviciute ◽

...

Keyword(s):

Heart Failure ◽

Endovascular Therapy ◽

Independent Predictor ◽

Intravenous Thrombolysis ◽

Stent Retriever ◽

Large Vessel ◽

Large Artery ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Significant Difference

Background and aims: To investigate whether stroke aetiology affects outcome in patients with acute ischaemic stroke who undergo endovascular therapy. Methods: We retrospectively analysed patients from the Bernese Stroke Centre Registry (January 2010–September 2018), with acute large vessel occlusion in the anterior circulation due to cardioembolism or large-artery atherosclerosis, treated with endovascular therapy (±intravenous thrombolysis). Results: The study included 850 patients (median age 77.4 years, 49.3% female, 80.1% with cardioembolism). Compared with those with large-artery atherosclerosis, patients with cardioembolism were older, more often female, and more likely to have a history of hypercholesterolaemia, atrial fibrillation, current smoking (each p < 0.0001) and higher median National Institutes of Health Stroke Scale (NIHSS) scores on admission ( p = 0.030). They were more frequently treated with stent retrievers ( p = 0.007), but the median number of stent retriever attempts was lower ( p = 0.016) and fewer had permanent stent placements ( p ⩽ 0.004). Univariable analysis showed that patients with cardioembolism had worse 3-month survival [72.7% versus 84%, odds ratio (OR) = 0.51; p = 0.004] and modified Rankin scale (mRS) score shift ( p = 0.043) and higher rates of post-interventional heart failure (33.5% versus 18.5%, OR = 2.22; p < 0.0001), but better modified thrombolysis in cerebral infarction (mTICI) score shift ( p = 0.025). Excellent (mRS = 0–1) 3-month outcome, successful reperfusion (mTICI = 2b–3), symptomatic intracranial haemorrhage and Updated Charlson Comorbidity Index were similar between groups. Propensity-matched analysis found no statistically significant difference in outcome between stroke aetiology groups. Stroke aetiology was not an independent predictor of favourable mRS score shift, but lower admission NIHSS score, younger age and independence pre-stroke were (each p < 0.0001). Stroke aetiology was not an independent predictor of heart failure, but older age, admission antithrombotics and dependence pre-stroke were (each ⩽0.027). Stroke aetiology was not an independent predictor of favourable mTICI score shift, but application of stent retriever and no permanent intracranial stent placement were (each ⩽0.044). Conclusion: We suggest prospective studies to further elucidate differences in reperfusion and outcome between patients with cardioembolism and large-artery atherosclerosis.

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Feasibility and safety of the strategy of first stenting without retrieval using Solitaire FR as a treatment for emergent large-vessel occlusion due to underlying intracranial atherosclerosis

Journal of Neurosurgery ◽

10.3171/2020.8.jns202504 ◽

2021 ◽

pp. 1-9

Author(s):

Jong-Hoon Kim ◽

Young-Jin Jung ◽

Chul-Hoon Chang

Keyword(s):

Functional Outcomes ◽

Medical Center ◽

Large Vessel ◽

Intracranial Atherosclerosis ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Stent Retrieval ◽

First Pass ◽

Solitaire Fr

OBJECTIVEThe optimal treatment for underlying intracranial atherosclerosis (ICAS) in patients with emergent large-vessel occlusion (ELVO) remains unclear. Reocclusion during endovascular treatment (EVT) occurs frequently (57.1%–77.3%) after initial recanalization with stent retriever (SR) thrombectomy in ICAS-related ELVO. This study aimed to compare treatment outcomes of the strategy of first stenting without retrieval (FRESH) using the Solitaire FR versus SR thrombectomy in patients with ICAS-related ELVO.METHODSThe authors retrospectively reviewed consecutive patients with acute ischemic stroke and intracranial ELVO of the anterior circulation who underwent EVT between January 2017 and December 2019 at Yeungnam University Medical Center. Large-vessel occlusion (LVO) of the anterior circulation was classified by etiology as follows: 1) no significant stenosis after recanalization (embolic group) and 2) remnant stenosis > 70% or lesser degree of stenosis with a tendency toward reocclusion and/or flow impairment during EVT (ICAS group). The ICAS group was divided into the SR thrombectomy group (SR thrombectomy) and the FRESH group.RESULTSA total of 105 patients (62 men and 43 women; median age 71 years, IQR 62.5–79 years) were included. The embolic, SR thrombectomy, and FRESH groups comprised 66 (62.9%), 26 (24.7%), and 13 (12.4%) patients, respectively. There were no significant differences between the SR thrombectomy and FRESH groups in symptom onset–to-door time, but puncture-to-recanalization time was significantly shorter in the latter group (39 vs 54 minutes, p = 0.032). There were fewer stent retrieval passes but more first-pass recanalizations in the FRESH group (p < 0.001). Favorable functional outcomes were significantly more frequent in the FRESH group (84.6% vs 42.3%, p = 0.017).CONCLUSIONSThis study’s findings suggest that FRESH, rather than rescue stenting, could be a treatment option for ICAS-related ELVO.

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Abstract WP502: Predictors Of First Pass Reperfusion In Anterior Circulation Large Vessel Occlusion Stroke

Stroke ◽

10.1161/str.51.suppl_1.wp502 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Mahmoud Mohammaden ◽

Leonardo Pisani ◽

Catarina Perry da Camara ◽

Mehdi Bousalma ◽

Alhamza Al bayati ◽

...

Keyword(s):

Mechanical Thrombectomy ◽

Univariate Analysis ◽

Multivariate Regression Analysis ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Performance Metric ◽

First Pass ◽

Thrombectomy Device

Introduction: The speed and completeness of endovascular reperfusion strongly correlate with functional outcomes. First-Pass Reperfusion (FPR) has been recently established as a critical procedural performance metric for mechanical thrombectomy (MT). We aimed to study the predictors of FPR and its effect on the outcome Methods: Review of a prospectively collected database of MT patients with large vessel occlusion strokes (LVOS) from 05/2012-11/2018. Patients were included in the analysis if they had an anterior circulation LVOS that was successfully reperfused (mTICI 2b-3). FPR was defined as the achievement of mTICI 2c-3 after a single pass with any thrombectomy device. Uni- and multivariate analyses were performed to identify the independent predictors of FPR. Results: A total of 563 patients qualified for the analysis (mean age, 64.4±12.3 years, baseline NIHSS 16.2). FPR was achieved in 202 (35.9%) patients. On univariate analysis, FPR was significantly associated with higher ASPECTS (8.1 vs. 7.8, p=0.008), higher usage of balloon guide catheters (BGC) (88.1% vs. 75.3%, p<0.001), lower use of general anesthesia (9.5% vs. 18.2%, p= 0.006), and shorter procedure duration (mean, 45.5 vs. 79.9 min, p <0.001 and 90.5%). Both BGC (OR, 2.26; 95%CI [1.32-3.87], p=0.003) and ASPECTS (OR, 1.15; 95% CI [1.03-1.28], p= 0.01) were independent predictors of FPE on multivariate regression analysis. Conclusion: Higher baseline ASPECTS score and the use of BGC are strong predictors of First-Pass Reperfusion in mechanical thrombectomy.

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Workflow Intervals of Endovascular Acute Stroke Therapy During On- Versus Off-Hours

Stroke ◽

10.1161/strokeaha.119.025381 ◽

2019 ◽

Vol 50 (10) ◽

pp. 2842-2850 ◽

Cited By ~ 3

Author(s):

Wouter H. Hinsenveld ◽

Inger R. de Ridder ◽

Robert J. van Oostenbrugge ◽

Jan A. Vos ◽

Adrien E. Groot ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Functional Outcome ◽

Large Vessel ◽

Complication Rates ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Significant Difference

Background and Purpose— Endovascular treatment (EVT) of patients with acute ischemic stroke because of large vessel occlusion involves complicated logistics, which may cause a delay in treatment initiation during off-hours. This might lead to a worse functional outcome. We compared workflow intervals between endovascular treatment–treated patients presenting during off- and on-hours. Methods— We retrospectively analyzed data from the MR CLEAN Registry, a prospective, multicenter, observational study in the Netherlands and included patients with an anterior circulation large vessel occlusion who presented between March 2014 and June 2016. Off-hours were defined as presentation on Monday to Friday between 17:00 and 08:00 hours, weekends (Friday 17:00 to Monday 8:00) and national holidays. Primary end point was first door to groin time. Secondary end points were functional outcome at 90 days (modified Rankin Scale) and workflow time intervals. We stratified for transfer status, adjusted for prognostic factors, and used linear and ordinal regression models. Results— We included 1488 patients of which 936 (62.9%) presented during off-hours. Median first door to groin time was 140 minutes (95% CI, 110–182) during off-hours and 121 minutes (95% CI, 85–157) during on-hours. Adjusted first door to groin time was 14.6 minutes (95% CI, 9.3–20.0) longer during off-hours. Door to needle times for intravenous therapy were slightly longer (3.5 minutes, 95% CI, 0.7–6.3) during off-hours. Groin puncture to reperfusion times did not differ between groups. For transferred patients, the delay within the intervention center was 5.0 minutes (95% CI, 0.5–9.6) longer. There was no significant difference in functional outcome between patients presenting during off- and on-hours (adjusted odds ratio, 0.92; 95% CI, 0.74–1.14). Reperfusion rates and complication rates were similar. Conclusions— Presentation during off-hours is associated with a slight delay in start of endovascular treatment in patients with acute ischemic stroke. This treatment delay did not translate into worse functional outcome or increased complication rates.

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Hyperdense vessel sign as a potential guide for the choice of stent retriever versus contact aspiration as first-line thrombectomy strategy

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-016005 ◽

2020 ◽

pp. neurintsurg-2020-016005 ◽

Cited By ~ 1

Author(s):

Mahmoud H Mohammaden ◽

Diogo C Haussen ◽

Catarina Perry da Camara ◽

Leonardo Pisani ◽

Marta Olive Gadea ◽

...

Keyword(s):

Stent Retriever ◽

Imaging Biomarker ◽

First Line ◽

Primary Analysis ◽

Anterior Circulation ◽

Vessel Occlusion ◽

First Line Therapy ◽

Guide Catheter ◽

First Pass ◽

Secondary Analyses

BackgroundThe first-pass effect (FPE) has emerged as a key metric for efficacy in mechanical thrombectomy (MT). The hyperdense vessel sign (HDVS) on non-contrast head CT (NCCT) indicates a higher clot content of red blood cells.ObjectiveTo assess whether the HDVS could serve as an imaging biomarker for guiding first-line device selection in MT.MethodsA prospective MT database was reviewed for consecutive patients with anterior circulation large vessel occlusion stroke who underwent thrombectomy with stent retriever (SR) or contact aspiration (CA) as first-line therapy between January 2012 and November 2018. Pretreatment NCCT scans were evaluated for the presence of HDVS. The primary outcome was FPE (modified Thrombolysis in Cerebral Infarction score 2c/3). The primary analysis was the interaction between HDVS and thrombectomy modality on FPE. Secondary analyses aimed to evaluate the predictors of FPE.ResultsA total of 779 patients qualified for the analysis. HDVS and FPE were reported in 473 (60.7%) and 286 (36.7%) patients, respectively. The presence of HDVS significantly modified the effect of thrombectomy modality on FPE (p=0.01), with patients with HDVS having a significantly higher rate of FPE with a SR (41.3% vs 22.2%, p=0.001; adjusted OR 2.11 (95% CI 1.20 to 3.70), p=0.009) and non-HDVS patients having a numerically better response to CA (41.4% vs 33.9%, p=0.28; adjusted OR 0.58 (95% CI 0.311 to 1.084), p=0.088). Age (OR 1.01 (95% CI 1.00 to 1.02), p=0.04) and balloon guide catheter (OR 2.08 (95% CI 1.24 to 3.47), p=0.005) were independent predictors of FPE in the overall population.ConclusionOur data suggest that patients with HDVS may have a better response to SRs than CA for the FPE. Larger confirmatory prospective studies are warranted.

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Safety and Effectiveness of the New Generation APERIO® Hybrid Stent-retriever Device in Large Vessel Occlusion Stroke

Clinical Neuroradiology ◽

10.1007/s00062-021-01122-1 ◽

2021 ◽

Author(s):

Marius L. Vogt ◽

Alexander M. Kollikowski ◽

Franziska Weidner ◽

Marc Strinitz ◽

Jörn Feick ◽

...

Keyword(s):

Median Number ◽

Stent Retriever ◽

Large Vessel ◽

Secondary Outcome ◽

Technological Advancement ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Hemorrhagic Complications ◽

First Pass ◽

New Generation

Abstract Background It is unknown whether technological advancement of stent-retriever devices influences typical observational indicators of safety or effectiveness. Methods Observational retrospective study of APERIO® (AP) vs. new generation APERIO® Hybrid (APH) (Acandis®, Pforzheim, Germany) stent-retriever device (01/2019–09/2020) for mechanical thrombectomy (MT) in large vessel occlusion (LVO) stroke. Primary effectiveness endpoint was successful recanalization eTICI (expanded Thrombolysis In Cerebral Ischemia) ≥ 2b67, primary safety endpoint was occurrence of hemorrhagic complications after MT. Secondary outcome measures were time from groin puncture to first pass and successful reperfusion, and the total number of passes needed to achieve the final recanalization result. Results A total of 298 patients with LVO stroke who were treated by MT matched the inclusion criteria: 148 patients (49.7%) treated with AP vs. 150 patients (50.3%) treated with new generation APH. Successful recanalization was not statistically different between both groups: 75.7% for AP vs. 79.3% for APH; p = 0.450. Postinterventional hemorrhagic complications and particularly subarachnoid hemorrhage as the entity possibly associated with stent-retriever device type was significantly less frequent in the group treated with the APH: 29.7% for AP and 16.0% for APH; p = 0.005; however, rates of symptomatic hemorrhage with clinical deterioration and in domo mortality were not statistically different. Neither the median number of stent-retriever passages needed to achieve final recanalization, time from groin puncture to first pass, time from groin puncture to final recanalization nor the number of cases in which successful recanalization could only be achieved by using a different stent-retriever as bail-out device differed between both groups. Conclusion In the specific example of the APERIO® stent-retriever device, we observed that further technological developments of the new generation device were not associated with disadvantages with respect to typical observational indicators of safety or effectiveness.

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Trevo 6 × 25mm vs. 4 × 30mm in Mechanical Thrombectomy of M1 LVO

Frontiers in Neurology ◽

10.3389/fneur.2021.677630 ◽

2021 ◽

Vol 12 ◽

Author(s):

Marion John Oliver ◽

Emily Brereton ◽

Muhib A. Khan ◽

Alan Davis ◽

Justin Singer

Keyword(s):

Mechanical Thrombectomy ◽

Perioperative Complications ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

First Pass Effect ◽

Significant Difference ◽

First Pass ◽

Stent Retrievers ◽

Complications And Mortality

Objectives: Our primary objective was to determine the successful rate of recanalization of M1 large vessel occlusion using either the Trevo 4 × 30 mm or 6 × 25 mm stent during mechanical thrombectomy. Our secondary objectives were to determine differences between the use of these two stent retrievers regarding first-pass effect, periprocedural complications, and mortality in the first 90 days.Methods: This is a retrospective cohort study. Data regarding the stent used, recanalization, number of passes, periprocedural complications, and mortality were determined via our mechanical thrombectomy database along with chart review.Conclusion: When comparing Trevo 4 × 30 mm to 6 × 25 mm stent retrievers used in mechanical thrombectomy for middle cerebral artery large-vessel occlusion causing stroke, there is no statistically significant difference in successful recanalization rates, first-pass effect, perioperative complications, or mortality at 90 days. Studies like this will hopefully lead to further prospective, randomized controlled trials that will help show experts in the field an additional way to perform this procedure effectively and safely.

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Abstract 132: Final Infarct Volume is a Critical Determinant of Hospitalization Cost in Anterior Circulation Large Vessel Occlusion Stroke

Stroke ◽

10.1161/str.48.suppl_1.132 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Christopher Streib ◽

Srikant Rangaraju ◽

Daniel G Winger ◽

David T Campbell ◽

Stephanie Paolini ◽

...

Keyword(s):

Infarct Volume ◽

Cost Effective ◽

Large Vessel ◽

Sensitivity Analyses ◽

Large Vessel Occlusion ◽

Primary Analysis ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Critical Determinant ◽

Hospitalization Cost

Background: Anterior circulation large vessel occlusion (ACLVO) stroke, one of the most devastating stroke subtypes, is associated with substantial economic burden. Identifying predictors of increased ACLVO stroke hospitalization cost is essential to developing cost-effective treatment strategies. Methods: We utilized comprehensive patient-level cost-tracking software to calculate hospitalization costs for ACLVO stroke patients at our institution between July 2012-October 2014. Patient demographics and neuroimaging findings were analyzed. Predictors of hospitalization cost were determined using multivariable linear regression. In addition to our primary analysis (all eligible ACLVO patients), we conducted subgroup analyses by treatment (endovascular, IV tPA-only, and no reperfusion therapy) and sensitivity analyses. Results: 341 patients (median age 69 [IQR 57-80], median NIHSS 16 [IQR 13-21], median hospitalization cost $16,446 [IQR $9823-$27,165]) were included in our primary analysis; final infarct volume (FIV), parenchymal hematoma, age, obstructive sleep apnea, and baseline NIHSS were significant predictors of hospitalization cost (Figure). FIV alone accounted for 20.51% of the total variance in hospitalization cost. Notably, FIV was consistently the most robust predictor of increased cost across primary, subgroup, and sensitivity analyses. Over the observed range of FIVs in our cohort, each additional 1cc of infarcted brain tissue increased hospitalization cost by $122.35. Conclusion: FIV is a critical determinant of increased hospitalization cost in ACLVO stroke. Therapies resulting in reduced FIV may not only improve clinical outcomes, but prove cost-effective.

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Addition of intracranial aspiration to balloon guide catheter does not improve outcomes in large vessel occlusion anterior circulation stent retriever based thrombectomy for acute stroke

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-017760 ◽

2021 ◽

pp. neurintsurg-2021-017760

Author(s):

Jordi Blasco ◽

Josep Puig ◽

Antonio López-Rueda ◽

Pepus Daunis-i-Estadella ◽

Laura Llull ◽

...

Keyword(s):

Clinical Outcomes ◽

Scale Score ◽

Outcome Data ◽

Stent Retriever ◽

Large Vessel ◽

Complete Revascularization ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Guide Catheter

BackgroundBalloon guide catheter (BGC) in stent retriever based thrombectomy (BGC+SR) for patients with large vessel occlusion strokes (LVOS) improves outcomes. It is conceivable that the addition of a large bore distal access catheter (DAC) to BGC+SR leads to higher efficacy. We aimed to investigate whether the combined BGC+DAC+SR approach improves angiographic and clinical outcomes compared with BGC+SR alone for thrombectomy in anterior circulation LVOS.MethodsConsecutive patients with anterior circulation LVOS from June 2019 to November 2020 were recruited from the ROSSETTI registry. Demographic, clinical, angiographic, and outcome data were compared between patients treated with BGC+SR alone versus BGC+DAC+SR. The primary outcome was first pass effect (FPE) rate, defined as near complete/complete revascularization (modified Thrombolysis in Cerebral Infarction (mTICI) 2c–3) after single device pass.ResultsWe included 401 patients (BGC+SR alone, 273 (66.6%) patients). Patients treated with BGC+SR alone were older (median age 79 (IQR 68–85) vs 73.5 (65–82) years; p=0.033) and had shorter procedural times (puncture to revascularization 24 (14–46) vs 37 (24.5–63.5) min, p<0.001) than the BGC+DAC+SR group. Both approaches had a similar FPE rate (52% in BGC+SR alone vs 46.9% in BGC+DAC+SR, p=0.337). Although the BGC+SR alone group showed higher rates for final successful reperfusion (mTICI ≥2b (86.8% vs 74.2%, p=0.002) and excellent reperfusion, mTICI ≥2 c (76.2% vs 55.5%, p<0.001)), there were no significant differences in 24 hour National Institutes of Health Stroke Scale score or rates of good functional outcome (modified Rankin Scale score of 0–2) at 3 months across these techniques.ConclusionsOur data showed that addition of distal intracranial aspiration catheters to BGC+SR based thrombectomy in patients with acute anterior circulation LVO did not provide higher rates of FPE or improved clinical outcomes.

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