Background Higher expanded Treatment In Cerebral Ischemia (eTICI) reperfusion scores after endovascular treatment (EVT) are associated with better outcomes. However, the influence of the number of passes on this association is unclear. We aimed to compare outcomes of single-pass good reperfusion (eTICI 2B) with multiple-pass excellent/complete reperfusion (eTICI 2C/3) in daily clinical practice.
Methods We compared outcomes of patients in the MR CLEAN Registry with good reperfusion (eTICI 2B) in a single pass to those with excellent/complete reperfusion (eTICI 2C/3) in multiple passes. Regression models were used to investigate the association of single-pass eTICI 2B versus multiple-pass eTICI 2C/3 reperfusion with 90-day functional outcome (modified Rankin Scale (mRS)), functional independence (mRS 0–2), per-procedural complications and safety outcomes.
Results We included 699 patients: 178 patients with single-pass eTICI 2B, and 242 and 279 patients with eTICI 2C/3 after 2 and ≥3 passes, respectively. Patients with eTICI 2C/3 after 2 or ≥3 passes did not achieve significantly better functional outcomes compared with patients with single-pass eTICI 2B (adjusted common OR (acOR) 1.06, 95% CI 0.75 to 1.50 and acOR 0.88, 95% CI 0.74 to 1.05 for 90-day mRS, and adjusted OR (aOR) 1.24, 95% CI 0.78 to 1.97 and aOR 0.79, 95% CI 0.52 to 1.22 for functional independence).
Conclusions Our results did not show better outcomes for patients who achieved eTICI 2C/3 in multiple, that is, two or more, passes when compared with patients with single-pass eTICI 2B. However, this concerns observational data. Further research is necessary to investigate the per-pass effect in relation to reperfusion and functional outcome.
Data availability statement
Data are available upon reasonable request. Source data of this study will not be available due to privacy regulations, but analytic methods, study materials and scripts of the statistical analysis are available upon reasonable request.
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Collaborators MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry Investigators: Diederik WJ Dippel; Aad van der Lugt; Charles BLM Majoie; Yvo BWEM Roos; Robert J van Oostenbrugge; Wim H van Zwam; Jelis Boiten; Jan Albert Vos;, Ivo GH Jansen; Maxim JHL Mulder; Robert- Jan B Goldhoorn; Kars CJ Compagne; Manon Kappelhof; Josje Brouwer; Sanne J den Hartog; Wouter H Hinsenveld; Bob Roozenbeek; Adriaan CGM van Es; Bart J Emmer; Jonathan M Coutinho; Wouter J Schonewille; Marieke JH Wermer; Marianne AA van Walderveen; Julie Staals; Jeannette Hofmeijer; Jasper M Martens; Geert J Lycklama à Nijeholt; Sebastiaan F de Bruijn; Lukas C van Dijk; H Bart van der Worp; Rob H Lo; Ewoud J van Dijk; Hieronymus D Boogaarts; J de Vries; Paul LM de Kort; Julia van Tuijl ; Jo P Peluso; Puck Fransen; Jan SP van den Berg; Boudewijn AAM van Hasselt; Leo AM Aerden; René J Dallinga; Maarten Uyttenboogaart; Omid Eschgi; Reinoud PH Bokkers; Tobien HCML Schreuder; Roel JJ Heijboer; Koos Keizer; Lonneke SF Yo; Heleen M den Hertog; Tomas Bulut; Paul JAM Brouwers; Marianne AA van Walderveen; Marieke ES Sprengers; Sjoerd FM Jenniskens; René van den Berg; Albert J Yoo; Ludo FM Beenen; Alida A Postma; Stefan D Roosendaal; Bas FW van der Kallen; Ido R van den Wijngaard; Lonneke SF Yo; Joost Bot, Pieter-Jan van Doormaal; Anton Meijer; Elyas Ghariq; Reinoud PH Bokkers; Marc P van Proosdij; G Menno Krietemeijer; Jo P Peluso; Hieronymus D Boogaarts; Rob Lo; Wouter Dinkelaar; Auke PA Appelman; Bas Hammer; Sjoert Pegge; Anouk van der Hoorn; Saman Vinke; H Zwenneke Flach; Hester F Lingsma; Naziha el Ghannouti; Martin Sterrenberg; Wilma Pellikaan; Rita Sprengers; Marjan Elfrink; Michelle Simons; Marjolein Vossers; Joke de Meris; Tamara Vermeulen; Annet Geerlings; Gina van Vemde; Tiny Simons; Gert Messchendorp; Nynke Nicolaij; Hester Bongenaar; Karin Bodde; Sandra Kleijn; Jasmijn Lodico; Hanneke Droste; Maureen Wollaert; Sabrina Verheesen; D Jeurrissen; Erna Bos; Yvonne Drabbe; Michelle Sandiman; Nicoline Aaldering; Berber Zweedijk; Jocova Vervoort; Eva Ponjee; Sharon Romviel; Karin Kanselaar; Denn Barning; Esmee Venema; Vicky Chalos; Ralph R Geuskens; Tim van Straaten; Saliha Ergezen; Roger RM Harmsma; Daan Muijres; Anouk de Jong; Olvert A Berkhemer; Anna MM Boers; J Huguet; PFC Groot; Marieke A Mens; Katinka R van Kranendonk; Kilian M Treurniet; Manon L Tolhuisen; Heitor Alves; Annick J Weterings; Eleonora LF Kirkels; Eva JHF Voogd; Lieve M Schupp; Sabine L Collette; Adrien ED Groot; Natalie E LeCouffe; Praneeta R Konduri; Haryadi Prasetya; Nerea Arrarte-Terreros; Lucas A Ramos.
Contributors AAEB and BJE developed the study. AAEB performed the data analysis, wrote the manuscript and is responsible for the overall content of the manuscript as the guarantor. BJE contributed to the study design. MK and SJdH helped with data acquisition and interpretation. JFB, OAB, ACGvE, WvZ, DWJD, JMC, CBLM and BJE contributed to the clinical assessment of the data. JMC, HAM, CBLM and BJE contributed to the research development and project supervision. All authors provided feedback and contributed to the final version of the manuscript.
Funding The MR CLEAN Registry was partly funded by the TWIN Foundation, Erasmus MC University Medical Center, Maastricht University Medical Center, and Amsterdam UMC.
Competing interests Amsterdam UMC received funds from Stryker for consultation by CBLM. Unrelated to this study, Amsterdam UMC received grants from the Netherlands Organization for Health Research and Development, Health Holland Top Sector LSH and Nicolab B.V. Erasmus University Medical Center received funds from Stryker, Siemens Healthineers, GE Healthcare and Bracco Imaging for consultation by DWJD. Maastricht University Medical Center received funds from Stryker, Cerenovus, Nicolab B.V. and Philips for consultation by WvZ. JMC reports a grant from Medtronic, all fees paid to institution. HAM is co-founder and shareholder of Nicolab B.V. Dr Charles BLM Majoie reports grants from the TWIN Foundation, CVON/Dutch Heart Foundation, European Commission, Health Evaluation Netherlands, and Stryker, all paid to the institution. CBLM is minor shareholder of Nicolab B.V. Dr Bart J Emmer reports a TKI-Private PPP Grant from the Dutch Ministry of Economics. The other authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Provenance and peer review Not commissioned; externally peer reviewed.
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