Beyond the first pass: revascularization remains critical in stroke thrombectomy

Jindal, Gaurav; Carvalho, Helio De Paula; Wessell, Aaron; Le, Elizabeth; Naragum, Varun; Miller, Timothy R; Wozniak, Marcella A.; Shivashankar, Ravi; Cronin, Carolyn A.; Schrier, Chad; Gandhi, Dheeraj

doi:10.1136/neurintsurg-2019-014773

Cited by 52 publications

(37 citation statements)

References 10 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…The number of passes required for reperfusion is a treatment effect modifier (as are age, infarct size, etc), but the data reported here suggest that the treatment effect still favors recanalization for these patients, despite a higher number of passes. Our findings are supported by the findings of Jindal et al , who retrospectively reviewed their institution’s experience with 205 cases of anterior circulation large vessel occlusion over 6 years in order to determine predictors of functional outcome; on multivariate analysis, the number of thrombectomy attempts alone was not an independent negative predictor of functional outcome 11. This is perhaps because some patients cannot be recanalized despite many attempts, therefore biasing the “higher passes” group to worse outcomes.…”

Section: Discussionsupporting

confidence: 86%

“…This is perhaps because some patients cannot be recanalized despite many attempts, therefore biasing the “higher passes” group to worse outcomes. In the study of Jindal et al , only age, presenting NIHSS score, and revascularization grade were predictors of functional outcome 11. This is consistent with prior literature12; revascularization remains the only modifiable factor.…”

Section: Discussionsupporting

confidence: 74%

See 1 more Smart Citation

Successful reperfusion, rather than number of passes, predicts clinical outcome after mechanical thrombectomy

Tonetti

Desai

Casillo

et al. 2019

J NeuroIntervent Surg

View full text Add to dashboard Cite

IntroductionFor patients undergoing mechanical thrombectomy, numerous (>3) thrombectomy passes may be harmful. However, non-recanalization leads to poor outcomes. For patients requiring multiple thrombectomy passes to achieve reperfusion, it remains unclear if the risk/benefit ratio favors recanalization.ObjectiveTo test the hypothesis that the benefits afforded by successful reperfusion outweigh the risk conveyed by the numerous passes required.MethodsWe retrospectively reviewed prospectively collected data for patients presenting to a comprehensive stroke center with anterior circulation large vessel occlusion (ACLVO) and undergoing thrombectomy requiring more than one pass over 24 months. We stratified patients into three groups: group 1 (successful reperfusion in 2–3 passes), group 2 (successful reperfusion in ≥4 passes), and group 3 (unsuccessful reperfusion).Results250 patients with ACLVO constituted the study cohort. Despite similar demographics, group 2 patients had better clinical outcomes than those in group 3 at 24 hours (National Institutes of Health Stroke Scale (NIHSS) score 13.5 vs 19.1, p<0.001) and at 90 days (modified Rankin Scale score 0–2 rates of 31.1% vs 0.0%, p=0.006) On multivariate logistic regression analysis, age (p=0.034), Alberta Stroke Program Early CT Score (p<0.01), NIHSS score (p=0.02), and parenchymal hematoma type 2 (p=0.015) were significant predictors of functional independence among those who achieved successful reperfusion, but the number of passes required did not predict outcome for these patients (p=0.74).ConclusionPatients who achieve successful reperfusion after many passes have better clinical outcomes than those who do not, despite the number of passes and procedural time required. The number of passes required to achieve successful reperfusion beyond the first pass is not a predictor of functional independence.

show abstract

Section: Discussionsupporting

confidence: 86%

Section: Discussionsupporting

confidence: 74%

Successful reperfusion, rather than number of passes, predicts clinical outcome after mechanical thrombectomy

Tonetti

Desai

Casillo

et al. 2019

J NeuroIntervent Surg

View full text Add to dashboard Cite

show abstract

“…Number of passes required for recanalization was not a predictor of functional independence in their series. These findings are further supported by the findings of Jindal et al [11], who also found that the number of thrombectomy attempts alone was not an independent negative predictor of functional outcome, and concluded that revascularization beyond the first pass should continue to be the goal of stroke thrombectomy.…”

supporting

confidence: 69%

Number of passes in mechanical thrombectomy: where is your limit?

Filioglo

Cohen

Simaan

et al. 2020

Endovasc. Neurorad.

View full text Add to dashboard Cite

Background and aims. Stent retriever based thrombectomy is the mainstay of treatment of acute ischemic stroke caused by large vessel occlusion. However, recanalization is sometimes not achieved even after multiple passes of the thrombectomy device. Whether revascularization becomes futile or harmful with an increasing number of passes as well as criteria for when to halt attempting recanalization remain unknown. The purpose of our work is to analyze literature data on this issue. Materials and methods. We performed a short review of the literature and summarized evidence on the impact of repeated stentriever attempts on outcome.Results. Despite some controversies, the published data indicate that up to 30 % of patients still reach favorable outcome even when ≥5 stentriever passes are performed. Probability of obtaining functional independence after multiple stentriever attempts is even higher in patients with lower baseline NIHSS score. Patients who achieve successful reperfusion after ≥5 passes have significantly higher rates of functional independence and significantly lower rates of hemorrhagic transformation compared with those who do not achieve reperfusion. Rate of target recanalization after ≥4 passes may reach 19 %. Number of passes alone is not an independent negative predictor of functional independence. The impact of multiple stentriever attempts on hemorrhagic transformation has not been well-established.Conclusions. Target vessel recanalization is an essential goal of mechanical thrombectomy, which should be pursued despite the additional number of passes and procedural time required. Number of stentriver attempts is not a game- changing factor in the decision to abort the procedure for technical futility. Treatment decisions need to be individualized for each patient based on operator’s experience and preferences, patient and clot-specific characteristics.

show abstract

“…proportion of patients who achieved good functional outcome was inversely related to the number of passes among anterior cerebral circulation stroke thrombectomy cases. 33 Similarly, multivariable analyses from Zaidat et al demonstrated that achieving FPE was an independent predictor of good functional outcome. 9 Although there are factors that might affect the likelihood of achieving FPE (eg, factors related to the treating physician such as training, settings such as available equipment, and patients such as clot composition), recent research has suggested that certain techniques involving the combined use of stent retrievers and intermediate aspiration catheters could improve recanalization rates and the rate of FPE.…”

Section: Ischemic Strokementioning

confidence: 96%

Health economic impact of first-pass success among patients with acute ischemic stroke treated with mechanical thrombectomy: a United States and European perspective

Zaidat

Ribó

Mattle

et al. 2020

J NeuroIntervent Surg

View full text Add to dashboard Cite

BackgroundFirst-pass effect (FPE), restoring complete or near complete reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI) 2c-3) in a single pass, is an independent predictor for good functional outcomes in the endovascular treatment of acute ischemic stroke. The economic implications of achieving FPE have not been assessed.ObjectiveTo assess the economic impact of achieving complete or near complete reperfusion after the first pass.MethodsPost hoc analyses were conducted using ARISE II study data. The target population consisted of patients in whom mTICI 2c–3 was achieved, stratified into two groups: (1) mTICI 2c–3 achieved after the first pass (FPE group) or (2) after multiple passes (non-FPE group). Baseline characteristics, clinical outcomes, and healthcare resource use were compared between groups. Costs from peer-reviewed literature were applied to assess cost consequences from the perspectives of the United States (USA), France, Germany, Italy, Spain, Sweden, and United Kingdom (UK).ResultsAmong patients who achieved mTICI 2c–3 (n=172), FPE was achieved in 53% (n=91). A higher proportion of patients in the FPE group reached good functional outcomes (90-day modified Rankin Scale score 0–2 80.46% vs 61.04%, p<0.01). The patients in the FPE group had a shorter mean length of stay (6.10 vs 9.48 days, p<0.01) and required only a single stent retriever, whereas 35% of patients in the non-FPE group required at least one additional device. Driven by improvement in clinical outcomes, the FPE group had lower procedural/hospitalization-related (24–33% reduction) and annual care (11–27% reduction) costs across all countries.ConclusionsFPE resulted in improved clinical outcomes, translating into lower healthcare resource use and lower estimated costs.

show abstract

Beyond the first pass: revascularization remains critical in stroke thrombectomy

Cited by 52 publications

References 10 publications

Successful reperfusion, rather than number of passes, predicts clinical outcome after mechanical thrombectomy

Successful reperfusion, rather than number of passes, predicts clinical outcome after mechanical thrombectomy

Number of passes in mechanical thrombectomy: where is your limit?

Health economic impact of first-pass success among patients with acute ischemic stroke treated with mechanical thrombectomy: a United States and European perspective

Contact Info

Product

Resources

About