Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA.
Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA.
Interv Neuroradiol. 2024 Aug;30(4):470-479. doi: 10.1177/15910199221138139. Epub 2022 Nov 14.
Endovascular thrombectomy(EVT) is the standard of care for large vessel occlusion(LVO) stroke. Data on technical and clinical outcome in proximal medium vessel occlusions(pMeVOs) comparing frontline techniques remain limited.
We report an international multicenter retrospective study of patients undergoing EVT for stroke at 32 centers between 2015-2021. Patients were divided into LVOs(ICA/M1/Vertebrobasilar) or pMeVOs(M2/A1/P1) and categorized by thrombectomy technique. Primary outcome was 90-day good functional outcome(mRS ≤ 2). Multivariate logistic regressions were used to evaluate the impact of technical variables on clinical outcomes. Propensity score matching was used to compare outcome in patients with pMeVO treated with aspiration versus stent-retriever.
In the cohort of 5977 LVO and 1287 pMeVO patients, pMeVO did not independently predict good-outcome(p = 0.55). In pMeVO patients, successful recanalization irrespective of frontline technique(aOR = 3.2,p < 0.05), procedure time ≤ 1-h(aOR = 2.2,p < 0.05), and thrombectomy attempts ≤ 4(aOR = 2.8,p < 0.05) were independent predictors of good-outcomes.In a propensity-matched cohort of aspiration versus stent-retriever pMeVO patients, there was no difference in good-outcomes. The rates of hemorrhage were higher(9%vs.4%,p < 0.01) and procedure time longer(51-min vs. 33-min,p < 0.01) with stent-retriever, while the number of attempts was higher with aspiration(2.5vs.2,p < 0.01). Rates of hemorrhage and good-outcome showed an exponential relationship to procedural metrics, and were more dependent on time in the aspiration group compared to attempts in the stent-retriever group.
Clinical outcomes following EVT for pMeVO are comparable to those in LVOs. The golden hour or 3-pass rules in LVO thrombectomy still apply to pMeVO thrombectomy. Different techniques may exhibit different futility metrics; SR thrombectomy was more influenced by attempts whereas aspiration was more dependent on procedure time.
血管内血栓切除术（EVT）是治疗大血管闭塞（LVO）卒中的标准治疗方法。关于比较一线技术的近端中等血管闭塞（pMeVOs）的技术和临床结果的数据仍然有限。
我们报告了一项国际多中心回顾性研究，该研究纳入了 2015 年至 2021 年间 32 个中心接受 EVT 治疗的卒中患者。患者分为 LVO（ICA/M1/椎基底动脉）或 pMeVOs（M2/A1/P1），并根据血栓切除术技术进行分类。主要结局为 90 天良好功能结局（mRS≤2）。多变量逻辑回归用于评估技术变量对临床结局的影响。采用倾向评分匹配比较 pMeVO 患者抽吸与支架取栓治疗的结局。
在 5977 例 LVO 和 1287 例 pMeVO 患者的队列中，pMeVO 不能独立预测良好结局（p=0.55）。在 pMeVO 患者中，无论一线技术如何，成功再通（aOR=3.2，p<0.05）、手术时间≤1 小时（aOR=2.2，p<0.05）和血栓切除术尝试次数≤4 次（aOR=2.8，p<0.05）是良好结局的独立预测因素。在抽吸与支架取栓治疗 pMeVO 患者的倾向评分匹配队列中，两组之间的良好结局没有差异。支架取栓组的出血率更高（9%比 4%，p<0.01），手术时间更长（51 分钟比 33 分钟，p<0.01），而抽吸组的尝试次数更多（2.5 次比 2 次，p<0.01）。出血率和良好结局与手术指标呈指数关系，并且在抽吸组中更依赖于时间，而在支架取栓组中更依赖于尝试次数。
pMeVO 患者接受 EVT 后的临床结局与 LVO 相似。LVO 血栓切除术的黄金时间或 3 次通过规则仍然适用于 pMeVO 血栓切除术。不同的技术可能表现出不同的无效性指标；SR 血栓切除术受尝试次数的影响更大，而抽吸则更多地依赖于手术时间。
