Higher Rates Of Successful Recanalization Research Articles

Abstract TP198: Factors Associated With Need for Decompressive Hemicraniectomy After Mechanical Thrombectomy in Stroke Patients

Background: Mechanical thrombectomy (MT) has significantly reduced morbidity and mortality in acute ischemic stroke (AIS). This study aims to analyze the outcomes and factors associated with decompressive hemicraniectomy (DHC) in AIS patients who underwent MT. Methods: We retrospectively analyzed data from an ongoing, multicenter database to investigate AIS patients who underwent MT for ICA, M1, or M2 occlusion. We compared clinical and procedural variables between patients who underwent DHC and those who did not. Propensity score (PS) matching between the two groups was conducted using age, sex, admission NIHSS, occluded vessel, ASPECTS, time from symptoms onset to arterial puncture, intracranial hemorrhage (ICH), and symptomatic ICH (sICH). Results: Among the 3,135 MT patients who met our inclusion criteria, 113 underwent DHC. A 1:3 propensity matching yielded a well-matched cohort of 113 in the DHC group versus 339 in the non-DHC group. The DHC group had a significantly higher rate of successful recanalization (mTICI ≥ 2C) (175 [51.6%] versus 36 [31.9%], P < 0.001) and a longer procedure duration, with a median of 30 minutes (IQR: 17-54) compared to 44 minutes (IQR: 25-78) in the non-DHC group (P = <0.001). Further comparison of patients with low ASPECTS (≤ 5) who underwent DHC (n = 36) with those who did not (n = 99) showed no significant difference in successful recanalization rates (15 [41.7%] versus 43 [43.4%], P > 0.90). However, procedure duration was significantly longer in the DHC group with a median of 29 minutes (IQR: 13-52), compared to 39 minutes (IQR: 27-86) in the non-DHC group (P = 0.02). Conclusions: Successful recanalization can help in preventing DHC in AIS patients with high ASPECTS, but not those with low ASPECTS. Procedure duration is independently related to DHC following MT, especially in low ASPECTS patients.

Abstract 208: Optimal Catheter Position and Aspiration Technique Improves Safety and Efficacy Using Next Generation Funnel Catheter

Introduction The Advanced Neurovascular Access (ANA5, Anaconda Biomed) is a novel stroke thrombectomy catheter comprising a distal self‐expanding covered funnel designed to locally restrict blood flow in the Internal Carotid Artery (ICA) and, when used in conjuction with available stent retreiver, reduce clot fragmentation during clot ingestion. The ANAIS study aimed to investigate the safety and efficacy of the ANA5 device (‘Funnel’) in different deployment locations and aspiration conditions. Methods Prospective, single‐arm, multi‐center study to assess the safety and performance of ANA5 in combination with a stent retriever in patients with Acute Ischemic Stroke (ANAIS). An independent imaging corelab and Clinical Events Committee assessed the different predefined outcomes. Patients with anterior circulation vessel occlusion admitted within 24 hours from symptom onset were eligible. The primary efficacy endpoint was successful recanalization, defined as mTICI ≥2b in the target vessel within three passes of the Funnel device. The primary safety endpoint was a composite of symptomatic Intracranial Hemorrhage within 24 hours and any device related severe adverse event. The impact of the funnel deployment location in the different ICA segments (C1 to C4 or above) and the condition of the aspiration on angiographical outcome was also evaluated. Results A total of 39 subjects who complied with all inclusion/exlusion criteria were treated by 10 different physicians in 3 stroke centers. Mean age was 69.9 ±13.2 years, 52.5% women, and the median National Institutes of Health Stroke Scale on admission was 16.0 [12.5‐19.5]. Initial occlusion location was: TICA 25.0%, M1‐MCA 52.5% and M2‐MCA 22.5%. The rate of succesful reperfusion within 3 passes was 74.4% (29/39) (primary efficacy endpoint). First pass effect (FPE) mTICI 2b‐3 and 2c‐3 was 56.4% (22/39) and 48.7% (19/39), respectively. Zero sICHs at 24h or SADE at 5 days were reported (primary safety endpoint). At 90 days, the rate of modified Rankin Scale score 0‐2 was: 57.9% (22/38). The efficacy of the thrombectomy procedure using the Funnel increases when: 1. The funnel was deployed in the higher ICA segments (below ophtalmic artery) with diameter between 3.5‐5.0mm, ensuring full apposition of the funnel to the vessel wall: C1(n=10): 40.0% vs. C2 or higher (n=29): 86.2% (p < 0.002). 2. Continuous aspiration was applied during the full retrieval of the stentriever in the Funnel (89.3% (n=28) vs. 36.4% (n=11), p < 0.0005). 3. When both continuous aspiration and appropriate ICA location were achieved, the Clinical efficacy endpoint improved to 95.5% (n=22), and FPE mTICI 2b‐3 and 2c‐3 were 72.7% and 59.1% respectively. Conclusion The use of the next generation Funnel Device in the ANAIS study results in a high rate of successful recanalization with an optimal safety profile and favorable 90 days clinical outcomes. The performance improved when the Funnel was deployed above the C1 cervical segment of the ICA, and continuous aspiration was applied during the full stent retrieval.

The Safety and Efficacy of Emergency Stenting during Bridging Therapy: A Single-Center Retrospective Study

Introduction: The objective of this study was to investigate the safety and efficacy of emergency stenting for patients with ischemic stroke treated with bridging therapy. Methods: Patients with onset of stroke who underwent bridging therapy were included in the two groups with emergency stenting (ESG) and without stenting (NSG). To avoid the bias due to confounding variables, subjects were further assigned in two groups using 1:1 propensity score matching (PSM). The safety outcomes include the incidence of intracranial hemorrhage (ICH), parenchymal hemorrhage type 2 (PH2), symptomatic intracranial hemorrhage (sICH), fatal hemorrhage, and mortality. The efficacy outcomes include successful recanalization, 3-month favorable outcome (modified Rankin Scale [mRS]: 0–2). Results: 175 patients treated with bridging therapy were included in this study, with 52 patients in the ES group and 123 patients in the groups without ES, and with 30 patients in each group after PSM. No significant differences in the incidences of ICH, PH2, sICH, fatal hemorrhage, and mortality were found between the two groups with ES and without ES before and after PSM (p > 0.05 for all groups). The analysis without PSM showed that the group with ES had a higher rate of successful recanalization (98.1 vs. 88.6%, p = 0.041) than the group without ES, but no significant difference was seen (96.6 vs. 93.3%, p = 0.554) between the two groups after PSM. There was no difference in favorable outcome between the two groups before and after matching as well (p > 0.05). Conclusions: It is safe and effective for patients with onset of ischemic stroke to receive emergency stenting during bridging therapy, without increasing the risk of hemorrhagic transformation and mortality.

Efficacy and safety of bridging therapy and direct mechanical thrombectomy in large vessel occlusions: a meta-analysis.

Efficacy and safety of bridging therapy and direct mechanical thrombectomy in large vessel occlusions: a meta-analysis.

Direct dotterising or angioplasty of acute stroke due to tandem atherosclerotic occlusions

BackgroundTandem occlusions cause 10–15% of LVO acute ischemic strokes but are difficult to treat endovascularly and frequently excluded from clinical trials. The optimum endovascular method is still debated, however going directly through the carotid occlusion can speed up the procedure and reduce procedural risk by eliminating an exchange maneuver.MethodUsing retrospective data from three centers, we compared treating atherosclerotic tandem occlusions using a 0.035'-guidewire and direct dotterisation or angioplasty with a peripheral vascular balloon suitable for the wire, vs. the usual technique of an 0.014'wire. We compared the successful recanalization (mTICI 2b-3) rates, 90 days' functional outcomes (mRS 0–2), and puncture-to-recanalization times between both procedures.ResultsForty-two consecutive patients with atherosclerotic tandem occlusions were included; 25 were treated with the 0.014'wire technique and 17 with the 0.035'-guidewire and direct dotterisation or angioplasty with a peripheral vascular balloon technique. The direct technique achieved a higher rate of successful recanalization (100 vs. 72%, P = 0.018), better functional outcome (88.4 vs. 48.0%, P = 0.044), and faster procedure times (mean 65.1 mins vs. 114.8 mins, P < 0.001). The number of attempts was similar between both groups (median 2 vs 3 attempts, P = 0.101). There was no significant difference in the complication rate between both groups (5.9 vs. 12.0%, P = 0.462).ConclusionCompared to previous endovascular techniques for treating atherosclerotic tandem occlusions, the direct technique using standard 0.035' guidewires and dotterisation or a peripheral vascular balloon is significantly faster with better outcomes. However, this will require further external validation in larger cohorts.

Thrombectomy in ischemic stroke patients with alberta stroke program early computed tomography score 4-5 and 0-3: Factors associated with favorable outcome

ObjectivesRecently published results of the ANGEL-ASPECT and SELECT2 trials suggest that stroke patients presenting with low Alberta Stroke Program Early Computed Tomography Score (ASPECTS) benefit from mechanical thrombectomy. Purpose of this retrospective study was to identify factors that are associated with a favorable outcome in patients with low ASPECTS of 4-5 and 0-3 undergoing mechanical thrombectomy. Material and methodsAll patients reported in the quality registry of the German Society for Neuroradiology that were treated between 2018 and 2020 were analyzed. Favorable outcome was defined as a National Institute of Health Stroke Scale (NIHSS) score of less than 9 at dismissal. Successful recanalization was defined as Thrombolysis in Cerebral Infarction (mTICI) ≥ 2b. Multivariable logistic regression analyses were performed to assess the association of baseline and treatment variables with favorable outcome. Results621 patients were included in the analysis, thereof 495 with ASPECTS 4-5 and 126 with ASPECTS 0-3. In patients with ASPECTS 4-5patients with favorable outcome had less severe neurological symptoms at admission with median NIHSS of 15 vs. 18 (p<0.001), had less often wake-up strokes (44% vs. 81%, p<0.001), received more often iv-lysis (37% vs. 30%, p<0.001), had more often conscious sedation (29% vs. 16%, p<0.001), had a higher rate of successful recanalization (94% vs. 66% and lower times from groin puncture to recanalization. In multivariate regression analysis lower NIHSS at admission (aOR 0.87, CI 0.89-0.91) and successful recanalization (aOR 3.96, CI 2-8.56) were associated with favorable outcome. For ASPECTS 0-3, patients with favorable outcome had lower median NIHSS at admission (16 vs. 18 (p<0.001), lower number of passes (1 vs. 3, p=0.003) and a higher rate of successful recanalization (94% vs. 66%, p<0.001) and lower times from groin puncture to recanalization. In multivariate regression analysis lower NIHSS at admission (aOR 0.87, CI 0.81-0.94) and successful recanalization, (aOR 11.19, CI 3.19-55.53), were associated with favorable outcome. ConclusionFull recanalization with low groin punction to recanalization times and low number of passes were associated with favorable outcome in patients with low ASPECTS.

Good collaterals and better outcomes after EVT for basilar artery occlusion: A systematic review and meta-analysis.

Stroke caused by acute basilar artery occlusion (BAO) is devastating with high dependency and mortality. Recent trials have demonstrated the efficacy of endovascular treatment (EVT) for acute BAO, while pretreatment collaterals may be a valuable prognostic indicator for post-EVT outcomes. To systematically review and synthesize evidence on the associations between pretreatment collateral status and outcomes after EVT in acute BAO. We retrieved relevant full-text articles published in English since 1 January 2010, reporting associations between pretreatment collateral status and outcomes after EVT for BAO, by searching MEDLINE and Embase. The primary outcome was favorable or good 90-day functional outcome (modified Rankin Scale [mRS] 0-2 or 0-3); secondary outcomes included successful recanalization, symptomatic intracranial hemorrhage, final infarct volume, and 90-day mortality. Risk ratios (RRs) with 95% confidence intervals (CIs) for good versus poor collaterals on the outcomes were synthesized using random-effects models. Subgroup and sensitivity analyses were conducted for the primary outcome. Overall, 29 primary studies (2995 participants) were included in qualitative review, among which 16 studies (1447 participants) were meta-analyzed. With different imaging modalities and methods to grade the collateral status, good collaterals were found in 33-85% of patients in the individual primary studies (I2 = 95.2%, p < 0.001), with a pooled proportion of 51% (95% CI: 40-62%) across all studies. Good pretreatment collaterals were associated with a doubled rate of favorable/good 90-day functional outcome (RR = 2.03, 95% CI: 1.63-2.51, p < 0.001), a higher rate of successful recanalization (RR = 1.23, 95% CI: 1.04-1.45, p = 0.015), and reduced 90-day mortality (RR = 0.59, 95% CI: 0.43-0.81, p = 0.001) after EVT for BAO. None of the primary studies reported the associations of good collaterals with the other secondary outcomes. Subgroup analyses revealed possibly more prominent protective effect of good pretreatment collaterals over the primary outcome, in studies with longer time windows in patient eligibility criteria for EVT (p = 0.028 for between-subgroup heterogeneity). In patients with BAO receiving EVT, good pretreatment collateral status was associated with a higher chance of favorable 90-day functional outcome, despite the various methods in grading the collateral circulation. Efforts are needed for more standardized collateral assessment in BAO, for more reliable and generalizable investigations of its clinical implications.

Abstract 98: The Impact Of Aspiration Catheter Size On Thrombectomy Outcomes Using Adapt Technique-analysis From The STAR Registry

Introductions: Clinical trials have shown that aspiration thrombectomy is as safe and effective as stent-retriever thrombectomy. Multiple improvements have been made to the aspiration technique over the last few years. In this study, we aim to assess the effect of aspiration catheter bore size on the outcomes of A direct aspiration first pass technique (ADAPT) thrombectomy. Methods: We included patients who underwent ADAPT thrombectomy for M1 or internal carotid artery terminus (ICA-T) occlusions in the Stroke Thrombectomy and Aneurysm (STAR) database. Patients included between July 2016 and July 2022. We compared baseline characteristics, procedural metrics and outcomes between patients who underwent thrombectomy using small bore (0.035”-0.060”), medium bore (0.062”-0.068”) and large bore (0.070”-0.074”) catheters. Results: A total of 1158 patients were included; 576 (49.7%) females, 645 (70%) White, and 464 (40.6%) received IV-tPA. No difference was noticed in age, sex, and vascular risk factors between the 3 different groups. There was higher rate of IV-tPA in the small-bore catheter group (48.8%) compared to the medium and large bore catheter groups (38.4% and 36.7%, respectively) (P=0.03). Procedure duration was shorter when using medium (20 min) and large (18 min) compared to small bore catheters (30 min) (P=0.01). Both medium and large bore catheters were associated with higher rate of successful recanalization (88.9% and 87.9%, respectively) compared to small bore catheters (81.6%) (P=0.010). However, the difference in successful recanalization or procedure duration between medium and large bore catheters was not significant. No difference was noted in the rate of symptomatic hemorrhagic transformation (sICH) (4.7%, 5.3%, and 7.1%; P=0.345), 90-day favorable outcome (modified Rankin Scale 0-2) (41.8%, 39.3%, 40.8%; P=0.766) or 90-day mortality (18.1%, 23.5%, 24.4%; P=0.111) between the groups. Conclusions: Higher rate of successful recanalization and shorter procedure duration were observed when using medium and large bore aspiration catheters compared with small bore catheters in ADAPT technique. However, these procedural benefits were not observed when comparing large bore to medium bore catheters.

The pivotal role of timing of intravenous thrombolysis bridging treatment prior to endovascular thrombectomy.

The role of intravenous thrombolysis (IVT) as bridging treatment prior to endovascular thrombectomy (EVT) is under debate and better patient selection is needed. As the efficacy and safety of IVT diminish with time, we aimed to examine the impact of bridging treatment within different time frames from symptom onset. A retrospective registry study. Data were extracted from ongoing prospective EVT registries in two large tertiary centers. The current study included IVT-eligible patients with onset to door (OTD) < 4 h. We examined the efficacy and safety of bridging treatment through a comparison of the IVT + EVT group with the direct-EVT group by different time frames. In all, 408 patients (age 71.1 ± 14.6, 50.6% males) were included, among them 195 received IVT + EVT and 213 underwent direct EVT. Both groups had similar characteristics. In the IVT + EVT group only, longer OTD was associated with lower rates of favorable outcome (p = 0.021) and higher rates of hemorrhagic transformation (HT; p = 0.001). In patients with OTD ⩽ 2 h, IVT + EVT compared to direct EVT had higher rates of TICI 2b-3 (86.2% versus 80.7%, p = 0.038). In patients with OTD > 2 h, IVT + EVT had lower rates of favorable outcome (33.3% versus 56.9%, p = 0.021), worse discharge National Institutes of Health Stroke Scale [7 (2-13) versus 3 (1-8), p = 0.024], and higher rates of HT (34.0% versus 8.5%, p < 0.001). In this study, we found OTD times to have a significant effect on the impact of IVT bridging treatment. Our study shows that among patients with OTD < 2 h bridging treatment may be associated with higher rates of successful recanalization. By contrast, in patients with OTD > 2 h, bridging treatment was associated with worse outcomes. Further time-sensitive randomized trials are needed.

Emergent Management of Tandem Occlusions in Anterior Circulation Stroke: A Single-Centre Experience

For anterior circulation tandem occlusions, the optimal management strategy for extracranial carotid lesions is controversial. We aimed to compare the efficacy and safety of acute stenting (AS) with balloon angioplasty (BA) only. Clinical data were collected from 98 patients with anterior circulation tandem occlusion who underwent endovascular treatment at our center. Of these patients, 64 and 34 were assigned to the AS and BA groups, respectively. The clinical characteristics and outcome data of the 2 groups were analyzed and compared. The proportion of patients with good outcomes was 59.2%. The AS group had a higher rate of successful recanalization (98.4% vs. 82.4%, P=0.007) and a lower rate of occlusion of the responsible vessel at 90days (14.1% vs. 32.4%, P=0.039) than the BA group. The AS group was also significantly better than the BA group in terms of good outcomes (67.2% vs. 44.1%, P=0.027), but there was no significant difference between the 2 groups in terms of 90-day mortality (6.3% vs. 8.8%, P=0.691) and asymptomatic intracranial hemorrhage (6.3% vs. 5.9%, P=1.000). Lower baseline National Institutes of Health Stroke Scale scores were associated with good outcomes (P<0.001), and the presence of symptomatic intracranial hemorrhage was associated with 90-day mortality (P=0.003). Acute stent placement in patients with acute ischemic stroke due to anterior circulation tandem occlusion may have a better outcome than BA alone, and the safety of both approaches is comparable.

Carotid artery stenting during endovascular thrombectomy for acute ischemic stroke with tandem occlusion: the Italian Registry of Endovascular Treatment in Acute Stroke.

The management of tandem extracranial internal carotid artery and intracranial large vessel occlusion during endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) has been under-investigated. We sought to investigate outcomes of AIS patients with tandem occlusion (TO) treated with carotid artery stenting (CAS) compared to those not treated with CAS (no-CAS) during EVT. We performed a cohort study using data from AIS patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke. Outcomes were 3months' mortality, functional outcome, complete and successful recanalization, any intracranial hemorrhage, parenchymal hematoma and symptomatic intracerebral hemorrhage. Among 466 AIS patients with TO, CAS patients were 122 and no-CAS patients were 226 (118 excluded). After adjustment for unbalanced variables, CAS was associated with a lower rate of 3months' mortality (OR 0.407, 95% CI 0.171-0.969, p = 0.042). After adjustment for pre-defined variables, CAS was associated with a lower rate of 3months' mortality (aOR 0.430, 95% CI 0.187-0.989, p = 0.047) and a higher rate of complete recanalization (aOR 1.986, 95% CI 1.121-3.518, p = 0.019), successful recanalization (aOR 2.433, 95% CI 1.263-4.686, p = 0.008) and parenchymal hematoma (aOR 2.876, 95% CI 1.173-7.050, p = 0.021). CAS was associated with lower 3months mortality (OR 0.373, 95% CI 0.141-0.982, p = 0.046) and higher rates of successful recanalization (OR 2.082, 95% CI 1.099-3.942, p = 0.024) after adjustment for variables associated with 3months' mortality and successful recanalization, respectively. Among AIS patients with TO, CAS during EVT was associated with a higher rate of successful reperfusion and a lower rate of 3months' mortality.

Combined technique as first approach in mechanical thrombectomy: Efficacy and safety of REACT catheter combined with stent retriever.

Mechanical thrombectomy (MT) with combined treatment including both a stent retriever and distal aspiration catheter may improve recanalization rates in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Here, we evaluated the effectiveness and safety of the REACT aspiration catheter used with a stent retriever. This prospective study included consecutive adult patients who underwent MT with a combined technique using REACT 68 and/or 71 between June 2020 and July 2021. The primary endpoints were final and first pass mTICI 2b-3 and mTICI 2c-3 recanalization. Analysis was performed after first pass and after each attempt. Secondary safety outcomes included procedural complications, symptomatic intracranial hemorrhage (sICH) at 24 h, in-hospital mortality, and 90-day functional independence (modified Rankin Scale [mRS] 0-2). A total of 102 patients were included (median age 78; IQR: 73-87; 50.0% female). At baseline, median NIHSS score was 19 (IQR: 11-21), and ASPECTS was 9 (IQR: 8-10). Final mTICI 2b-3 recanalization was achieved in 91 (89.2%) patients and mTICI 2c-3 was achieved in 66 (64.7%). At first pass, mTICI 2b-3 was achieved in 55 (53.9%) patients, and mTICI 2c-3 in 37 (36.3%). The rate of procedural complications was 3.9% (4/102), sICH was 6.8% (7/102), in-hospital mortality was 12.7% (13/102), and 90-day functional independence was 35.6% (36/102). A combined MT technique using a stent retriever and REACT catheter resulted in a high rate of successful recanalization and first pass recanalization in a sample of consecutive patients with AIS due to LVO in clinical use.

Significance of D-Dimer in Acute Ischemic Stroke Patients With Large Vessel Occlusion Accompanied by Active Cancer

BackgroundThis study aimed to investigate clinical outcome predictors of acute stroke patients with large vessel occlusion and active cancer and validate the significance of D-dimer levels for endovascular thrombectomy decisions.MethodsWe analyzed a prospectively collected hospital-based stroke registry to determine clinical EVT outcomes of acute stroke patients within 24 h with following criteria: age ≥18 years, NIHSS ≥6, and internal carotid artery or middle cerebral artery lesion. All patients were classified into EVT and non-EVT groups. Patients were divided into two groups by initial D-dimer level. We explored variables potentially associated with successful recanalization as well as 3-month functional outcomes and mortality rates.ResultsAmong 68 patients, 36 were treated with EVT, with successful recanalization in 55.6%. The low D-dimer group showed a higher rate of successful recanalization and favorable outcome than the high D-dimer group. The mortality rate was higher in the high D-dimer group. No EVT and high D-dimer level were independent predictors of mortality, whereas lesion volume and low D-dimer level were independently associated with favorable outcomes.ConclusionsD-dimer level is a prognostic factor in acute LVO stroke patients with active cancer, and its high value for EVT decisions provisionally supports its testing in this patient population.

804 Should the Direct Aspiration First Pass Technique be Advocated over the StentRetriever Technique for Acute Ischemic Stroke? A Meta-analysis of 7692 patients

INTRODUCTION: The direct aspiration first pass technique (ADAPT) was developed to achieve better recanalization in acute ischemic stroke patients. However, data from the literature are controversial regarding the comparative outcomes of this technique compared to the conventional thrombectomy by stent retriever (SR). METHODS: We searched PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials from inception to March 2021 for relevant clinical trials and observational studies. Eligible studies were identified, and all relevant outcomes were pooled in the meta-analysis random-effects model of DerSimonian-Liard. RESULTS: Thirty studies were included in the meta-analysis with a total of 7868 patients. Compared with the SR, the ADAPT provides slightly higher rates of successful recanalization (RR 1.06, 95% CI [1.02 to 1.10]) and complete recanalization (RR 1.20, 95% CI [1.01 to 1.43]) but with more need for rescue therapy (RR 1.81, 95% CI [1.29 to 2.54]). There were no significant differences between the two techniques in terms of mortality at discharge, mortality at 90 days, change in the National Institutes of Health Stroke Scale (NIHSS) score, the favorable outcome (modified Rankin scale (mRS) of 0-2), time to the groin puncture, or frequency of complications as intracerebral hemorrhage (ICH), symptomatic ICH (sICH), the occurrence of an embolus in a new territory, hemorrhagic infarction, parenchymal hematoma, subarachnoid hemorrhage (SAH), and procedural complications (all P&gt;0.05). CONCLUSIONS: Current evidence supports the use of the ADAPT technique to achieve successful and complete recanalization while considering the higher need for rescue therapy in some patients. Owing to its lower cost than the standard SR technique, we advocate that the ADAPT should replace the SR as the first-line thrombectomy technique in routine practice.

Combined Approach to Eptifibatide and Thrombectomy in Acute Ischemic Stroke Because of Large Vessel Occlusion: A Matched-Control Analysis.

In patients undergoing mechanical thrombectomy (MT), adjunctive antithrombotic might improve angiographic reperfusion, reduce the risk of distal emboli and reocclusion but possibly expose patients to a higher intracranial hemorrhage risk. This study evaluated the safety and efficacy of combined MT plus eptifibatide for acute ischemic stroke. This was a propensity-matched analysis of data from 2 prospective trials in Chinese populations: the ANGEL-ACT trial (Endovascular Treatment Key Technique and Emergency Workflow Improvement of Acute Ischemic Stroke) in 111 hospitals between November 2017 and March 2019, and the EPOCH trial (Eptifibatide in Endovascular Treatment of Acute Ischemic Stroke) in 15 hospitals between April 2019 and March 2020. The primary efficacy outcome was good outcome (modified Rankin Scale score 0-2) at 3 months. Secondary efficacy outcomes included the distribution of 3-month modified Rankin Scale scores and poor outcome (modified Rankin Scale score 5-6) and successful recanalization. The safety outcomes included any intracranial hemorrhage, symptomatic intracranial hemorrhage, and 3-month mortality. Mixed-effects logistic regression models were used to account for within-hospital clustering in adjusted analyses. Eighty-one combination arm EPOCH subjects were matched with 81 ANGEL-ACT noneptifibatide patients. Compared with the no eptifibatide group, the eptifibatide group had significantly higher rates of successful recanalization (91.3% versus 81.5%; P=0.043) and 3-month good outcomes (53.1% versus 33.3%; P=0.016). No significant difference was found in the remaining outcome measures between the 2 groups. All outcome measures of propensity score matching were consistent with mixed-effects logistic regression models in the total population. This matched-control study demonstrated that MT combined with eptifibatide did not raise major safety concerns and showed a trend of better efficacy outcomes compared with MT alone. Overall, eptifibatide shows potential as a periprocedural adjunctive antithrombotic therapy when combined with MT. Further randomized controlled trials of MT plus eptifibatide should be prioritized. URL: https://www. gov; Unique identifier: NCT03844594 (EPOCH), NCT03370939 (ANGEL-ACT).

Drug-coated balloon for the management of coronary chronic total occlusions.

There is a higher rate of successful recanalization of patients with coronary chronic total occlusions, nevertheless, the rate of patients referred for revascularization remains low. In addition, there is a greater need to improve long-term outcomes of chronic total occlusions after percutaneous coronary intervention, and although the implantation of new-generation drug-eluting stents has been optimized with coronary imaging guidance, the rate of stenting failure remains a major issue and long-term vessel patency could be improved. We reviewed clinical data regarding the benefit of treating chronic total occlusions and the use of drug-coated balloons as an alternative therapeutic modality in this setting. Although clinical data is limited, the initial evidence and the daily clinical practice point towards a synergistic hybrid treatment strategy based on the combination of drug-coated balloons plus drug-eluting stents, reducing the total stent length and maintaining the scaffolding properties of stents where it is mandatory. Additionally, drug-coated balloons allow natural enlargement of the open vessel after percutaneous coronary intervention (PCI), which is a major limitation of stents in chronic total occlusion (CTO).

Should the direct aspiration first pass technique be advocated over the stent-retriever technique for acute ischemic stroke? A systematic review and meta-analysis of 7692 patients.

Background: The present meta-analysis aimed to synthesize evidence from all published studies with head-to-head data on the outcomes of a direct aspiration first pass technique (ADAPT) and the stent-retriever (SR) in acute ischemic stroke (AIS) patients.Methods: We searched PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials from inception to March 2021 for relevant clinical trials and observational studies. Eligible studies were identified, and all relevant outcomes were pooled in the meta-analysis random-effects model of DerSimonian-Laird.Results: Thirty studies were included in the meta-analysis with a total of 7868 patients. Compared with the SR, the ADAPT provides slightly higher rates of successful recanalization (RR 1.06, 95% CI [1.02 to 1.10]) and complete recanalization (RR 1.20, 95% CI [1.01 to 1.43]) but with more need for rescue therapy (RR 1.81, 95% CI [1.29 to 2.54]). There were no significant differences between the two techniques in terms of mortality at discharge, mortality at 90 days, change in the National Institutes of Health Stroke Scale score, the favorable outcome (modified Rankin scale (mRS) of 0-2), time to the groin puncture, or frequency of complications as intracerebral hemorrhage (ICH), symptomatic intracranial hemorrhage (sICH), embolus in a new territory (ENT), hemorrhagic infarction, parenchymal hematoma, subarachnoid hemorrhage, or procedural complications (all P > 0.05).Conclusion: Current evidence supports the use of the ADAPT technique to achieve successful and complete recanalization while considering the higher need for rescue therapy in some patients.

Intracranial Stenting as Rescue Therapy After Failure of Mechanical Thrombectomy for Basilar Artery Occlusion: Data From the ANGEL-ACT Registry.

Background and Purpose: Studies on rescue therapy for acute posterior circulation stroke due to basilar artery occlusion (BAO) are limited in the modern era of mechanical thrombectomy (MT). The aim of this study was to evaluate the safety and efficacy of rescue stenting (RS) following MT failure in patients with BAO.Methods: Data were collected from the Endovascular Treatment Key Technique and Emergency Work Flow Improvement of Acute Ischemic Stroke (ANGEL-ACT) prospective registry in China. Patients who underwent MT for BAO with failure of recanalization were enrolled in this study. The patients were divided into the RS and non-RS groups. Clinical and laboratory findings, procedural details, and clinical outcomes were compared between the two groups.Results: Overall, 93 patients with acute BAO were analyzed. The RS group included 81 (87.1%) patients, and the non-RS group included 12 patients. A modified treatment in cerebral infarction (mTICI) score of 2b/3 was achieved in 75 (92.6%) patients in the RS group. Compared with the non-RS group, the RS group had a significantly higher rate of successful recanalization and favorable clinical outcomes (modified Rankin Scale score at 90 days post-procedure, 0–3: 16.7 vs. 51.9%, respectively; P = 0.023) without an increase in the rate of symptomatic intracranial hemorrhage and a significantly lower mortality rate (58.3 vs. 18.5%, respectively; P = 0.006). Furthermore, the use of a glycoprotein IIb/IIIa inhibitor improved the rate of recanalization of the target artery without increasing the rate of symptomatic intracranial hemorrhage.Conclusions: Permanent stenting appears to be a feasible rescue modality when MT fails and might provide functional benefits in patients with acute ischemic stroke due to BAO.

Mechanical thrombectomy with or without thrombolysis: A meta-analysis of RCTs.

Mechanical thrombectomy (MT) is effective in treating ischemic strokes due to large vessel occlusion. However, the risk-benefit ratio of intravenous thrombolysis (IVT) prior to MT is still unclear. Aim of the study was to provide a pooled analysis of only randomized controlled trials (RCTs) comparing direct MT (dMT) vs bridging treatment (IVT+MT). PubMed, EMBASE and Cochrane Central were searched only for RCTs comparing IVT+MT vs dMT in ischemic stroke patients. Primary endpoint was functional independence at 90days (mRS<3), while secondary endpoints were represented by successful recanalization (TICI>2a), mortality at 90days and symptomatic intracranial hemorrhage (sICH). Odds ratios for endpoints were pooled with meta-analysis and compared between reperfusion strategies. The pooled analysis comprised 5 studies (n. patients = 1657). The rates for the primary endpoint were 39% and 34.5% for dMT and IVT+MT, respectively (OR 1.06; 95%CI 0.80-1.40). For the secondary endpoints, we did not observe significant differences between groups, even if the rate of successful recanalization was higher in IVT+MT treated patients (OR: 0.58; 95%CI 0.26-1.30;pheterogeneity = 0.002), without a significant increase in sICH rates (4.3% vs 5.5%; OR: 0.96; 95%CI 0.43-2.13;pheterogeneity = 0.26). Finally, mortality rates were 19.8% and 15.9% for dMT and IVT+MT, respectively. In this meta-analysis including only RCTs, dMT and bridging treatment were substantially equivalent for good functional outcome. IVT+MT was associated to higher rates of successful recanalization, even if not significant. Therefore, further adequately powered RCTs comparing dMT vs IVT+MT are warranted.

Effectiveness of very low profile thrombectomy device in primary distal medium vessel occlusion, as rescue therapy after incomplete proximal recanalization or following iatrogenic thromboembolic events

BackgroundRecent progress with smaller retrievers has expanded the ability to reach distal brain arteries. We herein report recanalization, bleeding complications and short-term clinical outcomes with the smallest currently known low...