Abstract WMP96: When to Change? Altering Strategies in Mechanical Thrombectomy May Impact Reperfusion Rates

Abstract

Introduction: Earlier and greater reperfusion in mechanical thrombectomy (MT) leads to better clinical outcomes. The timing and potential benefit of switching thrombectomy techniques after failed device passes remains unclear. Methods: Retrospective analysis of a prospective comprehensive stroke center database including patients with intracranial ICA, MCA M1/M2, or Basilar occlusions undergoing MT with either Stent-Retriever (SR), Contact Aspiration (CA) or Combined technique (CT) from 2015 to 2023. Our primary endpoint was complete/near-complete reperfusion (eTICI 2c-3) at pass #2 (after pass #1 failure). Secondary endpoints included 1) eTICI2b-3 at pass#2, and 2) eTICI2c-3 with pass #3 (following failure in two consecutive passes with the same technique). We used logistic or Firth regression to compare reperfusion rates and Kaplan-Meier analysis for cumulative rates. Results: Among 3130 MTs in the study period, 1810 met inclusion criteria. Median age [IQR] was 65 [55 - 76] years and 51.5% were male. Following a failed first pass, switching from CA to either CT or SR was associated with higher eTICI 2c-3 (aOR [95%CI] 2.8 [1.3 - 6.5] and 7.4 [1.4-54.8], respectively). Changing from CT or SR to any other technique was not associated with higher reperfusion. Secondary endpoint analysis for eTICI2b-3 yielded comparable results. For the third pass, switching to CT after two repeated failed SR or two repeated failed CA attempts was associated with higher eTICI 2c-3 as compared to repeating the original strategy (SR aOR 5.8 [1.4 - 33.3]; AC aOR 5.6 [1.1 - 41.2]). We did not observe benefit in switching to alternative technique following one or two consecutive passes with CT. After three repeated attempts with the same technique, CT led to greater eTICI 2c-3 as compared to SR and CA (83% vs. 72% vs. 64%, p < 0.001). Conclusions: While limited by small subgroup sample sizes, our study strengthens the hypothesis that early changes in MT technique may have an impact on reperfusion. Our data indicates that if CA fails on first pass, transition to SR or CT should be considered. After two failed consecutive SR or CA passes, transition to CT should be contemplated.