Background

Three randomized clinical trials have reported similar safety and efficacy for contact aspiration (CA) and Stent-retriever (SR) thrombectomy.

Aim

We aimed to determine whether the Combined Technique (SR+CA) was superior to SR alone as first-line thrombectomy strategy in a patient cohort where balloon-guide catheter was universally used.

Methods

A prospectively maintained mechanical thrombectomy database from January 2018-December 2019 was reviewed. Patients were included if they had anterior circulation proximal occlusion ischemic stroke (intracranial ICA or MCA-M1/M2 segments) and underwent SR alone thrombectomy or SR+CA as first-line therapy. The primary outcome was the first-pass effect (FPE) (mTICI2c-3). Secondary outcomes included modified FPE (mTICI2b-3), successful reperfusion (mTICI2b-3) prior to and after any rescue strategy, and 90-day functional independence (mRS ≤2). Safety outcomes included rate of parenchymal hematoma (PH) type-2 and 90-day mortality. Sensitivity analyses were performed after dividing the overall cohort according to first-line modality into two matched groups.

Results

A total of 420 patients were included in the analysis (mean age 64.4 years; median baseline NIHSS 16[11-21]). As compared to first-line SR alone, first-line SR+CA resulted in similar rates of FPE (53% vs. 51%,aOR 1.122, 95%CI[0.745-1.691],p=0.58), mFPE (63% vs. 60.4%,aOR1.250, 95%CI[0.782-2.00],p=0.35), final successful reperfusion (97.6% vs. 98%,p=0.75) and higher chances of successful reperfusion prior to any rescue strategy (81.8% vs. 72.5%,aOR 2.033, 95%CI[1.209-3.419],p=0.007). Functional outcome and safety measures were comparable between both groups. Likewise, the matched analysis (148 patient-pairs) demonstrated comparable results for all clinical and angiographic outcomes except for significantly higher rates of successful reperfusion prior to any rescue strategies with the first-line SR+CA treatment (81.8% vs. 73.6%,aOR 1.881, 95%CI[1.039-3.405],p=0.037).

Conclusions

Our findings reinforce the findings of ASTER-2 trial in that the first-line thrombectomy with a Combined Technique did not result in increased rates of first-pass reperfusion or better clinical outcomes. However, addition of contact aspiration after initial SR failure might be beneficial in achieving earlier reperfusion.

背景

三项随机临床试验报告了接触抽吸 (CA) 和支架取栓 (SR) 血栓切除术的相似安全性和有效性。

目标

我们旨在确定在普遍使用球囊引导导管的患者队列中，作为一线血栓切除术策略的联合技术（SR+CA）是否优于单独的 SR。

方法

回顾了 2018 年 1 月至 2019 年 12 月前瞻性维护的机械血栓切除术数据库。如果患者患有前循环近端闭塞缺血性卒中（颅内 ICA 或 MCA-M1/M2 节段）并接受单独 SR 血栓切除术或 SR+CA 作为一线治疗，则纳入研究。主要结果是首过效应（FPE）（mTICI2c-3）。次要结果包括修改后的 FPE (mTICI2b-3)、成功的再灌注 (mTICI2b-3) 之前和之后的任何救援策略，以及 90 天的功能独立性 (mRS ≤ 2)。安全性结果包括 2 型实质血肿 (PH) 发生率和 90 天死亡率。在根据一线模式将整个队列分为两个匹配组后进行敏感性分析。

结果

共有 420 名患者被纳入分析（平均年龄 64.4 岁；中位基线 NIHSS 16[11-21]）。与单独的一线 SR 相比，一线 SR+CA 导致相似的 FPE 发生率（53% 对 51%，aOR 1.122, 95%CI[0.745-1.691]，p=0.58），mFPE（63% vs. 60.4%,aOR1.250, 95%CI[0.782-2.00],p=0.35)，最终成功再灌注 (97.6% vs. 98%,p=0.75) 和任何救援策略之前成功再灌注的机会更高 ( 81.8% 与 72.5%，aOR 2.033，95%CI[1.209-3.419]，p=0.007）。两组的功能结果和安全措施具有可比性。同样，匹配分析（148 对患者）显示了所有临床和血管造影结果的可比结果，除了在使用一线 SR+CA 治疗的任何救援策略之前显着更高的再灌注成功率（81.8% 对 73.6%， aOR 1.881, 95%CI[1.

结论

我们的研究结果强化了 ASTER-2 试验的结果，即联合技术的一线血栓切除术并未导致首次通过再灌注率的增加或更好的临床结果。然而，在初始 SR 失败后增加接触抽吸可能有利于实现早期再灌注。