Abstract TP41: The Importance of First Pass Substantial Reperfusion in the ARISE II Study

Abstract

Background: Recent studies report an approximately 90% rate of TICI 2b-3 reperfusion. With little room for further improvement, the resulting ceiling effect will limit the utility of this angiographic endpoint in future studies. We aimed to identify a more optimal definition of angiographic success along two dimensions: 1) the extent of tissue reperfusion and 2) the speed of revascularization. Methods: Data from the ARISE II study was used for this analysis. Core-lab adjudicated TICI scores (inclusive of 2c) after the first pass of EmboTrap and the final TICI scores after all interventions were collected. Receiver-operating characteristic (ROC) analyses were used to compare first pass and final TICI 2b-3, TICI 2c-3, and TICI 3 endpoints for the optimal prediction of 90-day mRS 0-2, 24-hour NIHSS improvement of ≥8 points, and 90-day mortality. The optimal procedural time from groin puncture to substantial reperfusion (TICI ≥2b) was also determined using ROC analysis. Results: Of 218 ARISE II subjects with anterior circulation occlusions, 201 (92.2%) had substantial reperfusion at the end of the procedure (final TICI 2b-3): 38 (17.4%) final TICI 2b, 52 (23.9%) final TICI 2c, and 111 (50.9%) final TICI 3. Substantial reperfusion after the first pass (first pass TICI 2b-3) was seen in 109 (50%) subjects. In 101 of these 109 (92.7%) cases, the first pass TICI score matched the final TICI score. The median procedural time from groin puncture to achieving TICI ≥2b was 29 minutes (interquartile range [IQR] 22.75-45 minutes) in the subjects who had first pass TICI 2b-3 versus 60 minutes (IQR 44.5-85 minutes) in those who did not (P<0.0001). In ROC analysis, first pass TICI 2b-3 had the highest c-statistic for predicting 90-day mRS 0-2 (0.644), ≥8-point improvement in NIHSS (0.625) and 90-day mortality (0.634). Among subjects with final TICI 2b-3, the subgroup with first pass TICI 2b-3 had lower median 90-day mRS (1 [IQR 0-2] vs. 2 [IQR 1-4], P<0.0001), lower mortality (4.8% vs. 13.2%, P=0.04), and lower rate of symptomatic intracranial hemorrhage (1.8% vs. 7.6%, P<0.05). The optimal procedural time to substantial reperfusion was ≤59 minutes. Conclusion: First pass TICI 2b-3 is the optimal angiographic endpoint for predicting clinical and safety outcomes in ARISE II.