The findings, from an observational analysis, must be confirmed in a randomized trial.
Outcomes using the direct aspiration first-pass technique (ADAPT) edge out those achieved with stent-retriever thrombectomy for the treatment of basilar artery occlusions (BAOs), according to an observational analysis published online January 12, 2018, ahead of print in the Journal of Neurosurgery.
“BAO represents 10 to 20% of strokes with LVO,” lead author Benjamin Gory, MD, PhD (CHRU Nancy, Hôpital Central, Nancy, France), told Neurovascular Exchange in an email. “Endovascular treatment is not easy due to the variability of the distal top of the basilar artery. In fact, some patients don't have a P1 segment, and there is a risk of vessel perforation with the stent-retriever technique.”
The rate of complete reperfusion “is relatively low and must be improved in posterior circulation strokes,” Gory said, calling ADAPT a “promising approach.”
Gory and colleagues prospectively collected data from three comprehensive stroke centers on 100 adult patients with basilar artery occlusions treated with first-line ADAPT (n = 46) or with a primary stent retriever (n = 54). The two groups of patients were similar with regard to baseline characteristics, except for a higher rate of diabetes among those who underwent ADAPT (19.6% vs 5.7%; P = 0.035).
Successful reperfusion, defined as an mTICI 2b-3, was achieved in 79% of patients. The overall rate of favorable outcome was 36.8%, with a 90-day all-cause mortality rate of 44.2%. Successful reperfusion was predictive of favorable outcome (OR 4.57; 95% CI 1.24-16.87; P = 0.023).
There was a nonsignificant trend toward a higher rate of successful reperfusion and a significantly higher rate of complete reperfusion among patients who underwent ADAPT.
Outcomes of ADAPT vs Stent-Retriever Thrombectomy
|
|
Unadjusted OR (95% CI) |
P Value |
|
mTICI 2b-3 |
2.56 (0.90-7.29) |
0.071 |
|
mTICI 3 |
2.59 (1.14-5.86) |
0.021 |
In addition, the rate of periprocedural complications was lower in the ADAPT group (4.3% vs 25.9%; P = 0.003) and the ADAPT procedure was shorter (median of 45 minutes vs 56 minutes; P = 0.05).
Rates of symptomatic intracranial hemorrhage (0.0% vs 4.0%; P = 0.51) and 90-day all-cause mortality (46.7% vs 42.0%; P = 0.65) were similar for both groups.
According to Gory, the results could potentially inform clinical practice. “Indeed, ADAPT may be a good option as a first-line approach in the setting of acute BAO, since rapid and complete reperfusion is the major objective of acute ischemic stroke therapy,” he said.
He acknowledged, however, that the findings are limited by the observational, nonrandomized nature of the study design. “We cannot rule out possible confounding effects by measured or unmeasured variables,” Gory said, recommending that a randomized trial be conducted. “Although our study included one of the largest reported series of stroke patients with BAO treated using [mechanical thrombectomy], no formal study sample size was calculated. Thus, we cannot exclude that some differences may have been overlooked due to a lack of statistical power.”
Source:
Gory B, Mazighi M, Blanc R, et al. Mechanical thrombectomy in basilar artery occlusion: influence of reperfusion on clinical outcome and impact of the first-line strategy (ADAPT vs stent retriever). J Neurosurg. 2018;Epub ahead of print.
Disclosure:
Gory reports no relevant conflicts of interest.
