Given the similar success rates, choosing the most cost-effective option is an ethical approach, the senior author concludes.
The four latest-generation large-bore catheters perform equally well when used for manual aspiration thrombectomy of large-vessel-occlusion stroke, according to a single-center comparative study published online February 7, 2019, ahead of print in the Journal of NeuroInterventional Surgery.
“There is an emerging enthusiasm for stroke thrombectomy in the wake of some very exciting recent trials,” senior author Bradley A. Gross, MD, (University of Pittsburgh, PA), told Neurovascular Exchange. “. . . As such, all of the companies that have a stake in endovascular are making aspiration catheters. Most, if not all, of the prior studies [of these catheters] are single experiences of one catheter. . . . As a practitioner, when there are four modern catheters that all have single-catheter, single-center [studies] saying they are great, [one wants to know]: which one is the best?”
Gross, along with lead author Daniel A. Tonetti, MD, and colleagues, all from the University of Pittsburgh Medical Center, conducted a comparative study of four of the latest-generation large-bore catheters used at their center. They reviewed prospectively collected demographic, angiographic, and clinical data on 180 patients with occlusions of the acute internal carotid artery, middle cerebral artery (M1 segment), or basilar artery treated with manual aspiration thrombectomy on the first pass over a 23-month period. They excluded patients in stent retriever-based randomized trials or registries.
The four catheters that were compared were: ACE68 Reperfusion Catheter (Penumbra), Sofia Plus (MicroVention), AXS Catalyst 6 Distal Access Catheter (CAT6; Stryker Neurovascular), and the 6F 0.072-inch Navien Intracranial Support Catheter (Medtronic).
Overall, first-pass success was achieved in 42% of cases, with a similar rate across catheters. All other outcomes were also similar for the four types of large-bore catheters evaluated. On multivariate analysis, primary aspiration catheter choice was not an independent predictor of a modified Rankin Scale score (mRS) ≤ 2 or mortality at 90 days.
Outcomes by Catheter Type
|
|
Overall (n = 180) |
Sofia Plus (n = 20) |
AXS CAT6 (n = 69) |
6F Navien (n = 25) |
ACE68 (n = 66) |
P Value |
|
First-Pass Recanalization |
41.7% |
50.0% |
44.9% |
40.0% |
36.4% |
0.67 |
|
Final TICI 2b+ |
94.4% |
95.0% |
97.1% |
92.0% |
92.4% |
0.70 |
|
Median Number of Passes |
2.0 |
2.0 |
2.1 |
2.0 |
2.0 |
0.98 |
|
Median Procedure Time, min |
31.7 |
22.0 |
32.0 |
46.0 |
29.0 |
0.15 |
|
90-Day mRS 0-2 |
36.1% |
22.2% |
47.0% |
29.2% |
37.1% |
0.18 |
|
90-Day Mortality |
27.2% |
33.3% |
22.7% |
25.0% |
35.5% |
0.42 |
“Our pretest hypothesis from our own experience was that [all four catheters] are excellent, and when the decision needs to be made of which one to pick, it should be the one that is most cost-efficient to your hospital,” said Gross. “. . . By showing that these are all equivalent, it reinforces that that is an ethical—and probably the best—approach.”
Small Differences in Diameter Not Significant
The fact that the catheters evaluated range in lumen size from 0.060 to 0.072 inches is unlikely to make a significant difference in terms of their clinical utility, said Gross. “The moral of the story is probably that these catheters are all so big that they are equally effective.”
Gross acknowledged that a limitation of the study is the small number of patients treated with some of the catheters.
“It is always possible that with greater numbers, a difference will be found,” he said. In addition, the study was not randomized. “There could be some unconceived biases in terms of selecting one catheter over the other,” he acknowledged, “but we know as practitioners that we typically just take whatever is in stock.”
Sources:
Tonetti DA, Desai SM, Casillo S, et al. Large-bore aspiration catheter selection does not influence reperfusion or outcome after manual aspiration thrombectomy. J NeuroInterv Surg. 2019;Epub ahead of print.
Disclosures:
Gross reports being a consultant to MicroVention.