Stroke

Procedures that go beyond 35 minutes carry higher risks of parenchymal hematoma and poorer outcomes.

Thrombectomy using the direct aspiration first pass technique (ADAPT) results in better outcomes when the procedure achieves recanalization within 35 minutes rather than lasting longer, according to a retrospective study. Beyond that time, interventionalists should reassess their treatment options, its authors advise.

“In a previous study employing older-generation thrombectomy techniques (Penumbra separator and stent retriever), we have shown that the duration of mechanical thrombectomy procedures is an important predictor of patient outcomes,” write investigators led by Alejandro M. Spiotta, MD (Medical University of South Carolina, Charleston). “Faster procedure time was associated with improved patient outcomes, and thrombectomies extending beyond 60 minutes increased complications and cost while diminishing the likelihood of a good outcome.”

The goal of the present study was to determine if the same holds true with the newer devices and techniques being used today, they say.

Spiotta and colleagues conducted a retrospective analysis of outcomes of ADAPT mechanical thrombectomy for acute ischemic stroke, based on procedure time. Their findings were published online May 2, 2017, ahead of print in the Journal of NeuroInterventional Surgery.

Among the 197 patients identified in their database, the overall time for recanalization (from percutaneous groin access to time that the affected vessel was recanalized) was 36.9 ± 34.2 minutes. The time to recanalization was within 35 minutes in 122 (62%) of these patients. In this “early recan” group, the mean time to recanalization was 17.8 minutes. In the remaining 75 patients whose time to recanalization was longer than 35 minutes, the mean time to recanalization was 70 minutes.

Baseline National Institutes of Health Stroke Scale (NIHSS) score was similar for both groups of patients. Nevertheless, the likelihood of a having a good outcome was greater among the early recan patients. In addition, the likelihood of experiencing a postprocedural hemorrhage was greater in the late recan group.

Outcomes of ADAPT Based on Time to Recanalization

Logistic regression analysis revealed that baseline NIHSS score, recanalization time, and the presence of atrial fibrillation were all independent predictors of 90-day outcome.

Reassess After 35 Minutes

Lower baseline NIHSS score was a predictor of good outcome only in the early recan group. The authors speculate that the score is likely a surrogate marker for poor collaterals and note that these finding highlights the importance of rapid recanalization among patients with a low NIHSS score.

“Although the pathophysiological processes underlying the relationship between procedure time and outcome is not fully elucidated,” they write, “the likely hypothesis is that longer procedure times are associated with increased stress on collateral circulation in the penumbra, resulting in a secondary ischemic insult that accelerates the loss of salvageable penumbra.”

The authors conclude that “extending ADAPT thrombectomy procedure times beyond 35 minutes increases the risk of hemorrhage and device cost rates while worsening outcomes. These data suggest that after a time window of 35 minutes during the ADAPT procedure, it might be relevant to reassess the risks and benefits of reattempting failed thrombectomy cases.”

Source:

Alawieh A, Pierce AK, Vargas J, et al. The golden 35 min of stroke intervention with ADAPT: effect of thrombectomy procedural time in acute ischemic stroke on outcome. J NeuroInterv Surg. 2017;Epub ahead of print.

Disclosures:

Spiotta reports receiving consulting fees and/or honoraria from Penumbra, Pulsar Vascular, Microvention, and Stryker.

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