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Original research
‘Real-world’ comparison of first-line direct aspiration and stent retriever mechanical thrombectomy for the treatment of acute ischemic stroke in the anterior circulation: a multicenter international retrospective study
  1. Michael Martini1,
  2. J Mocco2,
  3. Aquilla Turk3,
  4. Adnan H Siddiqui4,
  5. David Fiorella5,6,
  6. Ricardo A Hanel7,
  7. Keith Woodward8,
  8. Ansaar Rai9,
  9. Don Frei10,
  10. Josser E Delgado Almandoz11,
  11. Michael E Kelly12,
  12. Lissa Peeling13,
  13. Adam S Arthur14,
  14. Blaise Baxter15,
  15. Joey English16,
  16. Italo Linfante17,
  17. Reade De Leacy1
  1. 1 Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, USA
  2. 2 The Mount Sinai Health System, New York, USA
  3. 3 Department of Neurosurgery, Medical University of South Carolina - College of Medicine, Charleston, South Carolina, USA
  4. 4 Departments of Neurosurgery and Radiology and Toshiba Stroke Research Center, University at Buffalo, State University of New York, Buffalo, New York, USA
  5. 5 Department of Neurosurgery, Stony Brook University, Stony Brook, New York, USA
  6. 6 SUNY SB, New York, USA
  7. 7 Stroke and Cerebrovascular Center, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
  8. 8 Britton Woodward, Knoxville, Tennessee, USA
  9. 9 Department of Radiology, West Virginia University Hospitals, Morgantown, West Virginia, USA
  10. 10 Department of Interventional Neuroradiology, Radiology Imaging Associates, Englewood, Colorado, USA
  11. 11 Department of Interventional Neuroradiology, Abbott Northwestern Hospital, Minnesota, USA
  12. 12 Royal University Hospital, University of Saskatchewan, Department of Neurosurgery, Saskatoon, Saskatchewan, Canada
  13. 13 Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
  14. 14 UT Dept Neurosurgery/Semmes-Murphey Clinic, Memphis, Tennessee, USA
  15. 15 Department of Radiology, Erlanger Medical Center, Chattanooga, Tennessee, USA
  16. 16 Department of Neurology and Radiology, UCSF, San Francisco, California, USA
  17. 17 Baptist Cardiac and Vascular Institute, Miami, Florida, USA
  1. Correspondence to Dr Reade De Leacy, Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York NY 10029, USA; reade.deleacy{at}


Background Thrombectomy for anterior large vessel occlusion less than 24 hours since last known well is now standard of care. Certain aspects of clinical trials may limit generalizability to ’real-world' practice.

Objective To compare revascularization rates and outcomes for direct aspiration (ADAPT) and stent retriever thrombectomy following anterior acute ischemic stroke (AIS) in a real-life setting.

Methods Data from the most recent 20 consecutive patients with AIS treated with mechanical thrombectomy between 2015 and 2016 were collected from 15 high-volume stroke centers across North America for a total of 300 cases. Patients with proximal anterior large vessel occlusions were dichotomized by primary treatment technique. Ordinal logistic regression assessed the effects of clinical variables on patient disability using 90-day modified Rankin Scale (mRS) scores.

Results Adequate revascularization (Thrombolysis in Cerebral Infarction ≥2b) was ultimately achieved in 91.2% of first-line direct aspiration (ADAPT) cases with an average of 1.9±1.9 passes and in 87.5% of stent retriever cases with an average of 1.7±1.0 passes. Time from groin puncture to revascularization was shorter for ADAPT cases. The mean 90-day mRS score for both groups was 3.0±2.4. Number of passes using primary technique, and postintervention intracranial hemorrhage, were significant predictors of 90-day mRS scores after ADAPT, while age and preprocedure mRS score were predictive of outcomes following first-line stent retriever.

Conclusions Our data show similar adequate revascularization rates and 90-day functional outcomes for first-line direct aspiration and stent retrievers for anterior large vessel occlusion in a real-world setting. These results support the findings of other prospective trials evaluating the two techniques.

  • ischemic stroke
  • mechanical thrombectomy
  • stent-retriever
  • direct aspiration
  • revascularization

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  • Contributors All authors have made a substantial contribution to the conception and design of the studies and/or the acquisition and/or the analysis of the data and/or the interpretation of the data; drafted the work or revised it for significant intellectual content; approved the final version of the manuscript; and agree to be accountable for all aspects of the work, including its accuracy and integrity.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests AHS: financial interest/investor/stock options/ownership: Imperative Care, Q’Apel Medical, Inc; consultant/advisory board: Cerenovus, Imperative Care, Medtronic, MicroVention, Penumbra, Q’Apel Medical, Inc, Stryker. JE: consultant: Stryker Neurovascular, Medtronic. AT: consultant: BALT/Blockade, Cerenovus, Medtronic, Microvention-Terumo, Penumbra, Imperative Care, Stryker. KW0: consultant: Cerenovus, Medtronic, Microvention, Penumbra, Stryker. AR: consultant: Stryker, Cerenovus, Microvention. BB: consultant: Penumbra, Medtronic, Stryker; shareholder: Penumbra. RH: grant/research support: Medtronic, Stryker, Microvention; consultant: Medtronic, Stryker, Cerenovous, Microvention, Balt. JEDA: consultant: Penumbra, Medtronic, Microvention. ASA: consultant: Cerenovus, Medtronic, Microvention, Penumbra, Stryker; research support: Microvention, Cerenovus, Penumbra. AA: consultant: Cerenovus, Medtronic, Microvention, Penumbra, Stryker; research support: Microvention, Cerenovus, Penumbra. MK: consultant: Penumbra, Medtronic. LP: consultant: Medtronic. DF: consultant/speakers bureau: Penumbra; Stryker; research support: Cerenovus, Medtronic, Microvention, Penumbra, Stryker; stock ownership: Penumbra. IL: consultant: Medtronic, Stryker, Cerenovus. RDL: consultant: Cerenovus, Penumbra, Q’Apel Medical Inc, Imperative Care, Mivi Neuroscience; research support: Medtronic, Asahi Intec. JM: consultant: Cerebrotech, Rebound Therapeutics, TSP Inc, Lazarus Effect, Medina, Pulsar Vascular; investor: Blockade, Medina, Lazarus Effect, TSP Inc; research support: Penumbra

  • Ethics approval Approval was obtained from the institutional review boards of Mount Sinai, Medical University of South Carolina, State University of New York at Buffalo, Stony Brook School of Medicine, Lyerly Baptist Medical Center, Fort Sanders Regional Medical Center, West Virginia University Hospitals, Swedish Medical Center, Abbott Northwestern Hospital, University of Saskatchewan College of Medicine, University of Tennessee Health Sciences Center and Semmes Murphey Clinic, Erlanger Health System, California Pacific Medical Center, and Miami Cardiac and Vascular Institute.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Not required.