More than five stentriever passes: real benefit or futile recanalization?

Abstract

Background and aims

Clot extraction is associated with favorable outcome in patients with large vessel occlusions (LVO) undergoing endovascular thrombectomy (EVT). However, whether revascularization becomes futile or harmful with an increasing number of passes remains unknown.

Methods

We performed a retrospective analysis of 271 consecutive patients with LVO who underwent stentriever-based EVT as the primary recanalization strategy. Primary outcomes including favorable recanalization, survival, and favorable functional outcomes were compared according to a dichotomized number of stentriever passes utilized with a cutoff of 4.

Results

In the entire cohort, 234 (86%) patients reached favorable recanalization and 46 (17%) patients had ≥ 5 passes (range 5–40). Patients that had ≤ 4 passes had significantly higher rates of favorable recanalization and favorable outcomes and a trend towards lower mortality rates compared with those that had ≥ 5 stentriever passes (92% vs. 61%; p < 0.001, 52% vs. 30%; p = 0.009 and 12% vs. 22%, p = 0.098). Among patients that received ≥ 5 stentriever passes, 30% reached favorable outcomes. Patients who achieved recanalization after ≥ 5 passes had higher rates of favorable outcome in comparison with those who did not (p = 0.009). Among patients that had ≥ 5 stentriever passes favorable recanalization (OR 97.3, 95%CI 2.8–3399.3) and admission NIHSS (OR 0.77, 95%CI 0.60–0.99) remained independent predictors of favorable outcome, whereas the number of passes did not.

Conclusions

A substantial proportion of patients reach favorable outcomes even when ≥ 5 stentriever passes are performed. Treatment choices should be individualized based on personal preferences and expertise as well as on patient and clot-specific characteristics.

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References

  1. 1.

    Goyal M, Menon BK, van Zwam WH et al (2016) Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 387(10029):1723–1731

    Article  Google Scholar 

  2. 2.

    Kharouba R, Gavriliuc P, Yaghmour NE, Gomori JM, Cohen JE, Leker RR (2019) Number of stentriever passes and outcome after thrombectomy in stroke. J Neuroradiol 46(5):327–330

    Article  Google Scholar 

  3. 3.

    Zaidat OO, Castonguay AC, Linfante I, Gupta R, Martin CO, Holloway WE, Mueller-Kronast N, English JD, Dabus G, Malisch TW, Marden FA, Bozorgchami H, Xavier A, Rai AT, Froehler MT, Badruddin A, Nguyen TN, Taqi MA, Abraham MG, Yoo AJ, Janardhan V, Shaltoni H, Novakovic R, Abou-Chebl A, Chen PR, Britz GW, Sun CHJ, Bansal V, Kaushal R, Nanda A, Nogueira RG (2018) First pass effect: a new measure for stroke thrombectomy devices. Stroke 49(3):660–666

    Article  Google Scholar 

  4. 4.

    Baek JH, Kim BM, Heo JH, Nam HS, Kim YD, Park H, Bang OY, Yoo J, Kim DJ, Jeon P, Baik SK, Suh SH, Lee KY, Kwak HS, Roh HG, Lee YJ, Kim SH, Ryu CW, Ihn YK, Kim B, Jeon HJ, Kim JW, Byun JS, Suh S, Park JJ, Lee WJ, Roh J, Shin BS (2018) Number of stent retriever passes associated with futile recanalization in acute stroke. Stroke 49(9):2088–2095

    Article  Google Scholar 

  5. 5.

    Bourcier R, Saleme S, Labreuche J, Mazighi M, Fahed R, Blanc R, Gory B, Kyheng M, Marnat G, Bracard S, Desal H, Consoli A, Piotin M, Lapergue B, ASTER Trial Investigators (2019) More than three passes of stent retriever is an independent predictor of parenchymal hematoma in acute ischemic stroke. J Neurointerv Surg 11(7):625–629

    Article  Google Scholar 

  6. 6.

    Leischner H, Flottmann F, Hanning U, Broocks G, Faizy TD, Deb-Chatterji M, Bernhardt M, Brekenfeld C, Buhk JH, Gellissen S, Thomalla G, Gerloff C, Fiehler J (2019) Reasons for failed endovascular recanalization attempts in stroke patients. J Neurointerv Surg 11(5):439–442

    Article  Google Scholar 

  7. 7.

    Garcia-Tornel A, Requena M, Rubiera M et al (2019) When to stop. Stroke 50(7):1781–1788

    Article  Google Scholar 

  8. 8.

    Jindal G, Miller T, Shivashankar R, Mitchell J, Stern BJ, Yarbrough K, Gandhi D (2014) Relationship of thrombus length to number of stent retrievals, revascularization, and outcomes in acute ischemic stroke. J Vasc Interv Radiol 25(10):1549–1557

    Article  Google Scholar 

  9. 9.

    Leker RR, Eichel R, Keigler G, Gomori JM, Cohen JE (2015) Occlusion site does not impact outcome in patients with carotid stroke undergoing endovascular reperfusion. Int J Stroke 10(4):560–564

    Article  Google Scholar 

  10. 10.

    Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, Marsh EE 3rd (1993) Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 24(1):35–41

    Article  Google Scholar 

  11. 11.

    Barber PA, Demchuk AM, Zhang J, Buchan AM (2000) Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS Study Group. Alberta Stroke Programme Early CT Score. Lancet 355(9216):1670–1674

    CAS  Article  Google Scholar 

  12. 12.

    Dehkharghani S, Bammer R, Straka M, Bowen M, Allen JW, Rangaraju S, Kang J, Gleason T, Brasher C, Nahab F (2016) Performance of CT ASPECTS and collateral score in risk stratification: can target perfusion profiles be predicted without perfusion imaging? AJNR Am J Neuroradiol 37(8):1399–1404

    CAS  Article  Google Scholar 

  13. 13.

    Higashida R, Furlan A, Roberts H, Tomsick T, Connors B, Barr J, Dillon W, Warach S, Broderick J, Tilley B, Sacks D, Technology Assessment Committees of the American Society of Interventional and Therapeutic Neuroradiology and the Society of Interventional Radiology (2003) Trial design and reporting standards for intraarterial cerebral thrombolysis for acute ischemic stroke. J Vasc Interv Radiol 14(9 Pt 2):S493–S494

    PubMed  Google Scholar 

  14. 14.

    Rankin J (1957) Cerebral vascular accidents in patients over the age of 60. II. Prognosis. Scott Med J 2(5):200–215

    CAS  Article  Google Scholar 

  15. 15.

    Bourcier R, Alexandre PL, Eugene F et al (2017) Is bridging therapy still required in stroke due to carotid artery terminus occlusions? J Neurointerv Surg 10(7):625–628

    Article  Google Scholar 

  16. 16.

    Angermaier A, Michel P, Khaw AV, Kirsch M, Kessler C, Langner S (2016) Intravenous thrombolysis and passes of thrombectomy as predictors for endovascular revascularization in ischemic stroke. J Stroke Cerebrovasc Dis 25(10):2488–2495

    Article  Google Scholar 

  17. 17.

    Hassan AE, Kotta H, Shariff U, Preston L, Tekle W, Qureshi A (2019) There is no association between the number of stent retriever passes and the incidence of hemorrhagic transformation for patients undergoing mechanical thrombectomy. Front Neurol 10:818

    Article  Google Scholar 

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Acknowledgements and funding

This study was supported in part by the Peritz and Chantal Scheinberg Cerebrovascular Research Fund.

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All authors hereby declare they have no disclosures to make

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We declare that we have no conflict of interest.

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Correspondence to Ronen R. Leker.

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Filioglo, A., Cohen, J.E., Honig, A. et al. More than five stentriever passes: real benefit or futile recanalization?. Neuroradiology (2020). https://doi.org/10.1007/s00234-020-02469-x

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Keywords

  • Stroke
  • Endovascular
  • Thrombectomy
  • Stentriever