Thrombectomy Versus Combined Thrombolysis and Thrombectomy in Patients With Acute Stroke

Abstract

Background and Purpose: A recent randomized controlled trial DIRECT-MT (Direct Intra-Arterial Thrombectomy to Revascularize AIS Patients With Large Vessel Occlusion Efficiently in Chinese Tertiary Hospitals) compared the safety and efficacy of mechanical thrombectomy (MT) versus combined intravenous thrombolysis (IVT) and MT for acute large vessel occlusion. The current study utilized a prospective, nationwide registry to validate the results of the DIRECT-MT trial in a real-world practice setting. Methods: Subjects were selected from a prospective cohort of acute large vessel occlusion patients undergoing endovascular treatment at 111 hospitals from 26 provinces in China (ANGEL-ACT registry [Endovascular Treatment Key Technique and Emergency Work Flow Improvement of Acute Ischemic Stroke]) between November 2017 and March 2019. All patients eligible for IVT and receiving MT were reviewed and then grouped according to whether prior IVT or not (MT and combined IVT+MT). After a 1:1 propensity score matching, the outcome measures including the 90-day modified Rankin Scale, successful recanalization, door-to-puncture time, symptomatic intracranial hemorrhage, and intraprocedural embolization were compared. Results: A total of 1026 patients, 600 in the MT group and 426 in the combined group, were included. Among 788 patients identified after matching, there were no significant differences in the 90-day modified Rankin Scale (median, 3 versus 3 points; P =0.82) and successful recanalization (86.6% versus 89.3%; P =0.23) between the two groups; however, patients of the MT group had a shorter door-to-puncture time (median, 112 versus 136 minutes; β=−45.02 [95% CI, −68.31 to −21.74]), lower rates of symptomatic intracranial hemorrhage (5.5% versus 10.1%; odds ratio, 0.52 [95% CI, 0.30–0.91]), and embolization (4.6% versus 8.1%; odds ratio, 0.54 [95% CI, 0.30–0.98]) than those of the combined group. Conclusions: This matched-control study largely confirmed the findings of the DIRECT-MT trial in a real-world practice setting, suggesting that MT may carry similar effectiveness to combined IVT+MT for acute large vessel occlusion patients, despite MT alone seems to be associated with a shorter in-hospital delay until procedure, lower risks of symptomatic intracranial hemorrhage, and embolization. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03370939.

Direct versus Bridging Mechanical Thrombectomy in Elderly Patients with Acute Large Vessel Occlusion: A Multicenter Cohort Study

“…In terms of safety, we found bridging MT increased the incidence of PH-2 and showed a trend toward a higher incidence of sICH (10.06% vs 5.67%, respectively; adjusted P=0.061). The SKIP trial and two multicenter retrospective studies also showed that bridging thrombectomy had a higher risk of ICH, 11,14,19 which support our result to a certain extent. This suggests that IVT increases the risk of ICH in elderly patients.…”

“…The ANGEL-ACT is a nationwide, multicenter, prospective registry program for patients who undergo endovascular treatment for acute LVO from 111 stroke centers in China. 11 This research program was approved by the ethics committee of the Second Affiliated Hospital of Xi’an Jiaotong University and each participating site. Each participant or his/her representative gave written informed consent before being enrolled in the study.…”

“…The main reasons for not performing IVT included refusal by patients or their family members, fear of the side effect of IVT by physicians, and for the purpose of reducing financial burden. 11 Each participant or his/her legally authorized representative provided written informed consent before IVT and MT treatment. IVT was administered according to the current AHA/ASA guidelines within 4.5 h from symptom onset in the majority of patients (alteplase 0.9 mg/kg, maximum 90 mg, over 1 h with 10% initial bolus 1 ).…”

Endovascular treatment for acute ischemic stroke in patients with versus without atrial fibrillation: a matched-control study

“…Univariable comparisons of baseline characteristics between patients with and without AF were performed using Mann-Whitney or Pearson’s chi-square tests. To improve the comparability between the two groups, a 1:1 propensity score matching (PSM) was performed by using a caliper distance of 0.05 [ 25 ]. For comparing the outcomes between both groups, the odds ratios (OR) or common OR with their 95% confidence intervals (CI) were calculated using a binary or ordinal logistic regression model, if applicable.…”

Direct endovascular treatment versus bridging therapy in patients with acute ischemic stroke eligible for intravenous thrombolysis: systematic review and meta-analysis

“…We deemed nine of the 73 reviewed studies to be eligible. Three RCTs (DIRECT-MT, DEVT and SKIP [20][21][22] ) and six observational studies [23][24][25][26][27][28] were included after the full texts of the studies were screened. In all nine studies, patients with AIS-LVO who were eligible to undergo both IVT and EVT were assigned to undergo direct EVT or to undergo a combined treatment with intravenous alteplase before EVT.…”