Mechanical Thrombectomy in Stroke. Experience from Switching from Stent Retriever Only to Stent Retriever Combined with Aspiration Catheter

Abstract

Endovascular treatment is a rapidly evolving technique; therefore, there is a constant need to evaluate this method and its modifications. This paper discusses a single-center experience and the results of switching from the stent retriever only (SO) mechanical thrombectomy (MT) to the combined approach (CA), with a stent retriever and aspiration catheters. Methods: The study involved a retrospective analysis of 70 patients undergoing MT with the use of either SO or CA. The primary endpoint was the frequency of perfect reperfusion defined as grade 3 of the modified Thrombolysis in Cerebral Infarction scale (mTICI) after the first pass. The secondary endpoints were the procedure success, defined as mTICI grades 2b-3; time of the procedure; clinical outcome, measured by 90 days’ modified Rankin Scale (mRS) score; Δ NIHSS, defined as the difference between National Institutes of Health Stroke Scale (NIHSS) score at patients’ admission and discharge; and the total number of device passes. Results: Out of the 70 patients included, 33 were treated with SO and 37 with CA. In both groups, a total number of 42 patients received intravenous recombined tissue plasminogen activator (iv-rTPA: 20 patients (60.6%) in the SO group and 22 patients (59.5%) in the CA group (p = 1.000). There was a significant difference between the groups regarding first-pass success rate, with 46% in the CA group and 18% in the SO group, (OR 3.83, 95% CI 1.28 to 11.44, p = 0.016). Complete procedure success tended to be more frequent in the CA group than in the SO group—94.6% vs. 84.8% (OR 3.13, 95% CI 0.56 to 17.34, p = 0.193)—and CA tended to require a lower number of passes than SO (mean 1.76 vs. 2.09 passes per procedure, p = 0.114), yet these differences did not reach statistical significance. Mean duration of the procedure was significantly shorter in the CA group than in the SO group (49 min vs. 64 min, p = 0.017). There was a significant difference in clinical outcomes, with higher Δ NIHSS (9.3 in the CA group vs. 6.7 in the SO group, p = 0.025) after the procedure and 90-day mRS (median 2 in the CA group vs. 4 in the SO group, p = 0.031). Conclusions: Combining stent retrievers with aspiration catheters may offer a beneficial effect on angiographic results and clinical outcomes in stroke patients undergoing endovascular treatment.

Mechanical thrombectomy with combined stent retriever and contact aspiration versus stent retriever alone for acute large vessel occlusion: data from ANGEL-ACT registry

“…Notably, we found first-line SR+CA had more MT passes, longer procedure duration and a similar successful recanalisation rate after first technique alone compared with first-line SR alone with the adjustment for the confounders and PS, which was different from the previous studies reported 7–12 19 20. Three reasons might explain the difference: first, the high incidence of LVO due to LAA was found high in China, which was reported in 52.7% of patients from the ANGEL-ACT registry,21 and patients with LAA were more vascular tortuous.…”

“…In real-world practice, first-line SR+CA might increase additional costs compared with first-line SR alone. Meder et al reported that switching from SR alone to SR+CA could increase approximately 30% of the direct costs of MT in their institution 8. In addition, the AC was not widely used throughout China during the study period, resulting in its non-availability in some hospitals 16.…”

“…Several observational studies reported the concomitant use of CA during SR (SR+CA) as a more efficient technique. [6][7][8][9][10][11] However, the recent RCT-ASTER 2 (Combined Use of Contact Aspiration and the Stent Retriever Technique vs Stent Retriever Alone for Recanalization in Acute Cerebral Infarction)-demonstrated that SR+CA as first-line MT technique (SR+CA firstline) resulted in similar final angiographic and clinical outcomes with SR alone as first-line MT technique (SR alone first-line); the trial may have been underpowered to detect more minor differences between groups. 12 Currently, in the Asian population, there are still few comparative analyses between SR+CA first-line and SR alone first-line for patients with LVO.…”

“…Consequently, how to improve the reperfusion level with the best technique is still a hot topic in the era of MT. Several observational studies reported the concomitant use of CA during SR (SR+CA) as a more efficient technique 6–11. However, the recent RCT—ASTER 2 (Combined Use of Contact Aspiration and the Stent Retriever Technique vs Stent Retriever Alone for Recanalization in Acute Cerebral Infarction)—demonstrated that SR+CA as first-line MT technique (SR+CA first-line) resulted in similar final angiographic and clinical outcomes with SR alone as first-line MT technique (SR alone first-line); the trial may have been underpowered to detect more minor differences between groups 12…”

Mechanical Thrombectomy in Stroke—Retrospective Comparison of Methods: Aspiration vs. Stent Retrievers vs. Combined Method—Is Aspiration the Best Starting Point?

“…Blood flow restoration in the occluded vessel can be obtained mechanically through three main methods: using a stent retriever, aspiration catheters and combining both these methods. Many trials comparing those techniques have proven the equality of SO and CM, and many have demonstrated the superiority of CM over AO and SO [ 5 , 6 , 7 , 8 , 9 ]. Of the two recent network meta-analyses, both suggested CM to be superior in terms of technical efficacy with similar safety and clinical outcomes compared to AO and SO [ 10 , 11 ].…”