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Original research
First-line thrombectomy strategy for anterior large vessel occlusions: results of the prospective ETIS egistry
  1. Benjamin Maïer1,2,
  2. Stephanos Finitsis3,
  3. Romain Bourcier4,
  4. Panagiotis Papanagiotou5,6,
  5. Sébastien Richard7,
  6. Gaultier Marnat8,
  7. Igor Sibon9,
  8. Cyril Dargazanli10,
  9. Caroline Arquizan11,
  10. Raphael Blanc1,
  11. Michel Piotin1,
  12. Bertrand Lapergue12,
  13. Arturo Consoli13,14,
  14. Francois Eugene15,
  15. Stephane Vannier16,
  16. Suzana Saleme17,
  17. Francisco Macian18,
  18. Frédéric Clarençon19,20,
  19. Charlotte Rosso21,
  20. Olivier Naggara22,
  21. Guillaume Turc2,23,
  22. Alain Viguier24,
  23. Christophe Cognard25,
  24. Valerie Wolff26,
  25. Raoul Pop27,28,
  26. Mikael Mazighi1,2,
  27. Benjamin Gory29
  28. Endovascular Treatment in Ischemic Stroke (ETIS) Investigators
    1. 1 Department of Interventional Neuroradiology, Adolphe de Rothschild Ophthalmological Foundation, Paris, Île-de-France, France
    2. 2 Université de Paris, Paris, Île-de-France, France
    3. 3 Department of Interventional Neuroradiology, Aristotle University of Thessaloniki, Thessaloniki, Central Macedonia, Greece
    4. 4 Department of Interventional Neuroradiology, CHU Nantes, Nantes, Pays de la Loire, France
    5. 5 Department of Diagnostic and Interventional Neuroradiology, Klinikum Bremen-Mitte gGmbH, Bremen, Germany
    6. 6 First Department of Radiology, School of Medicine, National and Kapodistrian University of Athens - Aretaiio Hospital, Athens, Greece
    7. 7 Neurology Stroke Unit, University Hospital Centre Nancy, Nancy, France
    8. 8 Department of Interventional and Diagnostic Neuroradiology, Bordeaux University Hospital, Bordeaux, France
    9. 9 Neurology Department, CHU de Bordeaux, Bordeaux, France
    10. 10 Department of Neuroradiology, Centre Hospitalier Regional Universitaire de Montpellier, Montpellier, Languedoc-Roussillon, France
    11. 11 Department of Neurology, Hôpital Gui de Chauliac, Montpellier, Languedoc-Roussillon, France
    12. 12 Department of Neurology, Hospital Foch, Suresnes, Île-de-France, France
    13. 13 Department of Diagnostic and Interventional Neuroradiology, Hospital Foch, Suresnes, France
    14. 14 Interventional Neurovascular Unit, Azienda Ospedaliero Universitaria Careggi, Firenze, Italy
    15. 15 Department of Radiology, CHU Rennes, Rennes, France
    16. 16 Department of Neurology, CHU Rennes, Rennes, Bretagne, France
    17. 17 Department of Interventional Neuroradiology, CHU Limoges, Limoges, Limousin, France
    18. 18 Department of Neurology, CHU Limoges, Limoges, France
    19. 19 Department of Neuroradiology, University Hospital Pitié Salpêtrière, Paris, Île-de-France, France
    20. 20 Sorbonne University, Paris, Île-de-France, France
    21. 21 Urgences cérébro-vasculaires, University Hospital Pitié Salpêtrière, Paris, Île-de-France, France
    22. 22 Department of Neuroradiology, Saint Anne Hospital Centre, Paris, Île-de-France, France
    23. 23 Department of Neurology, Saint Anne Hospital Centre, Paris, Île-de-France, France
    24. 24 Department of Neurology, CHU Toulouse, Toulouse, Occitanie, France
    25. 25 Department of Diagnostic and Therapeutic Neuroradiology, Hospital Purpan, Toulouse, Midi-Pyrénées, France
    26. 26 Stroke unit, University Hospitals Strasbourg, Strasbourg, Alsace, France
    27. 27 Department of Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, France
    28. 28 Department of Interventional Radiology, Institut de Chirurgie Guidée par l'Image, Strasbourg, France
    29. 29 Department of Diagnostic and Interventional Neuroradiology, Centre Hospitalier Universitaire de Nancy, Nancy, France
    1. Correspondence to Dr Benjamin Maïer, Department of Interventional Neuroradiology, Hôpital Fondation Rothschild, 75019 Paris, France; bmaier{at}


    Background The best recanalization strategy for mechanical thrombectomy (MT) remains unknown as no randomized controlled trial has simultaneously evaluated first-line stent retriever (SR) versus contact aspiration (CA) versus the combined approach (SR+CA).

    Objective To compare the efficacy and safety profiles of SR, CA, and SR+CA in patients with acute ischemic stroke (AIS) treated by MT.

    Methods We analyzed data of the Endovascular Treatment in Ischemic Stroke (ETIS) Registry, a prospective, multicenter, observational study of patients with AIS treated by MT. Patients with M1 and intracranial internal carotid artery (ICA) occlusions between January 2015 and March 2020 in 15 comprehensive stroke centers were included. We assessed the association of first-line strategy with favorable outcomes at 3 months (modified Rankin Scale score 0–2), successful recanalization rates (modified Thrombolysis In Cerebral Infarction (mTICI) 2b/3), and safety outcomes.

    Results We included 2643 patients, 406 treated with SR, 1126 with CA, and 1111 with SR+CA. CA or SR+CA achieved more successful recanalization than SR for M1 occlusions (aOR=2.09, (95% CI 1.39 to 3.13) and aOR=1.69 (95% CI 1.12 to 2.53), respectively). For intracranial ICA, SR+CA achieved more recanalization than SR (aOR=2.52 (95% CI 1.32 to 4.81)), no differences were observed between CA and SR+CA. SR+CA was associated with lower odds of favorable outcomes compared with SR (aOR=0.63 (95% CI 0.44 to 0.90)) and CA (aOR=0.71 (95% CI 0.55 to 0.92)), higher odds of mortality at 3 months (aOR=1.56 (95% CI 1.22 to 2.0)) compared with CA, and higher odds of symptomatic intracranial hemorrhage (aOR=1.59 (95% CI 1.1 to 2.3)) compared with CA.

    Conclusions Despite high recanalization rates, our results question the safety of the combined approach, which was associated with disability and mortality. Randomized controlled trials are needed to evaluate the efficacy and safety of these techniques.

    • stent
    • stroke
    • catheter
    • device
    • thrombectomy

    Data availability statement

    The data that support the findings of this study are available from the corresponding author upon reasonable request.

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    Data availability statement

    The data that support the findings of this study are available from the corresponding author upon reasonable request.

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    • Twitter @BenjaminMaierMD, @RaoulPop25

    • BM and SF contributed equally.

    • Collaborators On behalf of the Endovascular Treatment in Ischemic Stroke (ETIS) Investigators: Hocine Redjem Simon Escalard, Jean-Philippe Desilles, Hocine Redjem, Gabriele Ciccio, Stanislas Smajda, Robert Fahed, Mikael Obadia, Candice Sabben, Ovide Corabianu, Thomas de Broucker, Didier Smadja, Sonia Alamowitch, Olivier Ille, Eric Manchon, Pierre-Yves Garcia, Guillaume Taylor, Malek Ben Maacha, Frédéric Bourdain, Decroix Jean-pierre, Adrien Wang, Serge Evrard, Maya tchikviladze, Oguzhan Coskun, Federico Di Maria, Georges Rodesh, Morgan Leguen, Marie Tisserand, Fernando Pico, Haja Rakotoharinandrasana, Philippe Tassan, Roxanna Poll, Florent Gariel, Xavier Barreau, Jérôme Berge, Patrice Menegon, Ludovic Lucas, Stéphane Olindo, Pauline Renou, Sharmila Sagnier, Mathilde Poli, Sabrina Debruxelles, François Rouanet, Thomas Tourdias, Jean-Sebastien Liegey, Pierre Briau, Nicolas Pangon, Lili Detraz, Benjamin Daumas-Duport, Pierre-Louis Alexandre, Monica Roy, Cédric Lenoble, Hubert Desal, Benoît Guillon, Solène de Gaalon, Cécile Preterre, Isabelle Costa, Serge Bracard, René Anxionnat, Marc Braun, Anne-Laure Derelle, Romain Tonnelet, Liang Liao, François Zhu, Emmanuelle Schmitt, Sophie Planel, Lisa Humbertjean, Gioia Mione, Jean-Christophe Lacour, Nolwenn Riou-Comte, Gabriela Hossu, Marine Beaumont, Mitchelle Bailang, Gérard Audibert, Marie Reitter, Agnès Masson, Lionel Alb, Adriana Tabarna, Marcela Voicu, Iona Podar, Madalina Brezeanu, Vincent Costalat, Grégory Gascou, Pierre-Henri Lefèvre, Imad Derraz, Carlos Riquelme, Nicolas Gaillard, Isabelle Mourand, Lucas Corti, Jean-Christophe Ferre, Helene Raoult, Thomas Ronziere, Maria Lassale, Fakhreddine Boustia, Jean-Yves Gauvrit, Clément Tracol, Sophie Langnier-Lemercier, Veronica Lassalle, Cecile Malrain, Clement Tracol, Thomas Ronziere.

    • Contributors Study concept and design: BM, SF, BL, RBl, MP, MM, BG. Acquisition of data: BM, SF, RBo, PP, SR, GM, IS, CD, CA, RBl, MP, BL, AC, FE, SV, SS, FM, FC, CR, ON, GT, AV, CC, VW, RP, MM, BG. Analysis and interpretation of data: BM, SF, MM, BG. Drafting of the manuscript: BM, SF, MM, BG. Critical revision of the manuscript for important intellectual content: BM, SF, RBo, PP, SR, GM, IS, CD, CA, RBl, MP, BL, AC, FE, SV, SS, FM, FC, CR, ON, GT, AV, CC, VW, RP, MM, BG. Statistical analysis: SF. Administrative, technical, or material support: BL, RBl, BG. Study supervision: RBl, MM, BG. All authors read and approved the final manuscript.

    • 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 None declared.

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

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.