The Source for Neurovascular News and Education

March 28, 2024

 

 

Achievement of TICI 2B-3 was independent of the device, site of occlusion, or use of carotid angioplasty and stenting, while TICI was linked to improved outcomes.

 

Endovascular treatment of primary arterial occlusive lesions using US Food and Drug Administration-approved devices beyond 6 hours after patients were last known well yields a similar rate of successful reperfusion as earlier treatment, according to a fresh look at the DEFUSE 3 trial.

Degree of successful reperfusion (TICI 3 vs TICI 2B) also independently predicts better clinical outcome, researchers showed.

“The time at which patient’s present with a symptomatic large vessel does not preclude the ability to efficiently retrieve clot, so late presentation should not be a contra-indication to thrombectomy,” Ashutosh P. Jadhav, MD (University of Pittsburgh Medical Center, Pittsburgh, PA), told Neurovascular Exchange. “In theory, an ‘older’ clot may be hard to retrieve but this may be offset by the likely presence of good collaterals.”

Earlier this year, results of two clinical trials, DAWN and DEFUSE 3, showed the benefit of endovascular treatment when extended to 16 to 24 hours after last seen well in selected patients. For the paper published online July 9 in Stroke, Michael P. Marks, MD (Stanford Stroke Center, Stanford, CA), and colleagues conducted a secondary analysis of data from the DEFUSE 3 study looking at whether angiographic outcomes of patients assigned to endovascular therapy in the trial correlated with clinical and imaging outcomes.

Baseline imaging revealed that 38% of 92 patients who underwent endovascular treatment had internal carotid artery common carotid artery occlusions, 59% had middle cerebral artery (MCA) M1 occlusions, 2% had MCA M2 occlusions, and 1% had no occlusion.

About three-quarters (76%) of patients achieved successful reperfusion—TICI 2B-3—on final angiogram, while 57% of patients had TICI 2B and 20% had TICI 3 reperfusion after treatment. The rate of successful reperfusion was similar whether the occlusion lesion was the carotid artery or the MCA M1, and it was independent of the device used or adjunctive use of carotid angioplasty and stenting.

Achievement of TICI 2B-3 showed a more favorable distribution of mRS scores at 90 days and therefore less disability compared with TICI 0-2A (OR 2.77; 95% CI 1.17-6.56; P = 0.019). In addition, patients achieving TICI 3 had less disability compared with TICI 2B (P = 0.037).

Rates of good functional outcome increased with increasing TICI score, and TICI score independently predicted good functional outcome. Patients who achieved TICI 3 reperfusion had lower rates of infarct growth at 24 hours compared with either TICI 0-2A (P = 0.0015) or TICI 2B (P = 0.0002).

Finally, the study showed no differences in the rate of successful reperfusion or good functional outcomes in patients treated with aspiration compared with stent retrievers. However, when aspiration was used first, treatment with the alternative therapy was used more frequently.

 

Changing Landscape

Jadhav pointed out to NVX that prior to the results of the DAWN trial there were no randomized data supporting the benefit of intraarterial therapy over medical management in patients presenting with anterior circulation large vessel occlusion beyond 6 hours of symptom onset.

“Previous single-arm series had demonstrated the safety and feasibility of clot retrieval in late time windows,” Jadhav said. “This secondary analysis of the DEFUSE 3 trial confirms that thrombectomy in the late time can lead to comparable rates of recanalization as has been observed in the early time window.”

In addition, the results highlight that both aspiration and stent retrievers lead to high rates of recanalization. Patients undergoing aspiration, however, were more likely to require rescue therapy, he noted, a result that requires further understanding.

Given the positive results seen here with TICI 3 flow, newer techniques or approaches to reach this level of reperfusion are needed, Jadhav said.

 


Sources:

Marks MP, Heit JJ, Lansberg MG, et al. Endovascular treatment in the DEFUSE 3 study. Stroke. 2018;Epub ahead of print.

 

Disclosures:

  • Marks reports having stock in Thrombx Medical.
  • Jadhav reports having no relevant conflicts of interest.