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Ischemic stroke
Original research
Repeat thrombectomy after large vessel re-occlusion: a propensity score matched analysis of technical and clinical outcomes
  1. Youssef M Zohdy1,
  2. Hassan Saad1,
  3. Brian M Howard1,
  4. C Michael Cawley1,
  5. Aqueel Pabaney1,
  6. Feras Akbik2,
  7. Laurie Dimisko1,
  8. Ilko Maier3,
  9. Alejandro M Spiotta4,
  10. Pascal Jabbour5,
  11. Stacey Q Wolfe6,
  12. Ansaar Rai7,
  13. Joon-tae Kim8,
  14. Justin Mascitelli9,
  15. Robert M Starke10,
  16. Amir Shaban11,
  17. Shinichi Yoshimura12,
  18. Reade De Leacy13,
  19. Peter Kan14,
  20. Isabel Fragata15,
  21. Adam J Polifka16,
  22. Adam S Arthur17,18,
  23. Min S Park19,
  24. Charles Matouk20,
  25. Michael R Levitt21,
  26. Stavropoula I Tjoumakaris22,
  27. Jan Liman23,
  28. Vanesha Waiters24,
  29. Gustavo Pradilla1,
  30. Kyle M Fargen6,
  31. Ali Alawieh1,
  32. Jonathan A Grossberg1
  33. STAR Collaborators
    1. 1Neurosurgery, Emory University, Atlanta, Georgia, USA
    2. 2Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, Georgia, USA
    3. 3Neurology, University Medicine Goettingen, Goettingen, Nova Scotia, Germany
    4. 4Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
    5. 5Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
    6. 6Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
    7. 7Radiology, West Virginia University Hospitals, Morgantown, West Virginia, USA
    8. 8Neurosurgery, Chonnam National University, Gwangju, Jeollanam-do, Korea (the Republic of)
    9. 9Deparment of Neurosurgery, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
    10. 10Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
    11. 11Neurology, University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
    12. 12Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
    13. 13Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
    14. 14Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
    15. 15Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
    16. 16Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
    17. 17Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
    18. 18Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
    19. 19Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
    20. 20Neurosurgery, Yale University, New Haven, Connecticut, USA
    21. 21Neurosurgery, University of Washington, Seattle, Washington, USA
    22. 22Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
    23. 23Department of Neurology, Universitatsklinikum Gottingen, Gottingen, Niedersachsen, Germany
    24. 24Morehouse School of Medicine, Atlanta, Georgia, USA
    1. Correspondence to Dr Ali Alawieh, Neurosurgery, Emory University, Atlanta, Georgia, USA; ali.mostafa.alawieh{at}emory.edu; Dr Jonathan A Grossberg; jonathan.a.grossberg{at}emory.edu

    Abstract

    Background Endovascular thrombectomy (EVT) remains the standard of care for acute large vessel occlusion (LVO) stroke. However, the safety and efficacy of repeat thrombectomy (rEVT) in recurrent LVO remains unclear. This study uses a large real-world patient cohort to study technical and clinical outcomes after rEVT.

    Methods This is a retrospective cohort study including patients who underwent thrombectomy between January 2013 and December 2022. Data were included from 21 comprehensive stroke centers globally through the Stroke Thrombectomy and Aneurysm Registry (STAR). Patients undergoing single EVT or rEVT within 30 days of LVO stroke were included in the study. Propensity score matching was used to compare patients undergoing single EVT versus rEVT.

    Results Out of a total of 7387 patients who underwent thrombectomy for LVO stroke, 90 (1.2%) patients underwent rEVT for the same vascular territory within 30 days. The median (IQR) time to re-occlusion was 2 (1–7) days. Compared with a matched cohort of patients undergoing a single EVT procedure, patients undergoing rEVT had a comparable rate of good functional outcome and mortality rate, but a higher rate of symptomatic intracranial hemorrhage (sICH). There was a significant reduction in the National Institutes of Health Stroke Scale (NIHSS) score of patients who underwent rEVT at discharge compared with baseline (−4.8±11.4; P=0.006). The rate of successful recanalization was similar in the single thrombectomy and rEVT groups (78% vs 80%, P=0.171) and between index and rEVT performed on the same patient (79% vs 80%; P=0.593).

    Conclusion Short-interval rEVT is associated with an improvement in the NIHSS score following large vessel re-occlusion. Compared with single thrombectomy, there was a higher rate of sICH with rEVT, but without a significant impact on rates of functional independence or mortality.

    • Thrombectomy
    • Stroke
    • Artery

    Data availability statement

    Data are available upon reasonable request.

    https://doi.org/10.1136/jnis-2023-021197

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      Data availability statement

      Data are available upon reasonable request.

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      Footnotes

      • Twitter @BrianHoward_MD, @PascalJabbourMD, @Starke_neurosurgery, @ashabanmd, @rdeleacymd, @PeterKa80460001, @AdamArthurMD, @DrMichaelLevitt, @stavtjouamakris, @JAGrossbergMD

      • YMZ and HS contributed equally.

      • Collaborators Stroke Thrombectomy and Aneurysm Registry (STAR): Sami Al Kasab (MD) (Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA), Reda Chalhoub (BS) (Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA), Tomas Garzon-Muvdi (MD, MSC) (Neurosurgery, Emory University, Atlanta, Georgia, USA), Frank Tong (MD) (Neurosurgery, Emory University, Atlanta, Georgia, USA), Marios-Nikos Psychogios (MD) (Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Switzerland), Edgar Samaniego (MD, Msc) (Neurology, University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA), Nitin Goyal (MD) (Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA).

      • Contributors Data acquisition and analysis was conducted by YMZ, HS, LD, VW and AMA. Analysis and first draft writing were done by YMZ and HS. Manuscript was reviewed and edited by BMH, CMC, AP, FA, IM, AMS, PJ, SW, AR, JK, KM, RS, AS, SY, RDL, PK, IF, AJP, ASA, MSP, CM, MRL, SIT, JL, GP, KMF, JAG. All authors approved the final version of the submission. AMA and JAG are co-corresponding authors and guarantors.

      • 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 AS is a consultant for Stryker, Penumbra, Terumo, and RapidAI. PJ is a consultant for Balt, Cerus endovascular, Microvention, and Medtronic. SQW is on the AANS board of directors, and AHA associate editor. JM is a consultant for Stryker. RDL received research funding from Hypervention, Kaneka Medical, Siemens, and SNIS Foundation, is a consultant for Stryker, Imperative Care, Cerenovus, and Asahi Intec, is a shareholder in Synchron, Endostream, Q’Apel and Spartan Micro, and is on the JNIS editoral board. PK is a consultant for Stryker, Imperative Care, and Microvention and is on the JNIS editorial board. AJP is a consultant for Stryker and Depuy Synthes. ASA received research funding from Balt, Medtronic, Microvention, Penumbra, and Siemens, is a consultant for Arsenal, Balt, Johnson, Medtronic, Microvention, Penumbra, Scientia, Siemens, and Stryker, and is a shareholder in Azimuth, Bendit, Cerebrotech, Endostream, Magneto, Mentice, Neurogami, Neuros, Scientia, Serenity, Synchron, Tulavi, Vastrax, VizAI. MSP served on a data monitoring board for Medtronic. CM is a consultant for Silk Road, Penumbra, Microvention, and Stryker. MRL received research funding from Stryker and Medtronic, is a consultant for Medtronic, adviser consultant for Aeaean, and innovative adviser for Metis, received travel support from Penumbra, is on the JNIS editorial board, is a shareholder in Hyperion Surgical, Propia, Synchron, Cerebrotech, Fluid Biomed, and Sterotaxis, and received equipment, material, drugs, medical writing, gifts and/or other services from Stryker and Medtronic. SIT is a consultant for Medtronic and Microvention and received payments for expert testimony. GP is a consultant for Stryker Corporation. KMF is on the JNIS editorial board. JAG received research funding from Georgia Research Alliance, Emory Medical Care Foundation, Department of Defense, Neurosurgery Catalyst and is a shareholder in NTI and Cognition. All other authors have no personal, financial, or institutional disclosures.

      • 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.