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Ischemic stroke
Original research
Early technique switch following failed passes during mechanical thrombectomy for ischemic stroke: should the approach change and when?
  1. Pedro N Martins1,2,
  2. Raul G Nogueira1,2,3,
  3. Mohamed A Tarek1,2,
  4. Jaydevsinh N Dolia1,2,
  5. Sunil A Sheth4,
  6. Santiago Ortega-Gutierrez5,
  7. Sergio Salazar-Marioni4,
  8. Ananya Iyyangar4,
  9. Milagros Galecio-Castillo5,
  10. Aaron Rodriguez-Calienes5,6,
  11. Aqueel Pabaney1,2,
  12. Jonathan A Grossberg1,2,
  13. Diogo C Haussen1,2
  1. 1Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
  2. 2Grady Memorial Hospital, Atlanta, Georgia, USA
  3. 3UPMC, Pittsburgh, Pennsylvania, USA
  4. 4Department of Neurology, University of Texas Health Science Center, Houston, Texas, USA
  5. 5Department of Neurology, Neurosurgery and Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
  6. 6Grupo de Investigacion Neurociencia, Efectividad Clinica y Salud Publica, Universidad Cientifica del Sur Facultad de Ciencias de la Salud, Lima, Peru
  1. Correspondence to Dr Diogo C Haussen, Department of Neurology and Radiology, Emory University School of Medicine, Atlanta, GA 30303, USA; diogo.haussen{at}emory.edu

Abstract

Background Fast and complete reperfusion in endovascular therapy (EVT) for ischemic stroke leads to superior clinical outcomes. The effect of changing the technical approach following initially unsuccessful passes remains undetermined.

Objective To evaluate the association between early changes to the EVT approach and reperfusion.

Methods Multicenter retrospective analysis of prospectively collected data for patients who underwent EVT for intracranial internal carotid artery, middle cerebral artery (M1/M2), or basilar artery occlusions. Changes in EVT technique after one or two failed passes with stent retriever (SR), contact aspiration (CA), or a combined technique (CT) were compared with repeating the previous strategy. The primary outcome was complete/near-complete reperfusion, defined as an expanded Thrombolysis in Cerebral Infarction (eTICI) of 2c–3, following the second and third passes.

Results Among 2968 included patients, median age was 66 years and 52% were men. Changing from SR to CA on the second or third pass was not observed to influence the rates of eTICI 2c–3, whereas changing from SR to CT after two failed passes was associated with higher chances of eTICI 2c–3 (OR=5.3, 95% CI 1.9 to 14.6). Changing from CA to CT was associated with higher eTICI 2c–3 chances after one (OR=2.9, 95% CI 1.6 to 5.5) or two (OR=2.7, 95% CI 1.0 to 7.4) failed CA passes, while switching to SR was not significantly associated with reperfusion. Following one or two failed CT passes, switching to SR was not associated with different reperfusion rates, but changing to CA after two failed CT passes was associated with lower chances of eTICI 2c–3 (OR=0.3, 95% CI 0.1 to 0.9). Rates of functional independence were similar.

Conclusions Early changes in EVT strategies were associated with higher reperfusion and should be contemplated following failed attempts with stand-alone CA or SR.

  • Thrombectomy
  • Stroke
  • Technique

Data availability statement

Data are available upon reasonable request. Data will be shared upon reasonable request to the corresponding author.

https://doi.org/10.1136/jnis-2024-021545

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    Data availability statement

    Data are available upon reasonable request. Data will be shared upon reasonable request to the corresponding author.

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    Footnotes

    • Twitter @CerebrovascLab, @mili_galecio, @AaronCalienes, @JAGrossbergMD, @diogohaussen

    • Correction notice Since this article first published, the authors identified errors in the results for the secondary outcome (eTICI 2b-3) presented in Table 1 and Figure 2. These and the results section were updated. This correction has no impact on the conclusions.

    • Contributors Conceptualization: DCH. Methodology: PM and DCH. Formal analysis: PM and DCH. Investigation: PM, MAT, SS-M, AI, MG-C, AR-C. Resources: RN, SAS, SO-G, DCH. Data curation: all authors. Writing - original draft: PM and DCH. Writing - review and editing: All authors. Visualization: PM and DCH. Project administration: PM. Supervision: DCH. Guarantor: DCH.

    • 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 RN: consultant: Anaconda, Biogen, Cerenovus, Genentech, Hybernia, Imperative Care, Medtronic, Phenox, Philips, Prolong Pharmaceuticals, Stryker Neurovascular, Shanghai Wallaby, and Synchron; stock options: Astrocyte, Brainomix, Cerebrotech, Ceretrieve, Corindus Vascular Robotics, Vesalio, Viz-AI, RapidPulse, Perfuze; principal investigator: ENDOLOW and DUSK trials; stock options: Viz-AI, Perfuze, Cerebrotech, Reist/Q’Apel Medical, Truvic, Tulavi Therapeutics, Vastrax, Piraeus Medical, Brain4Care, Quantanosis AI, Viseon. SAS: NIH grant (R01NS121154); consultant: Penumbra and Imperative Care; ownership: Motif Neurosciences. SO-G: grants: Medtronic, Stryker, NINDS, Methinks. personal fees: Medtronic and Stryker outside the submitted work. DCH: consultant: Stryker Neurovascular, Cerenovus, Chiesi USA, Brainomix, Poseydon Medical. Consulting/DSMB: Jacobs Institute/Medtronic, Vesalio, Rapid Pulse. Stock options: VizAI, Motif Neurotech. Other authors: none.

    • 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.