Introduction Current level 1 evidence support the use of endovascular thrombectomy (ET) as a standard of care for acute ischemic stroke (AIS). The initial randomized controlled trials on ET specifically used stent retrievers to achieve reperfusion, but recently completed ASTER and COMPASS trials have demonstrated that the use of direct aspiration technique (ADAPT) is non-inferior to stent retriever thrombectomy. In this work, we evaluate the impact of advancement in reperfusion catheter technologies on technical and clinical outcomes after ADAPT thrombectomy in the largest reported experience with ADAPT.
Methods We retrospectively reviewed a prospectively maintained database of AIS patients undergoing ADAPT thrombectomy between January 2013 and November 2017 at the Medical University of South Carolina. Patient charts were reviewed for demographics and baseline characteristics, procedure notes were reviewed for technical variables, and imaging and post-discharge notes were reviewed for radiological and clinical outcomes.
Results During the study period, a total of 510 patients (mean age: 67.7, 50.6% females) underwent ADAPT thrombectomy at our center. Successful recanalization (TICI 2B+) at first pass was achieved in 61.8% patients, and with aspiration only in 77.5% patients. The mean procedure time was 27.4 min, and the rate of good outcomes (mRS 0–2) at 90 days was 42.9%. We then compared the difference in patient characteristics and outcomes across four generations of reperfusion catheters 5 MAX (inner diameter (i.d.)=0.054’, aspiration force (a.f.)=14.8 gF), ACE (i.d.=0.060’, a.f.=18.3 gF), ACE 064 (i.d.=0.064’, a.f.=20.8 gF) and ACE 068 (i.d.=0.068’, a.f.=23.5 gF). Patient Baseline characteristics including demographics, baseline mRS, admission NIHSS, location of occlusion and the rate of meeting major trial criteria did not show a significant difference between groups treated with one of the four commonly used catheters (5 MAX, ACE, ACE 064, and ACE 068). However, the rate of recanalization with aspiration only was significantly higher and procedure time was significantly lower in patients treated with larger catheters (ACE 064 and ACE 068) compared to smaller catheters (5 MAX and ACE, p<0.05). Specifically, the mean procedure time was 20 min with ACE 068 compared to 28 min with 5 MAX (p<0.05) despite a significantly higher rate of tandem occlusions in ACE 068 compared to 5 MAX (19% vs 9%, p<0.05). The rate of using stent-retrievers following aspiration was significantly lower in the larger catheters (ACE 064 and ACE 068) compared to smaller catheters (5 MAX and ACE, p<0.05). There was no significant difference in complication rates or rates of post-op parenchymal hemorrhage across the different groups (p>0.05). On multivariate analysis, use of ACE 068 was an independent predictor of mRS 0–2 at 90 days (OR=1.6, p<0.05).
Conclusion Refinement of ADAPT thrombectomy by incorporating reperfusion catheters with higher inner diameters and thus higher aspiration forces is associated with shorter procedure times and lower likelihood of using additional devices without impacting clinical outcomes and complication rates.
Disclosures A. Alawieh: None. A. Chatterjee: None. J. Vargas: None. M. Chaudry: 1; C; Codman, Covidien, Penumbra, Blockade, Pulsar Vascular Stock, Medtronic. 2; C; Codman, Covidien, Penumbra, Blockade, Pulsar Vascular Stock, Medtronic. J. Lena: None. R. Turner: 1; C; Codman, Covidien, Penumbra, Blockade, Pulsar Vascular Stock, Medtronic. 2; C; Codman, Covidien, Penumbra, Blockade, Pulsar Vascular Stock, Medtronic. A. Turk: 1; C; Codman, Covidien, Penumbra, Blockade, Pulsar Vascular Stock, Medtronic. 2; C; Codman, Covidien, Penumbra, Blockade, Pulsar Vascular Stock, Medtronic. A. Spiotta: 1; C; Penumbra, Pulsar Vascular, Microvention, Stryker,. 2; C; Penumbra, Pulsar Vascular, Microvention, Stryker.
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