Abstract
BackgroundEmbolectomy is the standard of care in acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). Aim of this study was to compare two techniques: A Direct Aspiration First Pass Technique (ADAPT) and Stent-retriever Assisted Vacuum-locked Extraction (SAVE) stratified by the occluded vessel.MethodsOne hundred seventy-one patients (71 male) treated between January 2014 and September 2017 with AIS due to LVO of the anterior circulation (55 carotid T, 94 M1, 22 M2) were included. Treatment techniques were divided into two categories: ADAPT and SAVE. Primary endpoints were successful reperfusion (mTICI ≥2b), near-perfect reperfusion (mTICI ≥2c) and groin puncture to reperfusion time. Secondary endpoints were the number of device-passes, first-pass reperfusion, the frequency of emboli to new territory (ENT), clinical outcome at 90 days, and the frequency of symptomatic intracranial hemorrhage (sICH). Analysis was performed on an intention to treat basis.ResultsOverall, SAVE resulted in significant higher rates of successful reperfusion (mTICI≥2b) compared to ADAPT (93.5% vs 75.0%; p = 0.006). After stratification for the occluded vessel only the carotid T remained significant with higher rates of near-perfect reperfusion (mTICI≥2c) (55.2% vs 15.4%; p = 0.025), while for successful reperfusion a trend remained (93.1% vs 65.4%; p = 0.10). Groin to reperfusion times were not significantly different. Secondary analysis revealed higher rates of first-pass successful reperfusion (59.6% vs 33.3%; p = 0.019), higher rates of first-pass near-perfect reperfusion in the carotid T (35.4% vs 16.7%; p = 0.038) and a lower number of device-passes overall (median 1 IQR 1–2 vs 2 IQR 2–3; p < 0.001) and in the carotid T (median 2 IQR 1.3 vs 3 IQR 2–5; p < 0.001) for SAVE. Clinical outcome and safety parameters were comparable between groups.ConclusionsEmbolectomy using SAVE appears superior to ADAPT, especially for carotid T occlusions with regard to reperfusion success.
Highlights
Embolectomy is the standard of care in acute ischemic stroke (AIS) caused by large vessel occlusion (LVO)
Since multiple large randomized clinical trials demonstrated the superiority of endovascular treatment (EVT) over best medical treatment in patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO) of the anterior circulation [1,2,3,4,5], research priorities shifted among other things to improving angiographic outcomes
Several technical approaches were published in the recent years; they can generally be divided into three major categories: a direct aspiration first-pass technique (ADAPT), the primary use of a stent-retriever with Balloon-Guiding Catheter (BGC) and the primary combined approach with simultaneous intracranial use of an aspiration-catheter and a stent-retriever [6] with or without additional use of a BGC
Summary
Embolectomy is the standard of care in acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). While a recent randomized controlled study comparing the first two techniques showed no superiority of either one in terms of reperfusion scores (mTICI) and clinical outcome (90 days mRS) [7], smaller observational studies showed very high reperfusion rates and excellent functional outcome for combined approaches such as “Continuous aspiration prior to intracranial vascular embolectomy” (CAPTIVE), “Aspiration-Retriever Technique for Stroke” (ARTS) and “Stent-retriever Assisted Vacuum-locked Extraction” (SAVE) [8,9,10] This notion is supported by an in-vitro comparison of stent-retriever plus aspiration and stent-retriever alone, in which the combined approach showed significantly higher rates of successful revascularization [11]. This is in line with in vitro work performed by Chueh et al, showing a reduction in distal emboli due to proximal flow control [14]
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