Background Recent clinical trials, mainly using newer generation devices like stentrievers, have shown improved outcomes and reduced mortality in patients with large vessel occlusive ischemic strokes from endovascular therapy. Stentrievers have shown improved recanalization rates and reduced time to recanalization in the management of large vessel occlusive ischemic strokes. They are used extensively and preferentially over older mechanical thrombectomy devices in the management of acute ischemic stroke. We wanted to understand how the data from clinical trials translated into real world experience in a non-university community hospital setting. We also aimed to understand the opportunity for further innovation in the currently existing endovascular therapy devices.
Methods Texas Stroke Institute is a regional stroke network comprising of 11 community hospitals including 3 comprehensive stroke centers and 6 primary stroke centers in the Dallas-Fort Worth metroplex with a referral base of 148 free stand ERs and hospitals. Texas Stroke Institute Acute Stroke registry is a prospective database consisting of all stroke patients since Jan 2012. The database also includes prospectively entered information about the patients with large vessel occlusive ischemic stroke undergoing endovascular therapy. Demographic variables and clinical data including baseline NIH Stroke Scale score, symptomatic intracranial hemorrhage (ICH), modified ranking scale at 3 months, and angiographic outcomes were collected. Use of Solitaire FR and Trevo series (Trevo, Trevo ProVue and Trevo XP ProVue) as the primary endovascular therapy device was defined as stentriever therapy. Successful recanalization was defined as mTICI ≥2b. Endovascular rescue therapy was used when mTICI ≥ 2b was not achieved after 3 passes of a single stentriever device. We ascertained and compared the angiographic and clinical results with use of stentrievers and other endovascular rescue techniques.
Results A total of 44 patients (57% women) had attempted stentriever therapy for large vessel occlusive ischemic stroke. Baseline systolic BP (146, 103–201) and diastolic BP (79, 45–129) were noted. The comorbidities included hypertension (66%), Afib (25%), DM (23%), dyslipidemia (28%), smoking (20%) and CAD (20%). Intravenous thrombolysis was used in 56% of these patients. 56% of these patients came directly to the comprehensive stroke center. Endovascular rescue therapy was used in a total of 25% (11/44) of the patients. Intra-arterial lytic agent/vasodilator were used in 3/11, intra-arterial device were used in 3/11 and a combination of both were used in 5/11 cases. Age (Mean 60.7 ± 12.6 vs. 59.8 ± 11.1, p = 0.525), Baseline NIHSS (Mean 16.6 ± 6.9 vs. 17.1 ± 5.0, p = 0.4), site of occlusion (M1; 63.6% vs. 72.7%, p = 0.17) were not significantly different. There was no significant difference between the groups in patients with improvement in NIHSS by ≥4 at discharge (45% vs. 66%, p = 0.29), and symptomatic intracranial hemorrhage (9.09% vs. 12.12%, p = 0.784). The mTICI ≥2a rates were poorer in the rescue therapy group (45% vs. 81%, p = 0.04) however the rates of clinical outcome at 3 months were similar (45% vs. 51.5%, p = 1) between the groups.
Conclusions Translation of clinical trial results into real world experience is feasible and reiterates the unmet need and importance of continuing innovation to keep on improving upon current thrombectomy devices.
Disclosures K. Patel: None. P. Bhuva: None. P. Hansen: None. R. Gianatasio: None. T. Shams: None. V. Janardhan: None.
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