Background Endovascular thrombectomy (EVT) is the standard-of-care for proximal large vessel occlusion (LVO) stroke. Data on technical and clinical outcomes in distal vessel occlusions (DVOs) remain limited.
Methods This was a retrospective study of patients undergoing EVT for stroke at 32 international centers. Patients were divided into LVOs (internal carotid artery/M1/vertebrobasilar), medium vessel occlusions (M2/A1/P1) and isolated DVOs (M3/M4/A2/A3/P2/P3) and categorized by thrombectomy technique. Primary outcome was a good functional outcome (modified Rankin Scale ≤2) at 90 days. Secondary outcomes included recanalization, procedure-time, thrombectomy attempts, hemorrhage, and mortality. Multivariate logistic regressions were used to evaluate the impact of technical variables. Propensity score matching was used to compare outcome in patients with DVO treated with aspiration versus stent retriever
Results We included 7477 patients including 213 DVOs. Distal location did not independently predict good functional outcome at 90 days compared with proximal (p=0.467). In distal occlusions, successful recanalization was an independent predictor of good outcome (adjusted odds ratio (aOR) 5.11, p<0.05) irrespective of technique. Younger age, bridging therapy, and lower admission National Institutes of Health Stroke Scale (NIHSS) were also predictors of good outcome. Procedure time ≤1 hour or ≤3 thrombectomy attempts were independent predictors of good outcomes in DVOs irrespective of technique (aOR 4.5 and 2.3, respectively, p<0.05). There were no differences in outcomes in a DVO matched cohort of aspiration versus stent retriever. Rates of hemorrhage and good outcome showed an exponential relationship to procedural metrics, and were more dependent on time in the aspiration group and attempts in the stent retriever group.
Conclusions Outcomes following EVT for DVO are comparable to LVO with similar results between techniques. Techniques may exhibit different futility metrics; stent retriever thrombectomy was influenced by attempts whereas aspiration was more dependent on procedure time.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
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Collaborators Christian Mustroph, MD; Emory University School of Medicine, Atlanta, GA, USA
Kareem E Naamani, MD; Thomas Jefferson University, Philadelphia, PA, USA
Italo Linfante, MD; Florida International University; Miami, FL, USA
Clemens Schirmer, MD; Geisinger Medical Group, Danville, PA, USA
Toshiya Osanai, MD. PhD; Hokkaido University Hospita; Sapporo, Japan
Shinichi Yoshimura, MD PhD; Hyogo College of Medicine; Nishinomiya, Japan
Waleed Brinjikji, MD; Mayo Clinic, Rochester, MN, USA
Richard Crowley, MD; Rush Univeristy; Chicago, IL, USA
Adam Polifka, MD; University of Floride, Gainesville, FL, USA
Contributors All authors have: provided 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. JAG/AMS are guarantors of the work and the conduct of the study.
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 AMA: None, RMC: None, SAK: Grant Funding-Stryker; PJ: Consultant-Balt, Cerus, Microvention, Medtronic. M-NP Honoraria - Stryker, Medtronic, Penumbra, Acandis, Phenox, Siemens Healthineers, Research Support-Swiss National Science Foundation, Bangerter-Rhyner Stiftung, Stryker, Phenox, Medtronic, Rapid, Penumbra, Siemens Healthineers; RMS: None; ASA: Consultant for Arsenal, Balt, Johnson and Johnson, Medtronic, Microvention, Penumbra, Scientia, Siemens, Stryker, Research support from Balt, Medtronic, Microvention, Penumbra and Siemens, Shareholder-Azimuth, Bendit, Cerebrotech, Endostream, Magneto, Mentice, Neurogami, Neuros, Scientia, Serenity, Synchron, Tulavi, Vastrax, VizAI; KMF: Editorial Board-JNIS; RDL: Consultant-Stryker, Imperative Care, Cerenovus, Asahi Intec, Research Funding-Hypervention, Kaneka, Siemens Healthineers, SNIS Foundation, Equity-Synchron, Endostream, Q’Apel, Spartan Micro, Editorial Board-JNIS; PK: Consultant- Stryker, Imperative Care, Microvention, Grant Support-NIH, Editorial-Board JNIS; TD: None; AR: None; RJC: None; IM: None; NG: None; SQW: Board of Directors-AANS, Associate Editor- S:VIN Journal; CMC: None; JM: PI on trials funded by- Stryker Neurovascular, Microvention, and Penumbra, Consultant-Cerebrotech, Viseon, Endostream, Vastrax, RIST, Synchron, Viz.ai, Perflow, CVAid, Stockholder-Cerebrotech, Imperative Care, Endostream, Viseon, BlinkTBI, Myra Medical, Serenity, Vastrax, NTI, RIST, Viz.ai, Synchron, Radical, and Truvic; Editorial Board-JNIS; SIT: Consultant- Microvention, Medtronic; BMH: None; LD: None; HS: None; CSO: Grant Support- Bee Foundation, Brain Aneurysm Foundation, DSMB- Medtronic; RWC: Consultant/Proctor: Medtronic, Microvention; JMa: consultant-Stryker; IF: None; MRL: Educational Grant-Stryker, Medtronic, Consultant-Medtronic, Aeaean Advisers, Travel Support-Penumbra, Editorial Board, JNIS, Stock- Hyperion Surgical, Proprio, Synchron, Cerebrotech, Fluid Biomed, Stereotaxis, Advisor-Metis Innovative; J-tK: None; MSP: DSMB-Medtronic; BG: None; AJP: Consultant-Depuy Synthes, Stryker, CM: Consultant-Silk Road, Penumbra, Microvention, Cerevasc, Stryker, Speaker-Silk Road, Penumbra; JAG: Grant Support- Georgia Research Alliance, Department of Defense, Emory Medical Care Foundation, Neurosurgery Catalyst, Stock- NTI, Cognition; AMS: Consultant- Stryker, Penumbra, Terumo, RapidAI; STAR: funded by Penumbra, Medtronic, Stryker.
Provenance and peer review Not commissioned; externally peer reviewed.
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