Stent-retriever alone vs. aspiration and stent-retriever combination in large vessel occlusion stroke: A matched analysis

Abstract

Background Three randomized clinical trials have reported similar safety and efficacy for contact aspiration (CA) and Stent-retriever (SR) thrombectomy. Aim We aimed to determine whether the Combined Technique (SR+CA) was superior to SR alone as first-line thrombectomy strategy in a patient cohort where balloon-guide catheter was universally used. Methods A prospectively maintained mechanical thrombectomy database from January 2018-December 2019 was reviewed. Patients were included if they had anterior circulation proximal occlusion ischemic stroke (intracranial ICA or MCA-M1/M2 segments) and underwent SR alone thrombectomy or SR+CA as first-line therapy. The primary outcome was the first-pass effect (FPE) (mTICI2c-3). Secondary outcomes included modified FPE (mTICI2b-3), successful reperfusion (mTICI2b-3) prior to and after any rescue strategy, and 90-day functional independence (mRS ≤2). Safety outcomes included rate of parenchymal hematoma (PH) type-2 and 90-day mortality. Sensitivity analyses were performed after dividing the overall cohort according to first-line modality into two matched groups. Results A total of 420 patients were included in the analysis (mean age 64.4 years; median baseline NIHSS 16[11-21]). As compared to first-line SR alone, first-line SR+CA resulted in similar rates of FPE (53% vs. 51%,aOR 1.122, 95%CI[0.745-1.691],p=0.58), mFPE (63% vs. 60.4%,aOR1.250, 95%CI[0.782-2.00],p=0.35), final successful reperfusion (97.6% vs. 98%,p=0.75) and higher chances of successful reperfusion prior to any rescue strategy (81.8% vs. 72.5%,aOR 2.033, 95%CI[1.209-3.419],p=0.007). Functional outcome and safety measures were comparable between both groups. Likewise, the matched analysis (148 patient-pairs) demonstrated comparable results for all clinical and angiographic outcomes except for significantly higher rates of successful reperfusion prior to any rescue strategies with the first-line SR+CA treatment (81.8% vs. 73.6%,aOR 1.881, 95%CI[1.039-3.405],p=0.037). Conclusions Our findings reinforce the findings of ASTER-2 trial in that the first-line thrombectomy with a Combined Technique did not result in increased rates of first-pass reperfusion or better clinical outcomes. However, addition of contact aspiration after initial SR failure might be beneficial in achieving earlier reperfusion.

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.…”

Therapeutic Advancements in the Endovascular Management of Acute Ischemic Stroke

“…Three randomized controlled trials demonstrated noninferiority of contact aspiration to SR thrombectomy with similar procedural and clinical performance between the 2 techniques 60–62 . Moreover, similar results were reported between SR alone and combined SR plus contact aspiration thrombectomy when the procedures are done in conjunction with balloon guide catheters 63,64 …”

“…[60][61][62] Moreover, similar results were reported between SR alone and combined SR plus contact aspiration thrombectomy when the procedures are done in conjunction with balloon guide catheters. 63,64 Interestingly, several studies now reported that the performance of SR versus contact aspiration techniques might differ depending on thrombus composition, with better results in terms of early reperfusion and good outcomes in cases of SR alone thrombectomy for occlusions presenting with hyperdense vessel sign on noncontrast CT or blooming/susceptibility sign on magnetic resonance imaging (likely reflecting soft red blood cell-rich thrombus compared with occlusion not associated with these imaging signs [likely reflecting fibrinrich clots]). 65,66 Therefore, it is possible that baseline imaging may help in directing the best choice for firstline therapy.…”

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.…”

“…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…”