E-057 Clot perviousness but not density is associated with first-pass recanalization of aspiration thrombectomy in the compass trial

Abstract Background A large-bore aspiration catheter can be employed for recanalization of acute basilar artery occlusion. Here we compare the results of mechanical thrombectomy using a stent retriever (SR) and manual aspiration thrombectomy (MAT) using a large-bore aspiration catheter system as a first-line recanalization method in acute basilar artery occlusion (BAO). Methods The records of 50 patients with acute BAO who underwent mechanical thrombectomy were retrospectively reviewed. Patients were assigned to one of two groups based on the first-line recanalization method. The treatment and clinical outcomes were compared. Results Sixteen (32%) patients were treated with MAT with a large-bore aspiration catheter and 34 (68%) with a SR as the first-line treatment method. The MAT group had a shorter procedure time (28 vs. 65 min; p = 0.001), higher rate of first-pass recanalization (68.8% vs. 38.2%, p = 0.044), and lower median number of passes (1 vs 2; p = 0.008) when compared with the SR group. There was no significant difference in the incidence of any hemorrhagic complication (6.3% vs. 8.8%; p = 0.754) between the groups. However, there were four cases of procedure-related subarachnoid hemorrhage (SAH) in the SR group and one death occurred due to massive hemorrhage. Conclusions Selection of MAT using a large-bore aspiration catheter for acute BAO may be a safe and effective first-line treatment method with higher first-pass recanalization rate and shorter procedure time than SR.

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Comparison of aspiration-first versus stentriever-first techniques in performing mechanical thrombectomy for large vessel occlusions

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-016547 ◽

2020 ◽

pp. neurintsurg-2020-016547

Author(s):

Vance L Fredrickson ◽

Phillip A Bonney ◽

Shivani D Rangwala ◽

Joshua S Catapano ◽

Tyler S Cole ◽

...

Keyword(s):

Retrospective Cohort ◽

Mechanical Thrombectomy ◽

Rescue Therapy ◽

Multivariable Analysis ◽

Large Vessel ◽

Aspiration Thrombectomy ◽

Patient Demographics ◽

Radiographic Outcomes ◽

Operator Series ◽

First Pass

BackgroundBoth stentriever and direct-aspiration thrombectomy effectively treat large-vessel occlusions. However, data are limited comparing clinical outcomes after aspiration-first versus stentriever-assisted aspiration for thrombectomy.MethodsA retrospective cohort study compared procedure times and radiographic outcomes after two mechanical thrombectomy techniques (aspiration first or stentriever). To minimize bias and variability inherent to multi-operator series, we assessed consecutive patients with cerebrovascular occlusions treated by a single surgeon during a 1 year period at two stroke centers. Expanded Thrombolysis in Cerebral Infarction (eTICI) grades were assessed by an investigator blinded to treatment.ResultsData from 93 patients (median age 70 years) were analyzed: 73 patients (78.5%) were treated with a strentriever-first strategy and 20 (21.5%) were treated with aspiration first, with stentriever rescue therapy required in only three of these cases following unsuccessful aspiration. There were no significant differences in patient demographics, sites of occlusion, or rates of tandem occlusions between aspiration-first and stentriever-assisted groups (p≥0.36). The rate of first-pass eTICI ≥2b was 75.0% (15/20) for aspiration-first and 52.1% (38/73) for strentriever-first groups (p=0.07), while the rate of final eTICI ≥2b was 100% (20/20) and 82.2% (60/72), respectively (p=0.04). The aspiration-first technique was associated with procedural times ≤25 min in a multivariable analysis (adjusted OR 4.77, 95% CI 1.15 to 18.39; p=0.03).ConclusionsIn this single-surgeon series, an aspiration-first technique was associated with a statistically significant improvement in eTICI outcomes and faster procedure times compared with stentriever-assisted aspiration. Further prospective studies are necessary to minimize selection bias inherent in this study design.

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Need for rescue treatment and its implication: stent retriever versus contact aspiration thrombectomy

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2018-014696 ◽

2019 ◽

Vol 11 (10) ◽

pp. 979-983 ◽

Cited By ~ 9

Author(s):

Dong-Hun Kang ◽

Jin Woo Kim ◽

Byung Moon Kim ◽

Ji Hoe Heo ◽

Hyo Suk Nam ◽

...

Keyword(s):

Stent Retriever ◽

First Line ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Aspiration Thrombectomy ◽

Endovascular Thrombectomy ◽

Negatively Associated ◽

Good Outcome ◽

Rescue Treatment ◽

First Pass

BackgroudThe need for rescue treatment (RT) may differ depending on first-line modality (stent retriever (SR) or contact aspiration (CA)) in endovascular thrombectomy (EVT). We aimed to investigate whether the type of first-line modality in EVT was associated with the need for RT.MethodsWe identified all patients who underwent EVT for anterior circulation large-vessel occlusion from prospectively maintained registries of 17 stroke centers. Patients were dichotomized into SR-first and CA-first. RT involved switching to the other device, balloon angioplasty, permanent stenting, thrombolytics, glycoprotein IIb/IIIa antagonist, or any combination of these. We compared clinical characteristics, procedural details, and final recanalization rate between the two groups and assessed whether first-line modality type was associated with RT requirement and if this affected clinical outcome.ResultsA total of 955 patients underwent EVT using either SR-first (n=526) or CA-first (n=429). No difference occurred in the final recanalization rate between SR-first (82.1%) and CA-first (80.2%). However, recanalization with the first-line modality alone and first-pass recanalization rates were significantly higher in SR-first than in CA-first. CA-first had more device passes and higher RT rate. The RT group had significantly longer puncture-to-recanalization time (93±48 min versus 53±28 min). After adjustment, CA-first remained associated with RT (OR, 1.367; 95% CI, 1.019 to 1.834). RT was negatively associated with good outcome (OR, 0.597; 95% CI, 0.410 to 0.870).ConclusionCA was associated with requiring RT, while recanalization with first-line modality alone and first-pass recanalization rates were higher with SR. RT was negatively associated with good outcome.

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Aspiration thrombectomy using a novel 088 catheter and specialized delivery catheter

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-018318 ◽

2021 ◽

pp. neurintsurg-2021-018318

Author(s):

James Caldwell ◽

Ben McGuinness ◽

Shane S Lee ◽

P Alan Barber ◽

Andrew Holden ◽

...

Keyword(s):

Phase 1 ◽

Phase 2 ◽

Phase 3 ◽

Vessel Occlusion ◽

Aspiration Thrombectomy ◽

Aspiration System ◽

First Pass ◽

Reperfusion Rate ◽

Delivery Catheter ◽

Three Phases

BackgroundWe describe the first-in-human experience using the Route 92 Medical Aspiration System to perform thrombectomy in the initial 45 consecutive stroke patients enrolled in the SUMMIT NZ trial. This aspiration system includes a specifically designed delivery catheter which enables delivery of 0.070 inch and 0.088 inch aspiration catheters.MethodsThe SUMMIT NZ trial is a prospective, multicenter, single-arm study with core lab imaging adjudication. Patients presenting with acute ischemic stroke from large vessel occlusion are eligible to enrol. The study has had three phases which transitioned from use of the 0.070 inch to the 0.088 inch catheter.ResultsVessel occlusions were located in the internal carotid artery (27%), M1 (60%) and M2 (13%). Median baseline National Institutes of Health Stroke Scale (NIHSS) was 16 (IQR 10). Across the three phases, the first-pass reperfusion rate of modified Thrombolysis In Cerebral Infarction (mTICI) ≥2b was 62% using the Route 92 Medical system; this rate was 29% in phase 1, 56% in phase 2, and 80% in phase 3. The first-pass reperfusion rate of mTICI ≥2c was 42% overall, 29% in phase 1, 33% in phase 2%, and 55% in phase 3. A final reperfusion rate of mTICI ≥2b was achieved in 96% of cases, with 36% of cases using adjunctive devices. Patients had an average improvement of 6.7 points in NIHSS from baseline at 24 hours, and at 90 days 48% were functionally independent (modified Rankin Scale 0–2).ConclusionsIn this early experience, the Route 92 Medical Aspiration System has been effective and safe. The system has design features that improve catheter deliverability and have the potential to increase first-pass reperfusion rates in aspiration thrombectomy.

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MRS SOFIA: a multicenter retrospective study for use of Sofia for revascularization of acute ischemic stroke

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-017042 ◽

2021 ◽

pp. neurintsurg-2020-017042

Author(s):

Waleed Brinjikji ◽

Eytan Raz ◽

Reade De Leacy ◽

Dan Meila ◽

Maxim Mokin ◽

...

Keyword(s):

Ischemic Stroke ◽

Retrospective Study ◽

Acute Ischemic Stroke ◽

Median Number ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Aspiration Thrombectomy ◽

First Pass ◽

Number Of Passes

BackgroundOver the past several years there has been increased interest in the use of the Sofia aspiration system (MicroVention, Tustin, California) as a primary aspiration catheter.ObjectiveTo perform a multicenter retrospective study examining the efficacy of the Sofia aspiration catheter as a standalone aspiration treatment for large vessel occlusion.MethodsConsecutive cases in which the Sofia catheter was used for aspiration thrombectomy for large vessel occlusion were included. Exclusion criteria were the following: (1) Sofia not used for first pass, and (2) a stent retriever used as an adjunct on the first pass. The primary outcome of the study was first pass recanalization (Thrombolysis in Cerebral Infarction (TICI) 2c/3). Secondary outcomes included first pass TICI 2b/3, crossover to other thrombectomy devices, number of passes, time from puncture to recanalization, and complications.Results323 patients were included. First pass TICI 2c/3 was achieved in 49.8% of cases (161/323). First pass TICI 2b/3 was achieved in 69.7% (225/323) of cases. 74.8% had TICI 2b/3 with the Sofia alone. Crossover to other thrombectomy devices occurred in 29.1% of cases (94/323). The median number of passes was 1 (IQR=1–3). Median time from puncture to recanalization was 26 min (IQR=17–45). Procedure related complications occurred in 3.1% (10/323) of cases.ConclusionOur study highlights the potential advantage of the Sofia aspiration catheter for primary aspiration thrombectomy in acute ischemic stroke. High rates of first pass recanalization with low crossover rates to other thrombectomy devices were achieved. Median procedure time was low, as were procedural complications.

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Abstract WP15: Rates of Successful First-pass Recanalization During Thrombectomy for Acute Ischemic Stroke are Higher in the Absence of a Hyper-dense Vessel Sign

Stroke ◽

10.1161/str.47.suppl_1.wp15 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Cynthia L Kenmuir ◽

Alhamza R Al-Bayati ◽

Hazem Shoirah ◽

Amin Aghaebrahim ◽

Andrew F Ducruet ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

High Quality ◽

Aspiration Thrombectomy ◽

Endovascular Thrombectomy ◽

First Pass ◽

Multimodal Methods ◽

Ratio Versus

Background and Purpose: Rates of high quality recanalization after endovascular thrombectomy in acute ischemic stroke are excellent, but not all vessels are easily or quickly recanalized. Physical characteristics of the occlusion may affect recanalization. The hyper-dense vessel sign (HDVS) is an easily obtained marker of clot density and was hypothesized to predict success of recanalization. Methods: A prospectively maintained database of patients undergoing mechanical thrombectomy was retrospectively analyzed. The final quality of recanalization was scored by the treating interventionalist. The presence or absence of HDVS was scored blinded. HDVS was defined as an absolute HU >43 and ratio versus contralateral vessel of >1.2 on non-contrast head CT. Results: 408 patients were treated with endovascular thrombectomy between August 2012 to July 2015. Mean age was 67.7. 53% were men. Mean NIHSS was 17. 88% were MCA occlusions and 11% were basilar occlusions. Mean ASPECT was 8.6 for MCA occlusions. 90.6% of patients were successfully revascularized with TICI2b/3. HDVS was identified in 43.3% of patients. 40.5% of patients had TICI2b/3 reperfusion after the first pass of attempted thrombectomy. Manual aspiration thrombectomy was the first technique in 45.6% and stentreiver mediated manual aspiration thrombectomy was used first in 54.4% of cases. Of 357 attempted MCA thrombectomies, 43.3% had a HDVS. Of 44 attempted basilar thrombectomies, 56.7% had a HDVS. TICI 2b/3 reperfusion on first-pass was associated with absence of HDVS (p=0.001). Time from puncture to reperfusion was significantly increased with HDVS (p=0.003). Conclusion: Patients with a hyper-dense vessel sign have less successful first-pass revascularization with increased times to reperfusion versus patients without a hyper-dense vessel sign. The presence of HDVS may be indicative of more refractory occlusions and may warrant novel and multimodal methods of revascularization.

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Large-bore aspiration catheter selection does not influence reperfusion or outcome after manual aspiration thrombectomy

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2018-014633 ◽

2019 ◽

Vol 11 (7) ◽

pp. 637-640 ◽

Cited By ~ 8

Author(s):

Daniel A Tonetti ◽

Shashvat M Desai ◽

Stephanie Casillo ◽

Benjamin M Zussman ◽

Merritt W Brown ◽

...

Keyword(s):

Randomized Trials ◽

Internal Carotid ◽

Independent Predictor ◽

Procedure Time ◽

Multivariate Logistic Regression ◽

Aspiration Thrombectomy ◽

First Pass ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

Number Of Passes

IntroductionVarious large-bore catheters can be employed for manual aspiration thrombectomy (MAT); clinical differences are rarely explored.MethodsProspectively collected demographic, angiographic, and clinical data for patients with acute internal carotid artery, middle cerebral artery M1, or basilar occlusions undergoing MAT over 23 months at a comprehensive stroke center were reviewed. We excluded patients in stentriever-based randomized trials/registries. The four most commonly utilized aspiration catheters were analyzed, and multivariate logistic regression analyses were performed to determine the effect of primary aspiration catheter choice on first-pass success, final reperfusion, and modified Rankin Scale (mRS) score at 90 days.ResultsOf 464 large vessel thrombectomies, 180 were performed via MAT on the first pass with one of four catheters. First-pass success was achieved in 42% of cases overall; this rate did not differ significantly between catheters: 50% for Sofia, 45% for CAT6, 40% for 0.072 inch Navien, and 36% for ACE68, p=0.67. Final Thrombolysis in Cerebral Infarction 2b or 3 reperfusion was achieved in 94% of cases overall: 97% of cases with CAT6, 95% with Sofia, 92% with Navien, and 92% with ACE68, p=0.70. Mean number of passes for index thrombus (2.0 overall), median procedure time (32 min overall), 90-day good outcome (mRS 0–2, mean 36%), and 90-day mortality (mean 27%) did not differ significantly between patients treated with different initial catheters.ConclusionAmong large-bore aspiration catheters, catheter selection is not an independent predictor of first-pass success, final reperfusion, or clinical outcome.

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Abstract P365: Effect of Radiological Thrombus Characteristics on Results of First-Line Endovascular Treatment Approach for Acute Ischemic Stroke

Stroke ◽

10.1161/str.52.suppl_1.p365 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Manon Kappelhof ◽

Agnetha Bruggeman ◽

Josje Brouwer ◽

Nerea Arrarte Terreros ◽

Praneeta R Konduri ◽

...

Keyword(s):

Endovascular Treatment ◽

Intravenous Thrombolysis ◽

Stent Retriever ◽

First Line ◽

Aspiration Thrombectomy ◽

Negatively Associated ◽

Improved Outcomes ◽

First Pass ◽

Stent Retrievers ◽

Adjusted Logistic Regression

Introduction: Pervious thrombi benefit more from intravenous thrombolysis, but the role of perviousness in endovascular treatment (EVT) is not completely clear. Thrombus length is negatively associated with outcome after EVT. Pervious, long thrombi may be more difficult to aspirate, or fragment more easily than non-pervious, short thrombi. We assessed the effect of perviousness and thrombus length on results of first-line aspiration thrombectomy in EVT, in comparison to stent-retrievers. Methods: We included MR CLEAN Registry patients (N=1526) with thin-slice imaging available, and aspiration or stent-retriever as first EVT attempt (N=391). Thrombus perviousness was measured by thrombus attenuation increase (Houndsfield Units; HU). Associations with 90-day modified Rankin Scale score (mRS), and final and first-pass reperfusion (eTICI 2B-3) were tested with adjusted logistic regression analyses. Results: Sixty-five (21%) patients were treated with first-line aspiration, 252 (79%) with stent-retrievers. Perviousness was not significantly associated with mRS after either first-line approach (Figure 1). Analysis per perviousness quartile did show improved mRS for stent-retrievers in the highest quartile only (>12.3 HU; acOR for mRS shift with stent-retriever treatment 3.08, 95%CI 1.06-8.96). Thrombus length was negatively associated with mRS after first-line stent-retriever thrombectomy (acOR 0.96, 95%CI 0.93-0.99). First-pass reperfusion and thrombus length were significantly, negatively associated in the first-line aspiration group (acOR 0.88, 95%CI 0.80-0.96). Conclusions: Patients with longer thrombi may show worse outcomes after both aspiration and stent-retriever thrombectomy. In patients with high perviousness values, stent-retriever thrombectomy may be related to improved outcomes as compared to first-line aspiration.

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Clot perviousness is associated with first pass success of aspiration thrombectomy in the COMPASS trial

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-016434 ◽

2020 ◽

pp. neurintsurg-2020-016434

Author(s):

Maxim Mokin ◽

Muhammad Waqas ◽

Johanna Fifi ◽

Reade De Leacy ◽

David Fiorella ◽

...

Keyword(s):

Multivariate Analysis ◽

Stent Retriever ◽

Hounsfield Units ◽

First Line ◽

Vessel Occlusion ◽

Aspiration Thrombectomy ◽

Post Contrast ◽

Imaging Characteristics ◽

First Pass ◽

Post Hoc

BackgroundClot density (Hounsfield units, HU) and perviousness (post-contrast increase in the HU of clot) are thought to be associated with clot composition. We evaluate whether these imaging characteristics were associated with angiographic outcomes of aspiration and stent retriever thrombectomy in COMPASS: a trial of aspiration thrombectomy versus stent retriever thrombectomy as first-line approach for large vessel occlusion.MethodsClot density and perviousness were measured by two independent operators who were blind to all the final angiographic and clinical outcomes. The association of clot density and perviousness with the Thrombolysis In Cerebral Infarction (TICI) scale after first pass was assessed using univariate and multivariate analysis.ResultsAmong all patients enrolled in COMPASS, 165 were eligible for the post-hoc analysis (81 patients in the aspiration first and 84 in the stent retriever first groups). Overall mean perviousness of clot was significantly higher in patient with mTICI 2b-3 after first pass (28.6±22.9 vs 20.3±19.2, p=0.017). Mean perviousness among patients who achieved TICI 2c/3 versus TICI 2b versus TICI 0-2a in the aspiration first group varied significantly (32.6±26.1, 35.3±24.4, and 17.7±13.1, p=0.013). The association of perviousness with first pass success was not significant in the stent retriever group. Using multivariate analysis, high perviousness (defined as cut-off >27.6) was an independent predictor of TICI 2b-3 (OR 3.82, 95% CI 1.10 to 13.19; p=0.034).ConclusionsClot perviousness is associated with first pass angiographic success in patients treated with the aspiration first approach for thrombectomy.

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Stentriever salvage after failed manual aspiration thrombectomy

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2019-014828 ◽

2019 ◽

Vol 11 (8) ◽

pp. 747-750 ◽

Cited By ~ 2

Author(s):

Daniel A Tonetti ◽

Shashvat M Desai ◽

Stephanie Casillo ◽

Benjamin M Zussman ◽

Ashutosh Jadhav ◽

...

Keyword(s):

Primary Outcome ◽

National Institutes Of Health ◽

Large Vessel ◽

Aspiration Thrombectomy ◽

Nihss Score ◽

Clot Removal ◽

First Pass ◽

Successful Removal ◽

Comprehensive Stroke Center ◽

Stroke Center

IntroductionManual aspiration thrombectomy (MAT) and stent retriever mediated aspiration thrombectomy (SMAT) are well described reperfusion strategies for large vessel occlusions. This study aims to identify predictors of successful crossover to SMAT after failed first pass MAT.MethodsProspectively collected data for patients with acute large vessel occlusions undergoing thrombectomy over a 23 month period at a comprehensive stroke center were reviewed. The primary outcome was successful removal of the index clot with resultant Thrombolysis in Cerebral Infarction 2b or greater reperfusion at any point after a failed initial MAT attempt, and multivariate logistic regression analyses were performed to determine predictors of successful crossover to SMAT.ResultsOf 433 large vessel thrombectomies, 319 underwent first pass MAT, and 113 patients required a repeated pass for the index thrombus. Second pass MAT was performed in 77% of cases and was successful in 54%; second pass SMAT was performed in 23% of cases and was successful in 73% (P=0.11). Third pass MAT was employed in 45% of cases and was successful in 43% while SMAT was performed in 55% of cases and was successful in 77% (P=0.03). Overall, 12% of patients undergoing MAT on the first pass crossed over to successful SMAT. Predictors of successful crossover were internal carotid artery (ICA) location and higher presenting National Institutes of Health Stroke Scale (NIHSS) score.ConclusionAfter failed first pass MAT, subsequent passes with SMAT had higher rates of successful index clot removal; patients with a higher initial NIHSS score and ICA clot location should be considered for early crossover or even initial SMAT for their clots.

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