Abstract 7: Procedural Approaches and Angiographic Signs Predicting First-Pass Recanalization in Patients Treated With Mechanical Thrombectomy for Acute Ischemic Stroke

Abstract

Background: First pass recanalization via mechanical thrombectomy (MT) has been associated with improved clinical outcome in patients with acute ischemic stroke. However, the optimal approach to achieve First Pass Effect (FPE) remains unclear. No study has evaluated angiographic features associated with the FPE. We aimed to determine the procedural approaches and angiographic signs that may predict FPE. Methods: We performed a prospective, multi-center, observational, study in patients with large vessel occlusion of the anterior circulation treated with MT between February and June 2017. MT was performed using different devices, deployment manoeuvres (standard unsheathing versus the “Push and Fluff” technique), Proximal Balloon Guide Catheter (PBGC), Distal Aspiration Catheter (DAC), or both. The Angiographic Clot Protrusion Sign (ACPS) was recorded. The modified Thrombolysis in Cerebral Infarction (mTICI) scale was used to score different levels of revascularization: FPE was defined as mTICI2b-3 and complete FPE (cFPE) as mTICI2c-3 after first pass. Associations were sought between FPE/cFPE and procedural approaches and angiographic signs. Adjusted logistic regression model was used to define independent predictors of succesful recanalization. Results: A total of 193 patients were included. FPE was achieved in 97 (50.3%) and cFPE in 74 (38.3%) patients. When the interventionalist decided to combine a PBGB and the Push and Fluff technique, FPE was achieved in 75% vs 47% of other cases (p<0.01) and cFPE in 64% vs 34% respectively (p<0.01). When the combination concurred with APCS, higher incidence of FPE (91% vs 47% p<0.01) and cFPE (82% vs 35% p<0.01) were observed. The use of PBGC (OR 3.81, 95%CI:1.41-10.22, p<0.01), the use of Push and Fluff technique (OR 3.45, 95%CI:1.28-9.29, p=0.01) and the record of ACPS (OR 4.71, 95%CI:1.78-12.44, p<0.01) were independently associated with higher rates of cFPE. Conclusions: In our experience, the concurrence of the PBGC, the Push and Fluff technique, and the ACPS was associated with the highest rates of FPE and cFPE. Appropriate selection of the thrombectomy device and deployment technique may lead to better procedural outcomes. ACPS could be used to assess clot integration strategies in future trials.