Outcomes of Stent Retriever versus Aspiration-First Thrombectomy in Ischemic Stroke: A Systematic Review and Meta-Analysis.

BACKGROUND

There is ongoing debate regarding the optimal first-line thrombectomy technique for large-vessel occlusion.

PURPOSE

We performed a systematic review and meta-analysis of comparative studies on stent retriever-first and aspiration-first thrombectomy.

DATA SOURCES

We searched Ovid MEDLINE, PubMed, and EMBASE from 2009 to February 2018.

STUDY SELECTION

Two reviewers independently selected the studies. The primary end point was successful reperfusion (TICI 2b/3).

DATA ANALYSIS

Random-effects meta-analysis was used for analysis.

DATA SYNTHESIS

Eighteen studies including 2893 patients were included. There was no significant difference in the rate of final successful reperfusion (83.9% versus 83.3%; OR = 0.87; 95% CI, 0.62%-1.27%) or good functional outcome (mRS 0-2) at 90 days (OR = 1.07; 95% CI, 0.80-1.44) between the stent-retriever thrombectomy and aspiration groups. The stent-retriever thrombectomy-first group achieved a statistically significant higher TICI 2b/3 rate after the first-line device than the aspiration-first group (74.9% versus 66.4%; OR = 1.53; 95% CI, 1.14%-2.05%) and resulted in lower use of a rescue device (19.9% versus 32.5%; OR = 0.36; 95% CI, 0.14%-0.90%). The aspiration-first approach resulted in a statistically shorter groin-to-reperfusion time (weighted mean difference, 7.15 minutes; 95% CI, 1.63-12.67 minutes). There was no difference in the number of passes, symptomatic intracerebral hemorrhage, vessel dissection or perforation, and mortality between groups.

LIMITATIONS

Most of the included studies were nonrandomized. There was significant heterogeneity in some of the outcome variables.

CONCLUSIONS

Stent-retriever thrombectomy-first and aspiration-first thrombectomy were associated with comparable final reperfusion rates and functional outcome. Stent-retriever thrombectomy was superior in achieving reperfusion as a stand-alone first-line technique, with lower use of rescue devices but a longer groin-to-reperfusion time.