Contact aspiration and stent retriever versus stent retriever alone following mechanical thrombectomy for patients of acute ischemic stroke: A recanalization success analysis

Xu, Xiaowei; Shao, Xiangzhong; Cao, Jian; Huang, Xiaoyong; Li, Lin

doi:10.1016/j.clinsp.2023.100262

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Sumário

Original articles • Clinics 78 • 2023 • https://doi.org/10.1016/j.clinsp.2023.100262 copy

Contact aspiration and stent retriever versus stent retriever alone following mechanical thrombectomy for patients of acute ischemic stroke: A recanalization success analysis

Authorship SCIMAGO INSTITUTIONS RANKINGS

Highlights

A stent-assisted thrombectomy can use in symptomatic intracranial hemorrhage.
Contact aspiration plus stent retriever catheters have high chances of reperfusion.
Contact aspiration + stent retriever has fewer disease-related adverse effects.
The reperfusion parameter should be used to evaluate mechanical thrombectomy.
Failure attempts increased procedural time and procedural-adverse effects.

Abstract

Objective

Second-generation catheters used in mechanical thrombectomy have different advantages and disadvantages. The objective of this study was to evaluate the effectiveness and safety of the combination of contact aspiration and stent retriever technique on the rate of reperfusion after mechanical thrombectomy for large vessel occlusion.

Methods

Patients who underwent contact aspiration alone (CAA cohort, n = 150), stent retriever alone (SRA cohort, n = 129), or combined contact aspiration and stent retriever (CSR cohort, n = 122) techniques following mechanical thrombectomy were included in the analysis. A balloon guide catheter was used for all thrombectomies. Digital subtraction angiography was used to identify thrombolysis in cerebral infarction.

Results

The number of patients with thrombolysis in cerebral infarction score of ≥ 2c (near complete or complete antegrade reperfusion) was significantly higher in the CSR cohort than those in the CAA cohort (101 [83%] vs. 90 [60%], p < 0.0001) and those of SRA cohort (101 [83%] vs. 77 [59%], p = 0.0001). Arterial perforation was higher in patients in the CSR cohort than in those in the CAA (p < 0.0001) and SRA (p = 0.015) cohorts. Intracerebral hemorrhage was lower in patients in the CSR cohort than in those in the CAA (p = 0.0001) and SRA (p = 0.0353) cohorts. All-cause mortality at 1 year was fewer in the CSR cohort than in the CAA cohort (p = 0.018).

Conclusions

The combination of thrombo aspiration by large bore aspiration catheter and stent retriever is the most effective technique but has some related risks.

Level of evidence

IV.

Technical efficacy stage

Keywords
Acute ischemic stroke; Contact aspiration; Reperfusion; Stent retriever catheters; Thrombectomy; Thrombolysis in cerebral infarction

Parameters		Total	Cohorts			Comparisons among cohorts
Parameters		Total	CAA	SRA	CSR
Second generation catheter		Contact aspiration or/ and Stent retriever	Contact aspiration alone	Stent retriever alone	Contact aspiration + Stent retriever
Numbers of patients		401	150	129	122	p-value
Age (years)		64 (68-58)	65 (71-57)	64 (66-59)	62 (67-56)	0.0873 (Kruskal-Wallis’ test)
Gender	Male	220 (55)	80 (53)	70 (54)	70 (57)	0.7898 (χ²-test)
Gender	Female	181 (45)	70 (47)	59 (46)	52 (43)	0.7898 (χ²-test)
Hypertensive patients		199 (50)	67 (45)	62 (48)	70 (57)	0.1036 (χ²-test)
Diabetes		89 (22)	33 (22)	29 (22)	27 (22)	0.9952 (χ²-test)
Hypercholesterolemia		138 (34)	51 (34)	44 (34)	43 (35)	0.9733 (χ²-test)
Smoking	Current	43 (11)	15 (10)	14 (11)	14 (12)	0.9737 (χ²-test)
	Previous	50 (12)	17 (11)	17 (13)	16 (13)
	Non-smoker	308 (77)	118 (79)	98 (76)	92 (75)
Coronary artery disease		34 (8)	11 (7)	11 (9)	12 (10)	0.762 (χ²-test)
History of transient ischemic attack or stroke		73 (18)	30 (20)	16 (12)	27 (22)	0.1052 (χ²-test)
History of antiplatelet medication		168 (42)	61 (41)	58 (45)	49 (40)	0.6903 (χ²-test)
History of anticoagulant medication		92 (23)	32 (21)	30 (23)	30 (25)	0.8129 (χ²-test)

Parameters	Total	Cohorts			Comparisons among cohorts
Parameters	Total	CAA	SRA	CSR
Second generation catheter	Contact aspiration or/ and Stent retriever	Contact aspiration alone	Stent retriever alone	Contact aspiration + Stent retriever
Numbers of patients	401	150	129	122	p-value
SBP (mmHg)	156 (163-146)	157 (162-149)	158 (167-146)	153 (163-142)	0.057
Pre-thrombectomy NIHSS score	18 (21-16)	19 (21-16)	18 (20-17)	18 (20-16)	0.0906
Pre-thrombectomy the modified Rankin scale score	3 (4-2)	3 (4-2)	3 (4-2)	3 (4-2)	0.7863
ASPECTS	7 (8-6)	7 (8-6)	7 (8-6)	7	0.0791

Parameters	Total	Cohorts			Comparisons among cohorts
Parameters	Total	CAA	SRA	CSR
Second generation catheter	Contact aspiration or/ and Stent retriever	Contact aspiration alone	Stent retriever alone	Contact aspiration + Stent retriever
Numbers of patients	401	150	129	122	p-value
Middle cerebral artery M1	260 (66)	90 (60)	85 (66)	85 (70)	0.2041
Middle cerebral artery M2	40 (10)	20 (13)	10 (8)	10 (8)	0.2205
Intracranial internal carotid artery	53 (13)	22 (15)	19 (15)	12 (10)	0.4174
Tandem extracranial	22 (5)	9 (6)	6 (4)	7 (6)	0.876
Tandem intracranial	9 (2)	3 (2)	3(2)	3 (2)	0.9654
Extracranial internal carotid artery	9 (2)	3 (2)	4 (3)	2 (2)	0.7133
Anterior cerebral artery	7 (2)	3 (2)	2 (2)	3 (2)	0.876

Parameters	Total	Cohorts			Comparisons among cohorts
Parameters	Total	CAA	SRA	CSR
Second generation catheter	Contact aspiration or/and Stent retriever	Contact aspiration alone	Stent retriever alone	Contact aspiration + Stent retriever
Numbers of patients	401	150	129	122	p-value
Balloon guide catheter use	359 (90)	132 (88)	112 (86)	115 (94)	0.1166 (χ²-test)
Time from an arterial puncture to clot contact (min)	31 (35-26)	31 (35-26)	31 (34-26.5)	30 (34-25)	0.3218 (Kruskal-Wallis’ test)
Intracranial hemorrhage	33 (8)	12 (8)	11 (9)	10 (8)	0.9872 (χ²-test)
Procedural time (min)	55 (64-49.5)	50 (54-48)	56 (63-52)	71 (82-57)	<0.0001 (Kruskal-Wallis’ test)

Score	Total	Cohorts					Comparison between CAA and SRA cohorts
Score	Total	CSR	CAA		SRA
Second generation catheter	Contact aspiration or/ and Stent retriever	Contact aspiration + Stent retriever	Contact aspiration alone		Stent retriever alone
Numbers of patients	401	122	150	^b b Respect to CSR. 0, No reperfusion; 1, Antegrade reperfusion with limited distal branch filling; 2a, Antegrade reperfusion with less than half distal branch filling; 2b, Antegrade reperfusion with more than half distal branch filling; 2c, Near complete antegrade reperfusion, and 3, Complete antegrade reperfusion. The Chi-Square test with Bonferroni's correction was used for statistical analysis. A p < 0.05 was considered significant. p-value	129	^b b Respect to CSR. 0, No reperfusion; 1, Antegrade reperfusion with limited distal branch filling; 2a, Antegrade reperfusion with less than half distal branch filling; 2b, Antegrade reperfusion with more than half distal branch filling; 2c, Near complete antegrade reperfusion, and 3, Complete antegrade reperfusion. The Chi-Square test with Bonferroni's correction was used for statistical analysis. A p < 0.05 was considered significant. p-value	p-value
0	05 (1)	0 (0)	02 (1)	0.571	02 (2)	0.5025	0.8791
1	35 (9)	5 (4)	16 (11)	0.0734	14 (11)	0.0745	0.9601
2a	43 (11)	7 (6)	19 (13)	0.0844	17 (13)	0.0736	0.8989
2b	51 (13)	9 (7)	23 (15)	0.0663	19 (15)	0.073	0.888
2c	179 (44)	65 (53)	61 (41)	0.0509	53 (41)	0.0992	0.9435
3	89 (22)	36 (30)	29 (19)	0.0697	24 (18)	0.0606	0.9987
≥2c	268 (66)	101 (83)	90 (60)^a a Significantly fewer than that of patients of the CSR cohort.	<0.0001	77 (59)^a a Significantly fewer than that of patients of the CSR cohort.	0.0001	0.958
≥2b	319 (81)	110 (90)	113 (75)^a a Significantly fewer than that of patients of the CSR cohort.	0.0026	96 (74)^a a Significantly fewer than that of patients of the CSR cohort.	0.0011	0.9703

Score	Total	Cohorts			Comparisons among cohorts
Score	Total	CSR	CAA	SRA
Second generation catheter	Contact aspiration or/and Stent retriever	Contact aspiration + Stent retriever	Contact aspiration alone	Stent retriever alone
Numbers of patients	401	122	150	129	p-value
NIHSS score after 1-day of thrombectomy	18 (21-16)	19 (21-16)	18 (20-17)	18 (20-16)	0.1255
The modified Rankin scale score after 6-months of thrombectomy	3 (4-2)	3 (4-2)	3 (4-2)	3 (4-2)	0.7494

Adverse effect	Total	Cohorts					Comparison between CAA and SRA cohorts
Adverse effect	Total	CSR	CAA		SRA
Second generation catheter	Contact aspiration or/and Stent retriever	Contact aspiration + Stent retriever	Contact aspiration alone		Stent retriever alone
Numbers of patients	401	122	150	^b b Respect to CSR. A p < 0.05 was considered significant. p-value	129	^b b Respect to CSR. A p < 0.05 was considered significant. p-value	p-value
Arterial perforation	32 (8)	20 (16)	4 (3)^a a Significantly fewer than that of patients of the CSR cohort.	0.0002	8 (6)^a a Significantly fewer than that of patients of the CSR cohort.	0.0181	0.2481
Embolization in a new territory	32 (8)	15 (12)	7 (5)^a a Significantly fewer than that of patients of the CSR cohort.	0.0383	10 (8)	0.332	0.4104
Arterial dissection	21 (5)	10 (8)	4 (3)	0.0756	7 (5)	0.5431	0.383
Subarachnoid hemorrhage	18 (5)	9 (7)	3 (2)	0.0642	6 (5)	0.5194	0.3629
Spasms	15 (4)	7 (6)	3 (2)	0.1918	5 (4)	0.6928	0.5644
Total	118 (30)	61 (50)	21 (14)^a a Significantly fewer than that of patients of the CSR cohort. ,^c c Significantly fewer than that of patients of the SRA cohort.	<0.0001	36 (28)^a a Significantly fewer than that of patients of the CSR cohort.	0.0005	0.0065

Adverse effect	Total	Cohorts					Comparison between CAA and SRA cohorts
Adverse effect	Total	CSR	CAA		SRA
Second generation catheter	Contact aspiration or/ and Stent retriever	Contact aspiration + Stent retriever	Contact aspiration alone		Stent retriever alone
Numbers of patients	401	122	150	^a a Respect to CSR. p-value	129	^a a Respect to CSR. p-value	p-value
Symptomatic intracerebral hemorrhage	112 (28)	22 (18)	55 (37)^b b Significantly higher than that of the CSR cohort.	0.0011	35 (27)	0.1166	0.1164
Asymptomatic intracerebral hemorrhage	46 (11)	10 (8)	20 (13)	0.25	16 (12)	0.63	0.9585
Intracerebral hemorrhages	158 (39)	32 (26)	75 (50)^b b Significantly higher than that of the CSR cohort.	0.0001	51 (40)^b b Significantly higher than that of the CSR cohort.	0.0353	0.103
Total	316 (78)	64 (52)	150 (100)^b b Significantly higher than that of the CSR cohort. ,^c c Significantly higher than that of the SRA cohort. A p < 0.05 was considered significant.	<0.0001	102 (79)^b b Significantly higher than that of the CSR cohort.	<0.0001	<0.0001
All-cause mortality within 1 year	153 (38)	35 (29)	65 (43)^b b Significantly higher than that of the CSR cohort.	0.018	53 (41)	0.0542	0.7968

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[1] * Corresponding author. E-mail address:xiangzhong.shao@gmail.com (X. Shao).