Current status of aspiration thrombectomy for acute stroke patients in China: data from ANGEL-ACT Registry

Xu Tong, Yilong Wang, Clayton T Bauer, Baixue Jia, Xuelei Zhang, Xiaochuan Huo, Gang Luo, Anxin Wang, Ning Ma, Feng Gao, Dapeng Mo, Ligang Song, Xuan Sun, Lian Liu, Yiming Deng, Xiaoqing Li, Bo Wang, Gaoting Ma, Yongjun Wang, Zeguang Ren, Zhongrong Miao, Xu Tong, Yilong Wang, Clayton T Bauer, Baixue Jia, Xuelei Zhang, Xiaochuan Huo, Gang Luo, Anxin Wang, Ning Ma, Feng Gao, Dapeng Mo, Ligang Song, Xuan Sun, Lian Liu, Yiming Deng, Xiaoqing Li, Bo Wang, Gaoting Ma, Yongjun Wang, Zeguang Ren, Zhongrong Miao

Abstract

Background and aims: Although noninferior to stent retriever (SR) as first-line approach for endovascular treatment (EVT) of acute large vessel occlusion (LVO) stroke, little is known about the current status of direct aspiration (DA) as first-line thrombectomy in China. This analysis of a prospective, nationwide registry (ANGEL-ACT) aimed to investigate the prevalence and comparative effectiveness of DA-first thrombectomy in a real-world practice in China.

Methods: All patients receiving thrombectomy were screened from a prospective cohort of LVO patients undergoing EVT at 111 hospitals in China between November 2017 and March 2019, and divided into two groups based upon which type of thrombectomy was attempted first ("DA-first" and "SR-first"). The following outcome measures were compared using logistic regression models with adjustment: successful recanalization after first-device alone and all procedures, use of rescue treatment, intracranial hemorrhage (ICH) within 24 h, and modified Rankin Scale (mRS) score at 90 days.

Results: A total of 1225 patients, 102 (8.3%) in DA-first group and 1123 (91.7%) in SR-first group, were included. Patients receiving DA-first had less often successful recanalization after first-device alone [30.4 versus 66.4%; odds ratio (OR) = 0.23, 95% confidence interval (CI) = 0.15-0.37], more frequent rescue treatment (62.8 versus 27.0%; OR = 4.55, 95% CI = 2.92-7.08) and ICH (35.4 versus 22.1%; OR = 1.78, 95% CI = 1.12-2.83) than those receiving SR-first; however, no significant difference was found in successful recanalization after all procedures (84.3 versus 90.3%; p = 0.18) and 90-day mRS (median: 3 versus 3 points; p = 0.90) between both groups.

Conclusion: This real-world registry suggested that DA-first thrombectomy for acute stroke patients lagged behind in China during the study period. Far fewer DA-first than SR-first thrombectomies were performed, and DA-first was associated with lower first-device recanalization, more frequently requiring rescue treatment, and increased ICH risk.

Clinical trial registration: ClinicalTrials.gov, NCT03370939.

Keywords: China; aspiration; stent retriever; stroke; thrombectomy.

Conflict of interest statement

Conflict of interest statement: The authors declare that there is no conflict of interest.

© The Author(s), 2021.

Figures

Figure 1.
Figure 1.
Flow chart of patient selection. DA, direct aspiration; SR, stent retriever.
Figure 2.
Figure 2.
Treatment effects on the primary outcome according to exploratory subgroups. aAdjusted for the propensity score. bA total of 128 patients with other intracranial artery occlusions were excluded. cA total of 139 patients with undetermined ICAD were excluded. CI, confidence interval; DA, direct aspiration; ICAD, intracranial atherosclerotic disease; OR, odds ratio; SR, stent retriever; TOAST, Trial of ORG 10172 in Acute Stroke Treatment.

References

    1. Turc G, Kim AS. First-line use of contact aspiration or stent retriever thrombectomy for large vessel occlusion stroke. Stroke 2019; 50: 2634–2636.
    1. Lapergue B, Blanc R, Gory B, et al. Effect of endovascular contact aspiration vs stent retriever on revascularization in patients with acute ischemic stroke and large vessel occlusion: the ASTER randomized clinical trial. JAMA 2017; 318: 443–452.
    1. Turk AS, III, Siddiqui A, Fifi JT, et al. Aspiration thrombectomy versus stent retriever thrombectomy as first-line approach for large vessel occlusion (COMPASS): a multicentre, randomised, open label, blinded outcome, non-inferiority trial. Lancet 2019; 393: 998–1008.
    1. Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2019; 50: e344–e418.
    1. Bernsen M, Goldhoorn RB, van Oostenbrugge RJ, et al. Equal performance of aspiration and stent retriever thrombectomy in daily stroke treatment. J Neurointerv Surg 2019; 11: 631–636.
    1. Martini M, Mocco J, Turk A, et al. ‘Real-world’ comparison of first-line direct aspiration and stent retriever mechanical thrombectomy for the treatment of acute ischemic stroke in the anterior circulation: a multicenter international retrospective study. J Neurointerv Surg 2019; 11: 957–963.
    1. Kang DH, Kim JW, Kim BM, et al. Need for rescue treatment and its implication: stent retriever versus contact aspiration thrombectomy. J Neurointerv Surg 2019; 11: 979–983.
    1. Peschillo S, Diana F, Berge J, et al. A comparison of acute vascular damage caused by ADAPT versus a stent retriever device after thrombectomy in acute ischemic stroke: a histological and ultrastructural study in an animal model. J Neurointerv Surg 2017; 9: 743–749.
    1. Turk AS, Turner R, Spiotta A, et al. Comparison of endovascular treatment approaches for acute ischemic stroke: cost effectiveness, technical success, and clinical outcomes. J Neurointerv Surg 2015; 7: 666–670.
    1. Barber PA, Demchuk AM, Zhang J, et al. 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 2000; 355: 1670–1674.
    1. Puetz V, Sylaja PN, Coutts SB, et al. Extent of hypoattenuation on CT angiography source images predicts functional outcome in patients with basilar artery occlusion. Stroke 2008; 39: 2485–2490.
    1. Jia B, Feng L, Liebeskind DS, et al. Mechanical thrombectomy and rescue therapy for intracranial large artery occlusion with underlying atherosclerosis. J Neurointerv Surg 2018; 10: 746–750.
    1. Zaidat OO, Yoo AJ, Khatri P, et al. Recommendations on angiographic revascularization grading standards for acute ischemic stroke: a consensus statement. Stroke 2013; 44: 2650–2663.
    1. von Kummer R, Broderick JP, Campbell BC, et al. The Heidelberg bleeding classification: classification of bleeding events after ischemic stroke and reperfusion therapy. Stroke 2015; 46: 2981–2986.
    1. Adams HP, Bendixen BH, Kappelle LJ, et al. 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 1993; 24: 35–41.
    1. Goyal M, Menon BK, van Zwam WH, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 2016; 387: 1723–1731.
    1. Powers WJ, Derdeyn CP, Biller J, et al. 2015. American Heart Association/American Stroke Association focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2015; 46: 3020–3035.
    1. Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke 2007; 38: 967–973.
    1. Kim BM. Causes and solutions of endovascular treatment failure. J Stroke 2017; 19: 131–142.
    1. Banerjee G, Stone SP, Werring DJ. Posterior circulation ischaemic stroke. BMJ 2018; 361: k1185.
    1. Alonso de, Leciñana M, Kawiorski MM, Ximénez-Carrillo Á, et al. Mechanical thrombectomy for basilar artery thrombosis: a comparison of outcomes with anterior circulation occlusions. J Neurointerv Surg 2017; 9: 1173–1178.
    1. Weber R, Minnerup J, Nordmeyer H, et al. Thrombectomy in posterior circulation stroke: differences in procedures and outcome compared to anterior circulation stroke in the prospective multicentre REVASK registry. Eur J Neurol 2019; 26: 299–305.
    1. Bourcier R, Mazighi M, Labreuche J, et al. Susceptibility vessel sign in the ASTER trial: higher recanalization rate and more favourable clinical outcome after first line stent retriever compared to contact aspiration. J Stroke 2018; 20: 268–276.
    1. Ye G, Cao R, Lu J, et al. Association between thrombus density and reperfusion outcomes using different thrombectomy strategies: a single-center study and meta-analysis. Front Neurol 2019; 10: 843.
    1. Kim SK, Yoon W, Kim TS, et al. Histologic analysis of retrieved clots in acute ischemic stroke: correlation with stroke etiology and gradient-echo MRI. AJNR Am J Neuroradiol 2015; 36: 1756–1762.
    1. Brinjikji W, Duffy S, Burrows A, et al. Correlation of imaging and histopathology of thrombi in acute ischemic stroke with etiology and outcome: a systematic review. J Neurointerv Surg 2017; 9: 529–534.

Source: PubMed

スポンサーと協力者

医学的状態

薬物療法

3
購読する