Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA.
Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Atlanta, GA, USA.
Int J Stroke. 2022 Apr;17(4):465-473. doi: 10.1177/17474930211019204. Epub 2021 May 27.
Three randomized clinical trials have reported similar safety and efficacy for contact aspiration and stent-retriever thrombectomy.
We aimed to determine whether the combined technique (stent-retriever + contact aspiration) was superior to stent-retriever alone as first-line thrombectomy strategy in a patient cohort where balloon guide catheter was universally used.
A prospectively maintained mechanical thrombectomy database from January 2018 to December 2019 was reviewed. Patients were included if they had anterior circulation proximal occlusion ischemic stroke (intracranial ICA or MCA-M1/M2 segments) and underwent stent-retriever alone thrombectomy or stent-retriever + contact aspiration as first-line therapy. The primary outcome was the first-pass effect (mTICI2c-3). Secondary outcomes included modified first-pass effect (mTICI2b-3), successful reperfusion (mTICI2b-3) prior to and after any rescue strategy, and 90-day functional independence (mRS ≤ 2). Safety outcomes included rate of parenchymal hematoma type-2 and 90-day mortality. Sensitivity analyses were performed after dividing the overall cohort according to first-line modality into two matched groups.
A total of 420 patients were included in the analysis (mean age 64.4 years; median baseline NIHSS 16 (11-21)). As compared to first-line stent-retriever alone, first-line stent-retriever + contact aspiration resulted in similar rates of first-pass effect (53% vs. 51%, adjusted odds ratio (aOR) 1.122, 95%CI (0.745-1.691), p = 0.58), modified first-pass effect (63% vs. 60.4%, aOR1.250, 95%CI (0.782-2.00), p = 0.35), final successful reperfusion (97.6% vs. 98%, p = 0.75), and higher chances of successful reperfusion prior to any rescue strategy (81.8% vs. 72.5%, aOR 2.033, 95%CI (1.209-3.419), p = 0.007). Functional outcome and safety measures were comparable between both groups. Likewise, the matched analysis (148 patient-pairs) demonstrated comparable results for all clinical and angiographic outcomes except for significantly higher rates of successful reperfusion prior to any rescue strategies with the first-line stent-retriever + contact aspiration treatment (81.8% vs. 73.6%, aOR 1.881, 95%CI (1.039-3.405), p = 0.037).
Our findings reinforce the findings of ASTER-2 trial in that the first-line thrombectomy with a combined technique did not result in increased rates of first-pass reperfusion or better clinical outcomes. However, the addition of contact aspiration after initial stent-retriever failure might be beneficial in achieving earlier reperfusion.
三项随机临床试验报告了接触抽吸和支架取栓在安全性和疗效方面相似。
我们旨在确定在普遍使用球囊引导导管的患者队列中，联合技术（支架取栓+接触抽吸）是否优于支架取栓作为一线血栓切除术策略。
回顾了 2018 年 1 月至 2019 年 12 月期间前瞻性维护的机械血栓切除术数据库。如果患者患有前循环近端闭塞性缺血性卒中（颅内 ICA 或 MCA-M1/M2 段）并接受支架取栓单独血栓切除术或支架取栓+接触抽吸作为一线治疗，则将其纳入研究。主要结局是首次通过效应（mTICI2c-3）。次要结局包括改良首次通过效应（mTICI2b-3）、在任何挽救策略之前和之后成功再灌注（mTICI2b-3），以及 90 天功能独立性（mRS≤2）。安全性结局包括实质血肿类型 2 的发生率和 90 天死亡率。在根据一线治疗方式将总体队列分为两个匹配组后，进行了敏感性分析。
共有 420 名患者纳入分析（平均年龄 64.4 岁；中位基线 NIHSS 为 16[11-21]）。与一线支架取栓单独治疗相比，一线支架取栓+接触抽吸的首次通过效应率相似（53% vs. 51%，调整后的优势比（aOR）为 1.122，95%CI（0.745-1.691），p=0.58），改良首次通过效应率（63% vs. 60.4%，aOR1.250，95%CI（0.782-2.00），p=0.35），最终成功再灌注率（97.6% vs. 98%，p=0.75），以及在任何挽救策略之前成功再灌注的可能性更高（81.8% vs. 72.5%，aOR 2.033，95%CI（1.209-3.419），p=0.007）。两组的功能结局和安全性措施相似。同样，匹配分析（148 对患者）显示，除了在任何挽救策略之前成功再灌注的比率显著更高外，所有临床和血管造影结局的结果相似（81.8% vs. 73.6%，aOR 1.881，95%CI（1.039-3.405），p=0.037），使用一线支架取栓+接触抽吸治疗。
我们的研究结果强化了 ASTER-2 试验的结果，即一线联合技术血栓切除术并未导致首次通过再灌注率或更好的临床结局增加。然而，在初始支架取栓失败后添加接触抽吸可能有助于更早实现再灌注。
