Stent-retriever assisted vacuum-locked extraction (SAVE) versus a direct aspiration first pass technique (ADAPT) for acute stroke: data from the real-world

Abstract

Background Embolectomy is the standard of care in acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). Aim of this study was to compare two techniques: A Direct Aspiration First Pass Technique (ADAPT) and Stent-retriever Assisted Vacuum-locked Extraction (SAVE) stratified by the occluded vessel. Methods One hundred seventy-one patients (71 male) treated between January 2014 and September 2017 with AIS due to LVO of the anterior circulation (55 carotid T, 94 M1, 22 M2) were included. Treatment techniques were divided into two categories: ADAPT and SAVE. Primary endpoints were successful reperfusion (mTICI ≥2b), near-perfect reperfusion (mTICI ≥2c) and groin puncture to reperfusion time. Secondary endpoints were the number of device-passes, first-pass reperfusion, the frequency of emboli to new territory (ENT), clinical outcome at 90 days, and the frequency of symptomatic intracranial hemorrhage (sICH). Analysis was performed on an intention to treat basis. Results Overall, SAVE resulted in significant higher rates of successful reperfusion (mTICI≥2b) compared to ADAPT (93.5% vs 75.0%; p = 0.006). After stratification for the occluded vessel only the carotid T remained significant with higher rates of near-perfect reperfusion (mTICI≥2c) (55.2% vs 15.4%; p = 0.025), while for successful reperfusion a trend remained (93.1% vs 65.4%; p = 0.10). Groin to reperfusion times were not significantly different. Secondary analysis revealed higher rates of first-pass successful reperfusion (59.6% vs 33.3%; p = 0.019), higher rates of first-pass near-perfect reperfusion in the carotid T (35.4% vs 16.7%; p = 0.038) and a lower number of device-passes overall (median 1 IQR 1–2 vs 2 IQR 2–3; p < 0.001) and in the carotid T (median 2 IQR 1.3 vs 3 IQR 2–5; p < 0.001) for SAVE. Clinical outcome and safety parameters were comparable between groups. Conclusions Embolectomy using SAVE appears superior to ADAPT, especially for carotid T occlusions with regard to reperfusion success.

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

“…The shift in clinical outcomes is best visualized in Figure 1 . These results are in accordance with those reported in other papers [ 5 , 6 , 13 , 18 , 19 , 22 , 23 , 28 ].…”

“…Previous studies have shown that different techniques combining stent retrievers with aspiration catheters, such as SAVE, Solumbra or ARTS, present with high rates of reperfusion success and good clinical outcomes [ 5 , 6 , 13 , 14 , 15 , 16 , 17 ]. In 2019, Brehm et al, in a direct comparison, proved the superiority of SAVE over ADAPT in achieving faster and better recanalization with fewer device passes [ 18 ].…”

Direct aspiration stroke thrombectomy: a comprehensive review

“…After stratification according to the occlusion site, the combined approach was more efficient for carotid "T" occlusions with higher rates of recanalization (TICI 2c or more 55.2% vs 15.4%; p=0.025), with higher rates of first-pass mTICI 2c or more (59.6% vs 33.3%; p=0.019), and demonstrated a trend toward better final successful reperfusion rate (93.1% vs 65.4%; p=0.10). 59 For M1 segment occlusion, similar reperfusion rates were reported (94.8% vs 83.3%; p=0.187). Finally, two observational studies have also reported a lower rate of ENT with combined treatment but also an increased risk of sICH, 20 60 a difference that was not found in the RCT.…”

“…According to this recent meta-analysis, 61 combined treatment was associated with better successful reperfusion rates (OR 1.47, 95% CI 1.02 to 2.12) compared with DA alone; however, there was no difference in clinical outcomes (favorable outcome OR 0.84, 95% CI 0.38 to 1.86). One study 59 further investigated this result. After stratification according to the occlusion site, the combined approach was more efficient for carotid "T" occlusions with higher rates of recanalization (TICI 2c or more 55.2% vs 15.4%; p=0.025), with higher rates of first-pass mTICI 2c or more (59.6% vs 33.3%; p=0.019), and demonstrated a trend toward better final successful reperfusion rate (93.1% vs 65.4%; p=0.10).…”

Factors Associated with Failure of Reperfusion in Endovascular Therapy for Acute Ischemic Stroke

“…Furthermore, no differences were found in reperfusion success between patients treated exclusively with stent-retrievers or those treated with aspiration devices, as has also been reported by the COMPASS trial [ 26 ], as well as by a recent meta-analysis [ 23 ]. In this context, it is of importance to note that recent studies have demonstrated that a combined approach, such as stent retriever-assisted vacuum-locked extraction (SAVE) appears to be superior in achieving reperfusion with a single pass [ 36 ].…”