First-line Contact Aspiration Research Articles

Endovascular therapy of acute vertebrobasilar occlusions: influence of first-line strategy in the Endovascular Treatment in Ischemic Stroke (ETIS) Registry

BackgroundThe choice of the first-line technique in vertebrobasilar occlusions (VBOs) remains challenging. We aimed to report outcomes in a large cohort of patients and to compare the efficacy and safety...

Contact aspiration for basilar artery occlusion safely reduces the puncture-to-recanalization time

ObjectiveEffective thrombectomies in the posterior circulation remain controversial. Previous reports have demonstrated the superiority of contact aspiration in anterior circulation. Aspiration catheters and stent retrievers are often used alone on a global scale, while combined techniques are commonly used in Japan. This study evaluated the effect of first-line contact aspiration with other strategies for the treatment of basilar artery occlusion. MethodsThe primary outcome was the frequency of the first-pass effect, and the secondary outcome was the time from puncture to the first-pass effect. A multicenter observational registry including 16 Japanese stroke centers was used. Between December 2013 and February 2021, enrolled patients underwent endovascular thrombectomy for basilar artery occlusion. The efficacy of contact aspiration compared to other methods (including stent retrievers and combined techniques) was evaluated. ResultsEighty-four patients were included, all of whom had achieved effective recanalization. Twenty-six patients were treated with contact aspiration, 13 with combined technique, and 45 with stent retrievers. The two groups: contact aspiration and non-contact aspiration, had different backgrounds. Both had similar frequencies of effective recanalization and first-pass effects. The contact aspiration group experienced better functional outcomes without statistical significance, while this strategy was significantly associated with a shorter puncture-to-recanalization time (38 vs. 55 minutes, P=0.036). In particular, in the 55 patients with the first-pass effect, multivariate Cox proportional hazard analysis showed that contact aspiration was significantly associated with a shorter time from puncture to first-pass effect, independent of age and etiology of large-artery atherosclerosis (hazard ratio 2.02, 95% confidence intervals 1.10–3.69, P=0.023). ConclusionThis study suggested that contact aspiration for basilar artery occlusion may shorten the puncture-to-first-pass effect, compared to stent retrievers and combined techniques.

Mechanical thrombectomy in basilar artery occlusions: impact of first-line strategy as a function of the occlusion level

BackgroundRetrospective studies suggest the superiority of first-line contact aspiration (CA) thrombectomy over stent-retriever (SR) in basilar artery occlusions (BAO). We aimed to investigate the impact of first-line mechanical thrombectomy per...

Comparing Functional Outcomes and Safety Profiles of First-Line Aspiration Thrombectomy Versus Stentriever for Acute Basilar Artery Occlusion: Propensity Analysis of the PC-SEARCH Thrombectomy Registry.

Aspiration catheters (ASPs) and stentriever thrombectomy devices have comparable safety and efficacy in anterior circulation ischemic strokes. However, there is lack of high-quality comparative data in acute basilar artery occlusions. Our objective is to compare the outcomes and safety of ASPs and stentriever devices in acute basilar artery occlusions. This is an analysis of the retrospectively established PC-SEARCH Thrombectomy (Posterior-Circulation Ischemic Stroke Evaluation: Analyzing Radiographic and Intraprocedural Predictors for Mechanical Thrombectomy) registry. Patients were dichotomized based on their first-line thrombectomy device (ASP and stentriever) and associated with their 90-day functional outcomes, intraprocedural metrics, and safety measures. Propensity analysis based on unequal baseline characteristics was performed. Consecutive patients with acute basilar artery occlusions who received mechanical thrombectomy were included from January 2015 to December 2021. Patients received either first-line contact aspiration or stentriever mechanical thrombectomy. Primary clinical and safety outcomes were 90-day functional independence measured by a modified Rankin Scale score of 0 to 3 and symptomatic intracranial hemorrhage, respectively. Secondary outcomes included puncture-recanalization times, first-pass recanalization rates, crossovers to other thrombectomy device, and neurological/hospital complications. Five hundred eighteen patients were included in the registry, and a total of 383 patients were included (mean [SD] age, 65.5 [15] years; 228 [59%] men) in this analysis. Of these, 219 patients were first-line ASP while 164 patients received first-line stentriever devices. Median premorbid modified Rankin Scale was zero and median presenting National Institutes of Health Stroke Scale was 17 (interquartile range, 8-26). The proportion of favorable functional outcome was similar between the 2 techniques before (47.3% versus 42.5%; odds ratio, 1.22 [95% CI, 0.78-1.89]; P=0.38) and after propensity matching (odds ratio, 1.46 [95% CI, 0.85-2.49]; P=0.17). In our propensity-matched cohorts, puncture-recanalization times (18 versus 52 minutes; P<0.01) favored first-line ASP; however, first-pass recanalization rates (43.5% versus 44.5%; P=0.90) were similar between groups. First-line ASP was associated with higher rates of crossover (22% versus 6%; P<0.01), whereas stentriever was associated with higher rates of symptomatic intracranial hemorrhage (9.8% versus 3.4%; P=0.04). First-line ASP and stentriever methods demonstrated similar functional outcome and recanalization rates. Stentriever methods were associated with higher rates of symptomatic intracranial hemorrhage, whereas ASPs were associated with higher rates of crossover to alternative technique in patients with acute basilar occlusions.

Impact of vessel tortuosity and radiological thrombus characteristics on the choice of first-line thrombectomy strategy: Results from the ESCAPE-NA1 trial.

Despite improvements in device technology, only one-third of stroke patients undergoing endovascular thrombectomy (EVT) achieve first-pass effect (FPE). We investigated the effect of arterial tortuosity and thrombus characteristics on the relationship between first-line EVT strategy and angiographic outcomes. Patients with thin-slice baseline CT-angiography from the ESCAPE-NA1 trial (Efficacy and safety of nerinetide for the treatment of acute ischemic stroke) were included. Tortuosity was estimated using the tortuosity index extracted from catheter pathway, and radiological thrombus characteristics were length, non-contrast density, perviousness and hyperdense artery sign. We assessed the association of first-line EVT strategy (stent-retriever [SR] versus contact aspiration [CA] versus combined SR+CA) with FPE (eTICI score 2c/3 after one pass), final eTICI 2b/3, number of passes and procedure duration using multivariable regression. Interaction of tortuosity and thrombus characteristics with first-line technique were assessed using interaction terms. Among 520 included patients, SR as a first-line modality was used in 165 (31.7%) patients, CA in 132 (25.4%), and combined SR+CA in 223 (42.9%). FPE was observed in 166 patients (31.9%). First-line strategy was not associated with FPE. Tortuosity had a significant effect on FPE only in the CA group (aOR = 0.90 [95% CI 0.83-0.98]) compared with stent-retrievers and combined first-line approach (p interaction = 0.03). There was an interaction between thrombus length and first-line strategy for number of passes (p interaction = 0.04). Longer thrombi were associated with higher number of passes only in the CA group (acOR 1.03 [95% CI 1.00-1.06]). Our study suggests that vessel tortuosity and longer thrombi may negatively affect the performance of first-line contact aspiration catheters in acute stroke patients undergoing EVT.

First-line contact aspiration versus first-line stent retriever for acute ischemic stroke with M2 occlusion: A systematic review and meta-analysis

ObjectiveMechanical thrombectomy is widely used for acute ischemic stroke caused by middle cerebral artery M2 segment occlusion. However, the comparison between contact aspiration (CA) and stent retriever (SR) used as first-line techniques for acute M2 occlusion is still unclear. We aimed to perform a systematic review and meta-analysis on this issue. MethodsThe Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement was followed. Three databases (Pubmed, Embase, and Cochrane) were searched. The Newcastle-Ottawa scale was used to assess the risk of bias for the included studies. We focused on two main outcomes, the final successful reperfusion (modified Thrombolysis in Cerebral Infarction mTICI 2b/3) and 90-day functional independence (modified Rankin Scale score 0–2). The meta-analyses were performed using the random-effects models. ResultsSeven observational studies were included for systematic review. Only one study indicated a superiority of first-line SR in achieving final successful reperfusion, while the other six studies did not show significant difference between these two techniques. And all the seven studies showed comparable proportion of 90-day functional independence. Five studies were available for meta-analysis with 601 patients (239 received first-line CA, 362 received first-line SR). The pooled results also suggested that the proportion of final successful reperfusion (OR=1.18, 95%CI 0.72–1.93, I2 =0%) and 90-day functional independence (OR=1.18, 95%CI 0.82–1.68, I2 =0%) were comparable between these two strategies. ConclusionFor patients with acute M2 occlusion, first-line CA and SR techniques could achieve similar final reperfusion outcomes and 90-day clinical prognosis. Further studies with randomized controlled design are needed.

Association of Regular Thrombus Surface Phenotype With Complete Recanalization in First-Line Contact Aspiration Thrombectomy for Basilar Artery Occlusion.

Objective: To assess whether angiographic thrombus surface phenotype has an impact on efficacy of contact aspiration (CA) thrombectomy in patients with basilar artery occlusion (BAO).Methods: From January 2016 to December 2019, consecutive stroke patients with a BAO and first-line CA were analyzed in this retrospective study. We assessed baseline and imaging characteristics and treatment and clinical outcomes. We rated thrombus surface phenotype on pre-treatment digital subtraction angiography in a three-reader-consensus setting. Primary outcome was complete recanalization (modified treatment in cerebral ischemia [mTICI] 3 and arterial occlusive lesion [AOL] 3) after first-line CA without additionally stent retriever passes. Data analysis was stratified according to thrombus surface phenotype and complete first-line recanalization.Results: Seventy-eight patients met the inclusion criteria. Median age was 74 years (IQR 64–80), 64% were male, and median baseline NIHSS score was 24 (IQR 7–32). Thirty patients had a regular and 16 patients had an irregular thrombus phenotype. Thrombus surface was not assessable in 32 patients. In patients with a regular phenotype, complete recanalization was more often achieved compared to irregular and non-ratable phenotypes (50 vs. 18.8% and 21.9%; p = 0.027). Patients with a regular phenotype [odds ratio [OR] 8.3; 95% confidence interval [CI]: 1.9–35.8; p = 0.005], cardioembolic stroke (OR 12.1, 95% CI: 2.0–72.8; p = 0.007), and proximal end of the thrombus in the middle basilar artery segment (OR 5.2, 95% CI: 1.0–26.6; p = 0.046) were more likely to achieve complete recanalization after first-line CA without rescue therapy.Conclusion: The efficacy of CA may differ according to the angiographic thrombus surface phenotype in patients with BAO. A regular phenotype is associated with higher rates of complete recanalization in first-line CA. However, assessment of thrombus phenotype is frequently not feasible in BAO.

Mechanical thrombectomy in patients with acute cancer-related stroke: is the stent retriever alone effective?

BackgroundThe optimal first-line mechanical thrombectomy (MT) method in cancer-related stroke (CRS) patients with emergent large vessel occlusion (ELVO) remains largely unknown. The aim of this study is to evaluate the...

First-Line Contact Aspiration vs Stent Retriever for Proximal Occlusion in Acute Ischemic Stroke: A Systemic Review and Meta-Analysis

IntroductionThe aim of this systematic review and meta-analysis was to compare the performance of first-line contact aspiration (ASP) and stent retriever (SR) in acute ischemic stroke caused by proximal large vessel occlusion. MethodsCochrane databases, MEDLINE and EMBASE were systematically searched for literatures reporting outcomes on thrombectomy with both first-line aspiration and first-line stent retriever in proximal occlusion. ResultsThirteen studies with a total of 1614 patients were included. No differences were identified between the SR and ASP groups in terms of final reperfusion rate (modified thrombolysis in cerebral infarction 2b/3) (OR: 1.54, 95% CI: 0.88–2.70), complete recanalization rate (modified thrombolysis in cerebral infarction 3) (OR: 1.78, 95% CI: 0.58–5.44), and favorable outcomes (modified Rankin scale ≤2) (OR: 1.02, 95% CI: 0.79–1.32). With regard to adverse events, emboli to new territories (OR: 0.81, 95% CI: 0.31–2.14), intracranial hemorrhage (OR: 0.71, 95% CI: 0.40–1.28), 90-days mortality (OR: 1.02, 95% CI: 0.71–1.47) were similar between groups, while symptomatic intracerebral hemorrhage (OR: 0.43 95% CI: 0.21–0.86) was less seen in ASP. Subgroup analysis indicated that ASP was comparable to stent retriever with local aspiration (SRLA) (OR: 1.25 95% CI: 0.25–6.22) and superior to stent retriever alone (OR: 1.85 95% CI: 1.22–2.81). Moreover, in posterior circulation, contact aspiration achieved a significantly higher reperfusion (OR: 1.97 95% CI: 1.03–3.76) compared to stent retriever, and needed relatively less rescue therapies (21.5% vs 29.6%, p < 0.05). ConclusionOur study suggested that contact aspiration might be advantageous over stent retriever alone and more suitable in posterior circulation. While ASP and SRLA thrombectomy were equally effective in achieving good clinical outcomes. However, further studies are needed to confirm these results.

Does Device Selection Impact Recanalization Rate and Neurological Outcome?: An Analysis of the Save ChildS Study.

Background and Purpose- The recent Save ChildS study provides multicenter evidence for the use of mechanical thrombectomy in children with large vessel occlusion arterial ischemic stroke. However, device selection for thrombectomy may influence rates of recanalization, complications, and neurological outcomes, especially in pediatric patients of different ages. We, therefore, performed additional analyses of the Save ChildS data to investigate a possible association of different thrombectomy techniques and devices with angiographic and clinical outcome parameters. Methods- The Save ChildS cohort study (January 2000-December 2018) analyzed data from 27 European and United States stroke centers and included all pediatric patients (<18 years), diagnosed with arterial ischemic stroke who underwent endovascular recanalization. Patients were grouped into first-line contact aspiration (A Direct Aspiration First Pass Technique [ADAPT]) and non-ADAPT groups as well as different stent retriever size groups. Associations with baseline characteristics, recanalization rates (modified Treatment in Cerebral Infarction), complication rates, and neurological outcome parameters (Pediatric National Institutes of Health Stroke Scale after 24 hours and 7 days; modified Rankin Scale and Pediatric Stroke Outcome Measure at discharge, after 6 and 24 months) were investigated. Results- Seventy-three patients with a median age of 11.3 years were included. Currently available stent retrievers were used in 59 patients (80.8%), of which 4×20 mm (width×length) was the most frequently chosen size (36 patients =61%). A first-line ADAPT approach was used in 7 patients (9.6%), and 7 patients (9.6%) were treated with first-generation thrombectomy devices. In this study, a first-line ADAPT approach was neither associated with the rate of successful recanalization (ADAPT 85.7% versus 87.5% No ADAPT) nor with the complication rate or the neurological outcome. Moreover, there were no associations of stent retriever sizes with rates of recanalization, complication rates, or outcome parameters. Conclusions- Our study suggests that neurological outcomes are generally good regardless of any specific device selection and suggests that it is important to offer thrombectomy in eligible children regardless of technique or device selection. Registration- URL: https://www.drks.de/; Unique identifier: DRKS00016528.

First-Line Sofia Aspiration Thrombectomy Approach within the Endovascular Treatment of Ischemic Stroke Multicentric Registry: Efficacy, Safety, and Predictive Factors of Success.

After publications on the effectiveness of mechanical thrombectomy by stent retrievers in acute ischemic stroke with large-vessel occlusion, alternative endovascular approaches have been proposed using first-line aspiration catheters. Several devices are currently available to perform A Direct Aspiration First Pass Technique. The Sofia catheter aspiration has been widely used by interventionalists, but data are scarce about its efficacy and safety. Our aim was to report our multicenter thrombectomy experience with first-line Sofia catheter aspiration and to identify independent prognostic factors of clinical and procedural outcomes. We performed a retrospective analysis of the prospectively maintained Endovascular Treatment of Ischemic Stroke multicentric registry. Data from consecutive patients who benefited from thrombectomy with a first-line Sofia approach between January 2013 and April 2018 were studied. We excluded other first-line approaches (stent retriever or combined aspiration and stent retriever) and extracranial occlusions. Baseline characteristics, procedural data, and angiographic and clinical outcomes were analyzed. During the study period, 296 patients were treated. Mean age and initial NIHSS score were, respectively, 69.5 years and 16. Successful reperfusion, defined by the modified TICI 2b/3, was obtained in 86.1% (n = 255; 95% CI, 81.7%-89.9%). Complete reperfusion (modified TICI 3) was obtained in 41.2% (n = 122; 95% CI, 35.5%-47.1%). A first-pass effect was achieved in 24.2% (n = 71; 95% CI, 19.4%-29.6%). A rescue stent retriever approach was required in 29.7% (n = 88; 95% CI, 24.6%-35.3%). The complication rate was 9.5% (n = 28; 95% CI, 6.4%-13.5%). Forty-three percent (n = 122; 95% CI, 37.1%-48.9%) of patients presented with a favorable 3-month outcome (mRS ≤ 2). Older age, M1-occlusion topography, and intravenous thrombolysis use prior to thrombectomy were independent predictors of the first-pass effect. The first-line contact aspiration approach appeared safe and efficient with Sofia catheters. These devices achieved very high reperfusion rates with a low requirement for stent retriever rescue therapy, especially for M1 occlusions.

Thrombectomy for M1-Middle Cerebral Artery Occlusion: Angiographic Aspect of the Arterial Occlusion and Recanalization: A Preliminary Observation.

Despite the recent technical evolution of the endovascular treatment of acute ischemic stroke, late and incomplete recanalization can be achieved after several maneuvers but with a potentially higher risk of futile reperfusion and complications, such as clot fragmentation. The aim of this article is to investigate the impact of the angiographic phenotype of M1-middle cerebral artery occlusions, classified as regular and irregular in aspect, on the results of treatment by stent retrievers (SRs) or contact aspiration (CA). From January to April 2016, 84 consecutive patients, admitted for acute ischemic stroke with a middle cerebral artery occlusion, were treated by endovascular therapy. Among them, 60 patients (26M, 34F, median age, 70.5; interquartile range, 58.5-80.0) were treated by SR (25/60, 41.7%) or CA (35/60, 58.3%) as a first-line approach in 2 experienced centers. Patients' characteristics, timing, and procedural data were prospectively recorded and compared between the 2 study subgroups (regular and irregular phenotype). A regular phenotype at the occlusion site was observed in 24 patients (40%). Among these, successful recanalization after the first-line strategy (Thrombolysis in Cerebral Infarction 2b-3) was achieved in 100% of patients treated by CA and in only 33.3% of patients treated by SR (P=0.001). For irregular phenotypes, SR achieved Thrombolysis in Cerebral Infarction 2b-3 in 73.9% and CA, in 38.5% (P=0.036) of cases. Among regular phenotype patients, the average number of maneuvers was 1.3 (median, 1; range 1-3) with first-line CA and 2.7 (median, 3; range 1-5) with first-line SR (P=0.008). The angiographic phenotype of the occlusion site may be associated with a different response to SR and CA in this preliminary experience.

Contact Aspiration with the New ARC Catheter for Thrombectomy of Acute Ischemic Stroke: Single-Center Results.

Contact aspiration has gained growing acceptance in endovascular stroke therapy. The safety and efficacy data of the novel ARC catheter (Medtronic, Irvine, California, USA) used for intracranial thrombectomy have been poorly evaluated thus far. We report our preliminary results with the ARC with regard to angiographic reperfusion, duration of thrombectomy, safety, and clinical outcome at 90 days. In a single-center series including 20 large-vessel occlusion stroke patients who were collected prospectively, we retrospectively evaluated the safety and efficacy profiles of the ARC intracranial catheter for first-line contact aspiration. Successful reperfusion was defined as modified Thrombolysis in Cerebrovascular Infarction (mTICI) scores 2b-3 at final angiogram and functional independence as modified Rankin Scale score 0-2 at 90 days. Median admission National Institutes of Health Stroke Scale score was 15, and previous intravenous thrombolysis was administered in 12 patients (60%). Proximal occlusion was located in the anterior circulation in 16 patients (80%). Primary aspiration alone was successful in 10 of 15 patients (67%) within a median time of 26minutes. Overall successful reperfusion was achieved in 16 patients (80%) within a median time of 31 minutes. There were no device-related events. Median National Institutes of Health Stroke Scale score was 2.5 at discharge. Six of 17patients (35%) were independent, and 6 (35%) died at 90days. Symptomatic intracerebral hemorrhage occurred in5%. In our initial experience, the ARC appears safe and efficient for contact aspiration thrombectomy in large-vessel stroke therapy. However, improvement of its distal navigability needs further development to improve the success of aspiration alone, and large prospective studies are warranted.

First-Line Contact Aspiration vs. Stent Retriever for Acute Large-Vessel Ischemic Stroke

Most patients in recent mechanical thrombectomy trials were treated with stent retrievers. But the large-bore catheter that is required to deploy a

Effect of Endovascular Contact Aspiration vs Stent Retriever on Revascularization in Patients With Acute Ischemic Stroke and Large Vessel Occlusion

The benefits of endovascular revascularization using the contact aspiration technique vs the stent retriever technique in patients with acute ischemic stroke remain uncertain because of lack of evidence from randomized trials. To compare efficacy and adverse events using the contact aspiration technique vs the standard stent retriever technique as a first-line endovascular treatment for successful revascularization among patients with acute ischemic stroke and large vessel occlusion. The Contact Aspiration vs Stent Retriever for Successful Revascularization (ASTER) study was a randomized, open-label, blinded end-point clinical trial conducted in 8 comprehensive stroke centers in France (October 2015-October 2016). Patients who presented with acute ischemic stroke and a large vessel occlusion in the anterior circulation within 6 hours of symptom onset were included. Patients were randomly assigned to first-line contact aspiration (n = 192) or first-line stent retriever (n = 189) immediately prior to mechanical thrombectomy. The primary outcome was the proportion of patients with successful revascularization defined as a modified Thrombolysis in Cerebral Infarction score of 2b or 3 at the end of all endovascular procedures. Secondary outcomes included degree of disability assessed by overall distribution of the modified Rankin Scale (mRS) score at 90 days, change in National Institutes of Health Stroke Scale (NIHSS) score at 24 hours, all-cause mortality at 90 days, and procedure-related serious adverse events. Among 381 patients randomized (mean age, 69.9 years; 174 women [45.7%]), 363 (95.3%) completed the trial. Median time from symptom onset to arterial puncture was 227 minutes (interquartile range, 180-280 minutes). For the primary outcome, the proportion of patients with successful revascularization was 85.4% (n = 164) in the contact aspiration group vs 83.1% (n = 157) in the stent retriever group (odds ratio, 1.20 [95% CI, 0.68-2.10]; P = .53; difference, 2.4% [95% CI, -5.4% to 9.7%]). For the clinical efficacy outcomes (change in NIHSS score at 24 hours, mRS score at 90 days) and adverse events, there were no significant differences between groups. Among patients with ischemic stroke in the anterior circulation undergoing thrombectomy, first-line thrombectomy with contact aspiration compared with stent retriever did not result in an increased successful revascularization rate at the end of the procedure. clinicaltrials.gov Identifier: NCT02523261.