Introduction The direct aspiration first pass (ADAPT) technique has been shown to be fast, cost-effective, and associated with excellent angiographic and clinical outcomes in the treatment of acute ischemic stroke (AIS).^1–4 It would be useful to know which pre-procedural factors are associated with successful revascularization using aspiration alone to help choose a method of thrombectomy for patients with AIS.

Methods This is a retrospective review of patients with AIS treated with thrombectomy. Cohort 1 (n = 44) included ADAPT cases in which aspiration alone was successful (TICI 2 b or 3). Cohort 2 (n = 32) included ADAPT cases in which aspiration was unsuccessful (n = 23) as well as non-ADAPT cases in which there was a clear intent to use ADAPT but the aspiration catheter could not be navigated to the thrombus (n = 9). The majority of patients in Cohort 2 were ultimately treated with a stent retriever (SR). Cases in which SRs were used primarily with distal aspiration (a.k.a. Solumbra) were excluded. CTH/CTA/DSAs were graded for dense vessel sign, aortic arch type, number of reverse curves and severe stenosis on the path to the target vessel by an interventional radiologist who was blinded to study design.

Results There was no difference between cohorts with regards to gender, race, medications, NIHSS score, use of IV TPA, site or sidedness of thrombus, process times, presence of a dense vessel sign, aortic arch type, presence of severe stenosis, and guide/aspiration catheters used. Patients in Cohort 1 were on average younger (66.5 vs. 74.1 years, p = 0.025). There was a trend for more patients in Cohort 2 to have atrial fibrillation (AFib)/arrhythmias (62.5% vs. 45.5%, p = 0.168) and there was a trend for more patients in Cohort 2 with a cardiogenic stroke etiology (78.1% vs. 56.8%, p = 0.086). There was a trend for fewer reverse curves on average in Cohort 1 (1.7 vs. 2.3, p = 0.107).

Conclusions Aspiration success was associated with younger age. There was a trend for aspiration failure to be associated with cardiogenic etiology and more difficult vascular anatomy. Our findings suggest that the ADAPT technique can be used for the vast majority of patients but it may be beneficial to use a SR primarily when performing thrombectomy in the elderly. Further research analyzing thrombus characteristics is needed.

References 1 Turk AS, Frei D, Fiorella D, et al. ADAPT FAST study: a direct aspiration first pass technique for acute stroke thrombectomy. J Neurointerv Surg 2014 ;6(4):260–4.

2 Turk AS, Turner R, Spiotta A, et al. Comparison of endovascular treatment approaches for acute ischemic stroke: cost effectiveness, technical success, and clinical outcomes. J Neurointerv Surg 2015 ;7(9):666–70.

3 Delgado Almandoz JE, Kayan Y, Young ML, et al. Comparison of clinical outcomes in patients with acute ischemic strokes treated with mechanical thrombectomy using either Solumbra or ADAPT techniques. J Neurointerv Surg 2015.

4 Kowoll A, Weber A, Mpotsaris A, et al. Direct aspiration first pass technique for the treatment of acute ischemic stroke: initial experience at a European stroke centercenter. J Neurointerv Surg 2016 ;8(3):230–4.

Disclosures J. Mascitelli: None. C. Kellner: None. C. Oravec: None. R. DeLeacy: None. E. Oermann: None. S. Paramasivam: 2; C; Microvention. J. Fifi: 2; C; Microvention. 4; C; Lazarus Effect. J. Mocco: 1; C; National/International PI/Co-PI for: THERAPY (PI), FEAT (PI), INVEST (Co-PI), COMPASS (Co-PI), LARGE (Co-PI), COAST (Co-PI), POSITIVE (Co-PI). Steering Committee for MAPS Trial. 2; C; Rebound Therapeutics, TSP Inc, Cerebrotech, Lazarus Effect, Pulsar, Medina. 4; C; Blockade Medical, TSP Inc., Lazarus Effect, Medina.