Multicenter investigation of technical and clinical outcomes after thrombectomy for distal vessel occlusion by frontline technique

Ali M Alawieh; Reda M Chalhoub; Sami Al Kasab; Pascal Jabbour; Marios-Nikos Psychogios; Robert M Starke; Adam S Arthur; Kyle M Fargen; Reade De Leacy; Peter Kan; Travis M Dumont; Ansaar Rai; Roberto Javier Crosa; Ilko Maier; Nitin Goyal; Stacey Q Wolfe; C Michael Cawley; J Mocco; Stavropoula I Tjoumakaris; Brian M Howard; Laurie Dimisko; Hassan Saad; Christopher S Ogilvy; R Webster Crowley; Justin R Mascitelli; Isabel Fragata; Michael R Levitt; Joon-Tae Kim; Min S Park; Benjamin Gory; Adam J Polifka; Charles Matouk; Jonathan A Grossberg; Alejandro M Spiotta; STAR Collaborators

doi:10.1136/jnis-2022-019023

Multicenter investigation of technical and clinical outcomes after thrombectomy for distal vessel occlusion by frontline technique

J Neurointerv Surg. 2023 Sep;15(e1):e93-e101. doi: 10.1136/jnis-2022-019023. Epub 2022 Aug 2.

Authors

Ali M Alawieh¹, Reda M Chalhoub², Sami Al Kasab³, Pascal Jabbour⁴, Marios-Nikos Psychogios⁵, Robert M Starke⁶, Adam S Arthur^{7

8}, Kyle M Fargen⁹, Reade De Leacy¹⁰, Peter Kan¹¹, Travis M Dumont¹², Ansaar Rai¹³, Roberto Javier Crosa¹⁴, Ilko Maier¹⁵, Nitin Goyal¹⁶, Stacey Q Wolfe¹⁷, C Michael Cawley¹, J Mocco¹⁰, Stavropoula I Tjoumakaris¹⁸, Brian M Howard^{1

19}, Laurie Dimisko²⁰, Hassan Saad¹, Christopher S Ogilvy²¹, R Webster Crowley²², Justin R Mascitelli²³, Isabel Fragata²⁴, Michael R Levitt²⁵, Joon-Tae Kim²⁶, Min S Park²⁷, Benjamin Gory²⁸, Adam J Polifka²⁹, Charles Matouk³⁰, Jonathan A Grossberg³¹, Alejandro M Spiotta³²; STAR Collaborators

Affiliations

¹ Department of Neurosurgery, Emory University School of Medicine Atlanta, Atlanta, Georgia, USA.
² Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA.
³ Neurology, Medical University of South Carolina, Charleston, South Carolina, USA.
⁴ Neurological surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
⁵ Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland.
⁶ Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.
⁷ Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA.
⁸ Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA.
⁹ Neurosurgery, Wake Forest University, Winston-Salem, North Carolina, USA.
¹⁰ Neurosurgery, Icahn School of Medicine at Mount Sinai, NEW YORK, New York, USA.
¹¹ Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA.
¹² Department of Surgery, Division of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA.
¹³ Radiology, West Virginia University Hospitals, Morgantown, West Virginia, USA.
¹⁴ Endovascular Neurosurgery, Médica Uruguaya, Montevideo, Montevideo, Uruguay.
¹⁵ Neurology, University Medicine Goettingen, Goettingen, NS, Germany.
¹⁶ Neurology, The University of Tennessee Health Science Center, Memphis, Tennessee, USA.
¹⁷ Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA.
¹⁸ Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.
¹⁹ Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA.
²⁰ Emory Healthcare, Atlanta, Georgia, USA.
²¹ Neurosurgery, BIDMC, Boston, Massachusetts, USA.
²² Neurosurgery, Rush University, Chicago, Illinois, USA.
²³ Department of Neurosurgery, University of Texas Health Science Center, San Antonio, Texas, USA.
²⁴ Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal.
²⁵ Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA.
²⁶ Neurology, Chonnam National University, Gwangju, Jeollanam-do, Korea (the Republic of).
²⁷ Neurosurgery, University of Virginia, Charlottesville, Virginia, USA.
²⁸ Department of Diagnostic and Interventional Neuroradiology, CHRU Nancy, Nancy, Lorraine, France.
²⁹ Department of Neurosurgery, University of Florida, Gainesville, Florida, USA.
³⁰ Neurosurgery, Yale University, New Haven, Connecticut, USA.
³¹ Department of Neurosurgery, Emory University School of Medicine Atlanta, Atlanta, Georgia, USA [email protected] [email protected].
³² Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA [email protected] [email protected].

PMID: 35918129
DOI: 10.1136/jnis-2022-019023

Abstract

Background: Endovascular thrombectomy (EVT) is the standard-of-care for proximal large vessel occlusion (LVO) stroke. Data on technical and clinical outcomes in distal vessel occlusions (DVOs) remain limited.

Methods: This was a retrospective study of patients undergoing EVT for stroke at 32 international centers. Patients were divided into LVOs (internal carotid artery/M1/vertebrobasilar), medium vessel occlusions (M2/A1/P1) and isolated DVOs (M3/M4/A2/A3/P2/P3) and categorized by thrombectomy technique. Primary outcome was a good functional outcome (modified Rankin Scale ≤2) at 90 days. Secondary outcomes included recanalization, procedure-time, thrombectomy attempts, hemorrhage, and mortality. Multivariate logistic regressions were used to evaluate the impact of technical variables. Propensity score matching was used to compare outcome in patients with DVO treated with aspiration versus stent retriever RESULTS: We included 7477 patients including 213 DVOs. Distal location did not independently predict good functional outcome at 90 days compared with proximal (p=0.467). In distal occlusions, successful recanalization was an independent predictor of good outcome (adjusted odds ratio (aOR) 5.11, p<0.05) irrespective of technique. Younger age, bridging therapy, and lower admission National Institutes of Health Stroke Scale (NIHSS) were also predictors of good outcome. Procedure time ≤1 hour or ≤3 thrombectomy attempts were independent predictors of good outcomes in DVOs irrespective of technique (aOR 4.5 and 2.3, respectively, p<0.05). There were no differences in outcomes in a DVO matched cohort of aspiration versus stent retriever. Rates of hemorrhage and good outcome showed an exponential relationship to procedural metrics, and were more dependent on time in the aspiration group and attempts in the stent retriever group.

Conclusions: Outcomes following EVT for DVO are comparable to LVO with similar results between techniques. Techniques may exhibit different futility metrics; stent retriever thrombectomy was influenced by attempts whereas aspiration was more dependent on procedure time.

Keywords: Device; Stroke; Thrombectomy.

Publication types

Multicenter Study

MeSH terms

Arterial Occlusive Diseases* / etiology
Carotid Artery, Internal
Endovascular Procedures* / methods
Humans
Ischemic Stroke* / etiology
Retrospective Studies
Stents / adverse effects
Stroke* / diagnostic imaging
Stroke* / etiology
Stroke* / surgery
Thrombectomy / methods
Treatment Outcome