Effect of Thrombectomy With Combined Contact Aspiration and Stent Retriever vs Stent Retriever Alone on Revascularization in Patients With Acute Ischemic Stroke and Large Vessel Occlusion

Abstract

IMPORTANCE Mechanical thrombectomy using a stent retriever or contact aspiration is widely used for treatment of patients with acute ischemic stroke due to anterior circulation large vessel occlusion, but the additional benefit of combining contact aspiration with stent retriever is uncertain. OBJECTIVE To determine whether mechanical thrombectomy for treatment of anterior circulation large vessel occlusion stroke with initial contact aspiration and stent retriever combined results in better final angiographic outcome than with standard stent retriever alone. DESIGN, SETTING, AND PARTICIPANTS This trial was a multicenter randomized, open-label, blinded end point evaluation that enrolled 408 patients from October 16, 2017, to May 29, 2018, in 11 French comprehensive stroke centers, with a 12-month outcome follow-up. Patients with a large vessel occlusion in the anterior circulation were included up to 8 hours after symptom onset. The final date of follow-up was June, 19, 2019. INTERVENTIONS Patients were randomly assigned (1:1 allocation) to receive initial thrombectomy with contact aspiration and stent retriever combined (205) or stent retriever alone (203). MAIN OUTCOMES AND MEASURESThe primary outcome was the rate of expanded Thrombolysis In Cerebral Infarction score of 2c or 3 (eTICI 2c/3; ie, scores indicate near-total and total reperfusion grades) at the end of the procedure. RESULTS Among the 408 patients who were randomized, 3 were excluded, and 405 (99.3%) patients (mean age, 73 years; 220 [54%] women and 185 [46%] men) were included in the primary analysis. The rate of eTICI 2c/3 at the end of the endovascular procedure was not significantly different between the 2 thrombectomy groups (64.5% [131 of 203 patients] for contact aspiration and stent retriever combined vs 57.9% [117 of 202 patients] for stent retriever alone; risk difference, 6.6% [95% CI, -3.0% to 16.2%]; adjusted odds ratio [OR], 1.33 [95% CI, 0.88 to 1.99]; P = .17). Of 14 prespecified secondary efficacy end points, 12 showed no significant difference. A higher rate of successful reperfusion was achieved in the contact aspiration combined with stent retriever group vs the stent retriever alone group (eTICI 2b50/2c/3, 86.2% vs 72.3%; adjusted OR, 2.54 [95% CI, 1.51 to 4.28]; P < .001) and of near-total or total reperfusion (eTICI 2c/3, 59.6% vs 49.5%; adjusted OR, 1.52 [95% CI, 1.02 to 2.27]; P = .04) after the assigned initial intervention alone.CONCLUSIONS AND RELEVANCE Among patients with acute ischemic stroke due to large vessel occlusion, an initial thrombectomy technique consisting of contact aspiration and stent retriever combined, compared with stent retriever alone, did not significantly improve the rate of near-total or total reperfusion (eTICI 2c/3) at the end of the endovascular procedure, although the trial may have been underpowered to detect smaller differences between groups.

Poor clinical outcome despite successful basilar occlusion recanalization in the early time window: incidence and predictors

“…Pending the results of the future pc-ASTER trial, to date, data in the literature are insufficient to support a technical recommendation for a specific thrombectomy technique which might improve first-pass reperfusion rates. For anterior circulation occlusions, a recent large multicentric study12 found significantly higher first pass excellent reperfusion rates when combined stent retriever (SR)+contact aspiration (CA) technique was used as a frontline strategy, in conjunction with a balloon guide catheter, but this result was not replicated in other retrospective studies13 14 nor in the two ASTER (Contact Aspiration vs Stent Retriever for Successful Revascularization) randomized clinical trials (ASTER115 and ASTER216). For posterior circulation thrombectomies, a recently published multicentric cohort of 128 patients17 compared outcomes according to front-line technique (SR, CA, combined SR+CA).…”

Combined balloon guide catheter, aspiration catheter, and stent retriever technique versus balloon guide catheter and stent retriever alone technique: a systematic review and meta-analysis

“…After removing duplicates and screening for the titles and abstracts, 63 papers remained for full text review from which we excluded 58 papers (overlapping population, n=2; wrong outcome or no outcome reported, n=41; review, n=4; combined technique only used as salvage, n=2; unable to extract data, n=2; other endpoints, n=4; other, n=1). Finally, we included five studies in our meta-analysis,17 18 26–28 which included four cohort studies and one randomized trial. The quality of all of the included articles was high.…”

“…In fact, cardiac trials used non-inferiority margins of 3.5–4.4% for reperfusion. In the only randomized trial included in the meta-analysis, the sample size calculation was powered to accommodate a 15% difference between groups for the final reperfusion 17. In their study, the CI extended up to 16.2% and the study may have been underpowered to detect smaller benefits.…”

“…While individual operators have their own personal preferences, the combined use of stent retriever and aspiration catheter has been proposed as a more efficient technique to achieve a higher rate of complete reperfusion and better functional outcomes, due to the potential synergistic effects of the two techniques simultaneously 15 16. Conversely, a recent randomized controlled trial and a large registry have reported that the combination technique is not superior to the use of a stent retriever alone but the studies may have been underpowered to accurately show the differences between the two techniques 17 18…”

Human “live cadaver” neurovascular model for proximal and distal mechanical thrombectomy in stroke

“…Since 2015, thrombectomy has become the standard care for patients with large vessel occlusion stroke. Due to the accumulation of clinical experience and advancement of device technologies, the final complete recanalization rate has improved to about 60% in the latest randomized trial 1. However, after the first device pass, which is associated with the best patient outcome,2 complete recanalization has been hovering around 35% 3.…”