Introduction Mechanical thrombectomy is the standard of care in the management of acute ischemic stroke. With the recent expansion of the eligibility criteria and modernization in current devices, more and more patients are becoming candidates. Conducting further research into which technical variations are more optimal is imperative in order to improve clinical outcomes.

Material and Methods This was a multicenter retrospective analysis of consecutive patients who underwent mechanical thrombectomy for acute ischemic stroke at the UCLA Ronald Reagan and Long Beach Memorial medical centers between August of 2021-August 2023. The primary goal of this study was to compare the outcomes of patients based on the initial intraprocedural technique used. Primary outcomes included adequate reperfusion (defined as TICI ≥ 2b), postprocedural intracranial hemorrhage, new territory emboli, good 90 day modified Rankin Score (mRS 0–2), mortality, and mean arterial access to reperfusion time.

Results There were a total of 154 completed mechanical thrombectomy cases at UCLA Ronald Reagan (69.5%) and Long Beach Memorial medical centers (30.5%). Majority of occlusions involved the proximal middle cerebral artery (101 cases or 69.2%), followed by internal carotid artery (22.6%), distal middle cerebral artery (4.1%), anterior cerebral artery (2.7%), and posterior circulation (1.4%). Mean NIHSS at presentation was 15±7.6 and approximately a third of patients (34.7%) received intravenous alteplase. General anesthesia was employed in majority (89.6%) of the cases. Adequate reperfusion was achieved in 85.7% of the patients. Mean time from arterial access to reperfusion was 55.5±35.7 minutes. Of the 154 patients, 42 (39.6%) achieved good mRS (0–2) at 90 day follow up. The type of initial technique employed during thrombectomy (ADAPT vs. combined technique vs. stent retriever alone vs. other such as clot maceration) was not associated with any differences in rates of final reperfusion, hemorrhage, new territory emboli, mortality, or good 90 day mRS (p>0.05 for all). However, cases that used the combined technique (84 out of 154 cases) as the initial approach were associated with higher number of mean passes that achieved recanalization (2.2±1.4) in comparison to ADAPT as the first line approach (1.7±1.1), stent retriever alone (1.7±0.8), and other techniques (1.1±1.3) (p=0.005). And mean time from arterial access to reperfusion was significantly lower in ADAPT first line approach group (38.4±22.5 min) compared to the combined technique (60.2±39.4 min), stent retriever alone (59.4±36.5 min), and other (55.9±26 min) group (p=0.042).

Conclusion The aim of this multicenter study was to compare the efficacy and safety of various first line techniques used in mechanical thrombectomy for large and medium vessel occlusions. We found that the final clinical outcomes and rate of complications did not vary based on the type of initial technique employed during thrombectomy (ADAPT vs. combined technique vs. stent retriever alone vs. other). However, the combined technique was associated with more passes and ADAPT technique was associated with less time from arterial access to achieve reperfusion. Optimizing devices for ADAPT first line approach might be beneficial in achieving quicker reperfusion in select thrombectomy cases, but certainly more studies are needed to solidify these results.

Disclosures C. Peterson: None. A. Molaie: None. M. Blackwood: None. F. Mukarram: None. Y. Ghochani: None. P. Johnson-Black: None. N. Kaneko: None. R. Alfonso: None. F. Chatfield: None. J. Saver: None. V. Szeder: None.