Comparison of Four Food and Drug Administration–Approved Mechanical Thrombectomy Devices for Acute Ischemic Stroke: A Network Meta-Analysis

Abstract

The use of mechanical thrombectomy for the treatment of acute ischemic stroke (AIS) is rapidly increasing. However, there are limited data on the comparative effects of the various devices approved by the U.S. Food and Drug Administration for the treatment of AIS. We aimed to perform a network meta-analysis to assess the relative efficacy and safety of 4 thrombectomy devices. We searched PubMed, the Cochrane Library Central Register of Controlled Trials, and Embase for randomized controlled trials (RCTs) and parallel group observational studies that assessed thrombectomy devices in patients with AIS. Primary efficacy outcomes included functional independence (90-day modified Rankin Scale score) and recanalization rate (thrombolysis in cerebral infarction score). Safety outcomes included incidence of symptomatic intracranial hemorrhages and 90-day mortality. Five RCTs and 5 observational studies, including 1659 participants, were included. According to GRADE (Grading of Recommendations, Assessment, Development and Evaluations), most of the studies are of moderate quality of evidence. Compared with Penumbra, Solitaire and Trevo were associated with higher rates of functional independence (3.75 [1.44-7.66] and 4.68 [1.42-11.50], respectively). For revascularization, Solitaire and Trevo had higher rates of successful recanalization than Merci (2.99 [1.15-6.53] and 3.34 [1.20-8.01], respectively). In terms of safety outcomes (symptomatic intracerebral hemorrhage and mortality), there was no significant difference between any comparators. We concluded that stent retriever devices were superior to non-stent retriever devices in functional outcomes and recanalization without significant increases in death or symptomatic hemorrhage. We found no evidence for a differential therapy effect by stent type. Further high-quality RCTs assessing efficacy difference between these 2 stent retrievers are justified.