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.
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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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.
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