First pass effect with contact aspiration and stent retrievers in the Aspiration versus Stent Retriever (ASTER) trial

Célina Ducroux, Michel Piotin, Benjamin Gory, Julien Labreuche, Raphael Blanc, Malek Ben Maacha, Bertrand Lapergue, Robert Fahed, ASTER Trial investigators, Hocine Redjem, Gabriele Ciccio, Stanislas Smajda, Mikael Mazighi, Jean-Philippe Desilles, Simon Escalard, Georges Rodesch, Arturo Consoli, Oguzhan Coskun, Federico Di Maria, Frédéric Bourdain, Jean Pierre Decroix, Adrien Wang, Maya Tchikviladze, Serge Evrard, Francis Turjman, Benjamin Gory, Paul Emile Labeyrie, Roberto Riva, Charbel Mounayer, Suzanna Saleme, Vincent Costalat, Alain Bonafe, Omer Eker, Grégory Gascou, Cyril Dargazanli, Serge Bracard, Romain Tonnelet, Anne Laure Derelle, René Anxionnat, Hubert Desal, Romain Bourcier, Benjamin Daumas-Duport, Jérome Berge, Xavier Barreau, Gauthier Marnat, Lynda Djemmane, Julien Labreuche, Alain Duhamel, Célina Ducroux, Michel Piotin, Benjamin Gory, Julien Labreuche, Raphael Blanc, Malek Ben Maacha, Bertrand Lapergue, Robert Fahed, ASTER Trial investigators, Hocine Redjem, Gabriele Ciccio, Stanislas Smajda, Mikael Mazighi, Jean-Philippe Desilles, Simon Escalard, Georges Rodesch, Arturo Consoli, Oguzhan Coskun, Federico Di Maria, Frédéric Bourdain, Jean Pierre Decroix, Adrien Wang, Maya Tchikviladze, Serge Evrard, Francis Turjman, Benjamin Gory, Paul Emile Labeyrie, Roberto Riva, Charbel Mounayer, Suzanna Saleme, Vincent Costalat, Alain Bonafe, Omer Eker, Grégory Gascou, Cyril Dargazanli, Serge Bracard, Romain Tonnelet, Anne Laure Derelle, René Anxionnat, Hubert Desal, Romain Bourcier, Benjamin Daumas-Duport, Jérome Berge, Xavier Barreau, Gauthier Marnat, Lynda Djemmane, Julien Labreuche, Alain Duhamel

Abstract

Background: The 'first pass effect' (FPE), which was originally described with stent retrievers, designates a (near-)complete revascularization obtained after a single device pass with no rescue therapy, and is associated with improved clinical outcome and decreased mortality.

Objective: We report the rate and benefits of FPE in the Aspiration versus Stent Retriever (ASTER) trial.

Materials and methods: ASTER is a randomized trial comparing angiographic revascularization with the stent retriever (SR) and contact aspiration (CA) thrombectomy techniques, assessed by an external core laboratory using the modified Thrombolysis in Cerebral Infarction (mTICI) scale. Rates of FPE (defined by mTICI 2c/3 after a single pass with no rescue therapy) were compared between patients treated with SR and CA techniques. Outcomes were compared between FPE-SR and FPE-CA patients, and between FPE and non-FPE patients.

Results: FPE was achieved in 97/336 patients (28.9%), with no significant difference between SR and CA (respectively 53/169 patients (31.3%) vs 44/167 patients (26.3%), adjusted RR for CA versus SR 0.84, 95% CI 0.54 to 1.31; p=0.44). After prespecified adjustment for allocated arm and randomization stratification factors, FPE in patients was associated with a significantly improved clinical outcome and a decreased mortality, and a significantly lower rate of hemorrhagic transformation and procedural complications than in non-FPE patients.

Conclusion: In the ASTER trial, similar rates of FPE were achieved with SR and CA, and FPE was associated with a significantly improved outcome. New techniques and devices to improve the rate of FPE are warranted.

Trial registration number: Unique identifier: NCT02523261.

Keywords: recanalization; stroke; thrombectomy.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
Study flow chart. CA, contact aspiration; SR, stent retriever
Figure 2
Figure 2
Distribution of modified Rankin Scale scores at 90 Days according to first pass effect in the ASTER trial. cOR was calculated for one-point improvement in the modified Rankin Scale score using a mixed ordinal logistic regression model including center as random effect and first-line mechanical thrombectomy strategy and intravenous recombinant tissue plasminogen activator as fixed effects. cOR, common odds ratio; FPE, first pass effect.

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Source: PubMed

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