More Retrieval Attempts are Associated with Poorer Functional Outcome After Unsuccessful Thrombectomy

F Flottmann, N van Horn, M E Maros, H Leischner, M Bechstein, L Meyer, M Sauer, M Deb-Chatterji, A Alegiani, G Thomalla, J Fiehler, C Brekenfeld, GSR investigators, F Flottmann, N van Horn, M E Maros, H Leischner, M Bechstein, L Meyer, M Sauer, M Deb-Chatterji, A Alegiani, G Thomalla, J Fiehler, C Brekenfeld, GSR investigators

Abstract

Purpose: In mechanical thrombectomy, it has been hypothesized that multiple retrieval attempts might the improve reperfusion rate but not the clinical outcome. In order to assess a potential harmful effect of a mechanical thrombectomy on patient outcome, the number of retrieval attempts was analyzed. Only patients with a thrombolysis in cerebral infarction (TICI) score of 0 were reviewed to exclude the impact of eventual successful reperfusion on the mechanical hazardousness of repeated retrievals.

Methods: In this study 6635 patients who underwent endovascular thrombectomy (EVT) for acute large vessel occlusion (LVO) from the prospectively administered multicenter German Stroke Registry were screened. Insufficient reperfusion was defined as no reperfusion (TICI score of 0), whereas a primary outcome was defined as functional independence (modified Rankin scale [mRS] 0-2 at day 90). Propensity score matching and multivariable logistic regressions were then performed to adjust for confounders.

Results: A total of 377 patients (7.8%) had a final TICI score of 0 and were included in the study. After propensity score matching functional independence was found to be significantly more frequent in patients who underwent ≤ 2 retrieval attempts (14%), compared to patients with > 2 retrieval attempts (3.9%, OR 0.29, 95% CI 0.07-0.73, p = 0.009). After adjusting for age, sex, admission NIHSS score, and location of occlusion, more than two retrieval attempts remained significantly associated with lower odds of functional independence at 90 days (OR 0.2, 95% CI 0.07-0.52, p = 0.002).

Conclusion: In patients with failure of reperfusion, more than two retrieval attempts were associated with a worse clinical outcome, therefore indicating a possible harmful effect of multiple retrieval attempts.

Keywords: Endovascular therapy; Ischemic stroke; Prognostic factors; Retrieval attempts; Thrombectomy.

Conflict of interest statement

N. van Horn, H. Leischner, M. Bechstein, L. Meyer, M. Sauer, M. Deb-Chatterji, A. Alegiani and C. Brekenfeld declare that they have no competing interests. J. Fiehler reports unrelated consultancy for Acandis, Boehringer Ingelheim, Cerenovus, Covidien, Evasc Neurovascular, MD-Clinicals, Medtronic, Medina, MicroVention, Penumbra, Route 92 Medical, Stryker, Transverse Medical. Grants/grants pending: MicroVention, Medtronic, Stryker, Cerenovus. CEO Eppdata. F. Flottmann reports unrelated personal fees from Eppdata GmbH outside the submitted work. M.E. Maros reports funding from the German Federal Ministry for Economic Affairs and Energy within the scope of Zentrales Innovationsprogramm Mittelstand (ZF 4514602TS8) outside the submitted work and unrelated consultancy for Siemens Healthineers. G. Thomalla reports unrelated consultancy for Acandis, Stryker; payment for lectures including service on speakers bureaus: Bayer, Bristol-Myers Squibb, Boehringer Ingelheim, Daiichi Sankyo; personal fees from Portola and Biogen outside the submitted work.

© 2021. The Author(s).

Figures

Fig. 1
Fig. 1
Ordinal modified Rankin scale after 90-day follow-up (mRS 90) in patients without reperfusion (TICI 0) after ≤ 2 vs. > 2 retrieval attempts (n = 258, 1:1 propensity-score matched patients). Functional independence (mRS 0–2) was observed in 18/129 patients (14%) with ≤ 2 retrieval attempts, and 5/129 patients (3.9%) with > 2 retrieval attempts

References

    1. Turc G, Bhogal P, Fischer U, Khatri P, Lobotesis K, Mazighi M, Schellinger PD, Toni D, de Vries J, White P, Fiehler J. European Stroke Organisation (ESO) – European Society for Minimally Invasive Neurological Therapy (ESMINT) guidelines on mechanical thrombectomy in acute ischemic stroke. J Neurointerv Surg. 2019;11:535–538. doi: 10.1136/neurintsurg-2018-014568.
    1. Flottmann F, Leischner H, Broocks G, Nawabi J, Bernhardt M, Faizy TD, Deb-Chatterji M, Thomalla G, Fiehler J, Brekenfeld C. Recanalization rate per retrieval attempt in mechanical thrombectomy for acute ischemic stroke. Stroke. 2018;49:2523–2525. doi: 10.1161/strokeaha.118.022737.
    1. Seker F, Pfaff J, Wolf M, Ringleb PA, Nagel S, Schönenberger S, Herweh C, Möhlenbruch MA, Bendszus M, Pham M. Correlation of thrombectomy maneuver count with recanalization success and clinical outcome in patients with ischemic stroke. AJNR Am J Neuroradiol. 2017;38:1368–1371. doi: 10.3174/ajnr.A5212.
    1. García-Tornel Á, Requena M, Rubiera M, Muchada M, Pagola J, Rodriguez-Luna D, Deck M, Juega J, Rodríguez-Villatoro N, Boned S, Olivé-Gadea M, Tomasello A, Hernández D, Molina CA, Ribo M. When to stop. Stroke. 2019;50:1781–1788. doi: 10.1161/strokeaha.119.025088.
    1. Flottmann F, Brekenfeld C, Broocks G, Leischner H, McDonough R, Faizy TD, Deb-Chatterji M, Alegiani A, Thomalla G, Mpotsaris A, Nolte CH, Fiehler J, Maros ME. Good clinical outcome decreases with number of retrieval attempts in stroke thrombectomy: beyond the first-pass effect. Stroke. 2021;52:482–490. doi: 10.1161/strokeaha.120.029830.
    1. 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 C-HJ, Bansal V, Kaushal R, Nanda A, Nogueira RG. First pass effect: a new measure for stroke thrombectomy devices. Stroke. 2018;49:660–666. doi: 10.1161/strokeaha.117.020315.
    1. Nikoubashman O, Dekeyzer S, Riabikin A, Keulers A, Reich A, Mpotsaris A, Wiesmann M. True first-pass effect. Stroke. 2019;50:2140–2146. doi: 10.1161/strokeaha.119.025148.
    1. Settecase F, McCoy DB, Darflinger R, Alexander MD, Cooke DL, Dowd CF, Hetts SW, Higashida RT, Halbach VV, Amans MR. Improving mechanical thrombectomy time metrics in the angiography suite: stroke cart, parallel workflows, and conscious sedation. Interv Neuroradiol. 2018;24:168. doi: 10.1177/1591019917742326.
    1. Kleine JF, Wunderlich S, Zimmer C, Kaesmacher J. Time to redefine success? TICI 3 versus TICI 2b recanalization in middle cerebral artery occlusion treated with thrombectomy. J Neurointerv Surg. 2017;9:117–121. doi: 10.1136/neurintsurg-2015-012218.
    1. García-Tornel Á, Rubiera M, Requena M, Muchada M, Pagola J, Rodriguez-Luna D, Deck M, Juega J, Rodríguez-Villatoro N, Boned S, Olivé-Gadea M, Tomasello A, Piñana C, Hernández D, Molina CA, Ribo M. Sudden recanalization. Stroke. 2020;51:1313–1316. doi: 10.1161/strokeaha.119.028787.
    1. Alegiani AC, Dorn F, Herzberg M, Wollenweber FA, Kellert L, Siebert E, Nolte CH, von Rennenberg R, Hattingen E, Petzold GC, Bode FJ, Pfeilschifter W, Schäfer JH, Wagner M, Röther J, Eckert B, Kraft P, Pham M, Boeckh-Behrens T, Wunderlich S, Bernkopf K, Reich A, Wiesmann M, Mpotsaris A, Psychogios M, Liman J, Maier I, Berrouschot J, Bormann A, Limmroth V, Spreer J, Petersen M, Krause L, Lowens S, Kraemer C, Zweynert S, Lange KS, Thonke S, Kastrup A, Papanagiotou P, Alber B, Braun M, Fiehler J, Gerloff C, Dichgans M, Thomalla G. Systematic evaluation of stroke thrombectomy in clinical practice: the German Stroke Registry endovascular treatment. Int J Stroke. 2019;14:372–380. doi: 10.1177/1747493018806199.
    1. Wollenweber FA, Tiedt S, Alegiani A, Alber B, Bangard C, Berrouschot J, Bode FJ, Boeckh-Behrens T, Bohner G, Bormann A, Braun M, Dorn F, Eckert B, Flottmann F, Hamann GF, Henn K-H, Herzberg M, Kastrup A, Kellert L, Kraemer C, Krause L, Lehm M, Liman J, Lowens S, Mpotsaris A, Papanagiotou P, Petersen M, Petzold GC, Pfeilschifter W, Psychogios M-N, Reich A, von Rennenberg R, Röther J, Schäfer J-H, Siebert E, Siedow A, Solymosi L, Thonke S, Wagner M, Wunderlich S, Zweynert S, Nolte CH, Gerloff C, Thomalla G, Dichgans M, Fiehler J. Functional outcome following stroke thrombectomy in clinical practice. Stroke. 2019;50:2500–2506. doi: 10.1161/strokeaha.119.026005.
    1. Flottmann F, Broocks G, Faizy TD, McDonough R, Watermann L, Deb-Chatterji M, Thomalla G, Herzberg M, Nolte CH, Fiehler J, Leischner H, Brekenfeld C, GSR investigators Factors associated with failure of reperfusion in endovascular therapy for acute ischemic stroke: a multicenter analysis. Clin Neuroradiol. 2020 doi: 10.1007/s00062-020-00880-8.
    1. Brookhart MA, Schneeweiss S, Rothman KJ, Glynn RJ, Avorn J, Stürmer T. Variable selection for propensity score models. Am J Epidemiol. 2006;163:1149–1156. doi: 10.1093/aje/kwj149.
    1. Ho D, Imai K, King G, Stuart EA. MatchIt: nonparametric preprocessing for parametric causal inference. J Stat Softw. 2011;42:1–28. doi: 10.18637/jss.v042.i08.
    1. McDonald JS, Brinjikji W, Rabinstein AA, Cloft HJ, Lanzino G, Kallmes DF. Conscious sedation versus general anaesthesia during mechanical thrombectomy for stroke: a propensity score analysis. J Neurointerv Surg. 2015;7:789–794. doi: 10.1136/neurintsurg-2014-011373.
    1. Goyal M, Menon BK, van Zwam WH, Dippel DWJ, Mitchell PJ, Demchuk AM, Dávalos A, Majoie CBLM, van der Lugt A, de Miquel MA, Donnan GA, Roos YBWEM, Bonafe A, Jahan R, Diener H-C, van den Berg LA, Levy EI, Berkhemer OA, Pereira VM, Rempel J, Millán M, Davis SM, Roy D, Thornton J, Román LS, Ribó M, Beumer D, Stouch B, Brown S, Campbell BCV, van Oostenbrugge RJ, Saver JL, Hill MD, Jovin TG, HERMES collaborators Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016;387:1723–1731. doi: 10.1016/S0140-6736(16)00163-X.
    1. Bath PMW, Lees KR, Schellinger PD, Altman H, Bland M, Hogg C, Howard G, Saver JL. Statistical analysis of the primary outcome in acute stroke trials. Stroke. 2012;43:1171–1178. doi: 10.1161/strokeaha.111.641456.
    1. Bai Y, Pu J, Wang H, Yang D, Hao Y, Xu H, Zhang M, Geng Y, Wan Y, Wang W, Zhang H, Zi W, Liu X, Xu G. Impact of retriever passes on efficacy and safety outcomes of acute ischemic stroke treated with mechanical thrombectomy. Cardiovasc Intervent Radiol. 2018;41:1909–1916. doi: 10.1007/s00270-018-2022-0.
    1. 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 More than three passes of stent retriever is an independent predictor of parenchymal hematoma in acute ischemic stroke. J Neurointerv Surg. 2019;11:625–629. doi: 10.1136/neurintsurg-2018-014380.
    1. Maros ME, Brekenfeld C, Broocks G, Leischner H, McDonough R, Deb-Chatterji M, Alegiani A, Thomalla G, Fiehler J, Flottmann F. Number of retrieval attempts rather than procedure time is associated with risk of symptomatic intracranial hemorrhage. Stroke. 2021;52:1580–1588. doi: 10.1161/strokeaha.120.031242.
    1. Chueh J-Y, Puri AS, Wakhloo AK, Gounis MJ. Risk of distal embolization with stent retriever thrombectomy and ADAPT. J Neurointerv Surg. 2016;8:197–202. doi: 10.1136/neurintsurg-2014-011491.
    1. Schönfeld MH, Kabiri R, Kniep HC, Meyer L, Sedlacik J, Ernst M, Broocks G, Faizy TD, Cheng B, Thomalla G, Fiehler J, Hanning U. Sub-angiographic peripheral emboli in high resolution DWI after endovascular recanalization. J Neurol. 2020;267:1401–1406. doi: 10.1007/s00415-020-09719-1.
    1. Brinjikji W, Pasternak J, Murad MH, Cloft HJ, Welch TL, Kallmes DF, Rabinstein AA. Anesthesia-related outcomes for endovascular stroke revascularization. Stroke. 2017;48:2784–2791. doi: 10.1161/strokeaha.117.017786.
    1. Whitney E, Khan YR, Alastra A, Schiraldi M, Siddiqi J. Contrast extravasation post thrombectomy in patients with acute cerebral stroke: a review and recommendations for future studies. Cureus. 2020;12:e10616. doi: 10.7759/cureus.10616.
    1. Goebel J, Gaida B-J, Wanke I, Kleinschnitz C, Koehrmann M, Forsting M, Moenninghoff C, Radbruch A, Junker A. Is histologic thrombus composition in acute stroke linked to stroke etiology or to interventional parameters? AJNR Am J Neuroradiol. 2020;41:650–657. doi: 10.3174/ajnr.A6467.
    1. Barber PA, Davis SM, Infeld B, Baird AE, Donnan GA, Jolley D, Lichtenstein M. Spontaneous reperfusion after ischemic stroke is associated with improved outcome. Stroke. 1998;29:2522–2528. doi: 10.1161/01.STR.29.12.2522.
    1. Rha J-H, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke. 2007;38:967–973. doi: 10.1161/01.STR.0000258112.14918.24.
    1. Leischner H, Flottmann F, Hanning U, Broocks G, Faizy TD, Deb-Chatterji M, Bernhardt M, Brekenfeld C, Buhk J-H, Gellissen S, Thomalla G, Gerloff C, Fiehler J. Reasons for failed endovascular recanalization attempts in stroke patients. J Neurointerv Surg. 2019;11:439–442. doi: 10.1136/neurintsurg-2018-014060.
    1. Kaesmacher J, Gralla J, Mosimann PJ, Zibold F, Heldner MR, Piechowiak E, Dobrocky T, Arnold M, Fischer U, Mordasini P. Reasons for reperfusion failures in stent-retriever-based thrombectomy: registry analysis and proposal of a classification system. AJNR Am J Neuroradiol. 2018;39:1848–1853. doi: 10.3174/ajnr.A5759.

Source: PubMed

Sponsor e collaboratori

Condizioni mediche

Interventi farmacologici

3
Sottoscrivi