First-Pass Effect Predicts Clinical Outcome and Infarct Growth After Thrombectomy for Distal Medium Vessel Occlusions

Abstract

BACKGROUND:The first-pass effect in endovascular thrombectomy (EVT) has been associated with better clinical outcomes and decreased stroke progression in large vessel occlusion but has not been evaluated in distal, medium vessel occlusions (DMVOs). OBJECTIVE: To assess the impact on clinical outcome and stroke progression of the modified first-pass effect (defined as a successful first-pass [modified Thrombolysis In Cerebral Infarction 2b/2c/3] revascularization) in patients who underwent EVT for a primary DMVOs. METHODS: We collected data from consecutive patients who underwent EVT for a primary DMVO at a single large academic center. We compared the rate of good clinical outcome (modified Rankin Scale of 0-2 at 3 months) and stroke progression between patients who demonstrated modified first-pass effect (mFPE) vs those who did not (no-mFPE). RESULTS: Between January 2018 and January 2021, we included 60 patients who underwent EVT for an acute ischemic stroke with a primary DMVO. Overall, mFPE was achieved in 32% (19/60) of EVTs. The mFPE was associated with a higher rate of good clinical outcome compared with no-mFPE (89% vs 46%, odds ratio = 16. 04 [2.23-115.39], P = .006 in multivariate analysis). Final stroke volume was less among mFPE patients (6.9 mL [4.7-13.6] vs 23 mL [14.6-47], P = .001) as was stroke progression (6.8 mL [4-12.1] vs 17.8 mL [8.1-34.9], P = .016). The mFPE was still associated with higher rates of good clinical outcome when compared with patients reaching an modified Thrombolysis In Cerebral Infarction score ≥2b in more than 1 pass (89% vs 53%; odds ratio = 7.37 [1.43-38.08], P = .017). CONCLUSION: The mFPE may be associated with better clinical outcomes and lower stroke progression in DMVO.

First pass effect as an independent predictor of functional outcomes in medium vessel occlusions: An analysis of an international multicenter study

“…A small retrospective study reported an FPE rate of 32% in MeVO, associated with a higher likelihood of favorable clinical outcomes. 6 This is similar to FPE rates observed in the LVO trials. 7 Several other retrospective studies and meta-analyses have identified FPE rates of up to 50% in distal and middle vessel occlusions (DMVO).…”

“…Concerning stroke severity, this is in line with previous studies that showed that higher infarct volumes are associated with non-FPE recanalization. 6 The strength of this finding is supported by the consistent result obtained when comparing FPE with non-FPE in the subgroup of patients with mTICI 2c/3 recanalization (see Supplemental Analysis). This secondary analysis also reported unknown onset stroke as a predictor of FPE.…”

“…The patient and treatment characteristics in the study groups are reported in Table 1. Overall, the mean age was 72.3 years (SD, 13.6), 50.4% (n = 421) were women, and the median admission NIHSS score was 10 (IQR, [6][7][8][9][10][11][12][13][14][15][16]. Hypertension occurred in 76% of the population (n = 635), and 76.2% had a prestroke mRS of 0-1 (n = 596).…”

“…The technique was recently improved using a quadriaxial approach to obliviate the need for a blind exchange and reduce the chance of unwanted complications due to inadequate vessel collapse or traction. 6,32,33 A balloon-guide catheter’s added benefit might not be as evident in MeVOs as in LVOs. Most of these cases are performed with distal access catheters, even if they are not used for aspiration, and it was previously shown that this could reduce the utility of the balloon guide.…”

Predictors of futile recanalization in basilar artery occlusion patients undergoing endovascular treatment: a post hoc analysis of the ATTENTION trial

“…Compared with incomplete reperfusion, complete reperfusion ( 18 ), especially the first pass to achieve complete reperfusion, which is called the first pass effect ( 19 – 21 ), is related to better outcomes. De Havenon et al’s study also showed that the benefit of recanalization in BAO patients was significantly decreased when recanalization was achieved after more than three attempts ( 22 ).…”