Basilar Artery Occlusion Thrombectomy Technique: An International Survey of Practice Patterns

Abstract

BACKGROUND Two recent trials demonstrated a benefit for endovascular therapy (EVT) in the treatment of basilar artery occlusion (BAO). In light of the expected increase in the use of EVT for BAO, we sought to understand the technique preferences of neurointerventionalists performing EVT for BAO. METHODS We conducted an international online survey of physician opinions on the use of EVT in BAO between January and March 2022. The survey was distributed through stroke and neurointerventional organizations. Survey questions examined selection of patients for the procedure and the techniques currently used for EVT in BAO. Responses from neurointerventionalists were analyzed. RESULTS More than 3000 participants were invited yielding 1245 respondents, of whom 543 were classified as neurointerventionalists across 52 countries and included in this analysis. Most neurointerventionalists would proceed to EVT for occlusions of the V4 segment, the basilar artery, or the posterior cerebral artery, without regard for prior intravenous thrombolysis. For BAO of embolic etiology, aspiration only thrombectomy was the preferred method of 50.3% of neurointerventionalists. For BAO of intracranial atherosclerotic disease etiology, combined stent retriever and aspiration thrombectomy was the preferred method of 40.5% of neurointerventionalists. The majority of neurointerventionalists (88.0%) would proceed to stenting after 3 or fewer failed passes for patients with BAO of intracranial atherosclerotic disease etiology. In patients undergoing stenting, aspirin and clopidogrel was the most common antiplatelet regime (52.4%). CONCLUSIONS Among the surveyed neurointerventionalists, the most common techniques for EVT of patients with BAO were contact aspiration or combined stent retriever with aspiration thrombectomy. For patients with BAO due to intracranial atherosclerotic disease, the majority of neurointerventionalists were willing to stent and do so most often after 3 or fewer failed passes and with the use of dual antiplatelet medications. Further study is needed to determine the optimal technique for EVT of BAO with or without intracranial atherosclerotic disease. Key Words

First pass effect of mechanical thrombectomy for acute vertebrobasilar artery occlusion: data from the ANGEL-ACT registry

“…Additionally, the etiology of basilar artery occlusion (BAO) may influence the neurointerventionalist's selection of the first line MT technique. Recently, an international survey on BAO thrombectomy techniques reported that neurointerventionalists preferred CA as the first line MT strategy for embolic etiology, whereas SR plus CA was preferred as the first line MT strategy for ICAD etiology 25. Because identifying BAO caused by ICAD before EVT is a challenge, most neurointerventionalists perform MT 1–3 times before rescue balloon angioplasty or stenting to prevent re-occlusion, which is similar to our experience 25.…”

Endovascular versus Medical Management of Acute Basilar Artery Occlusion: A Systematic Review and Meta-Analysis of the Randomized Controlled Trials

“…The generalizability of these findings need to be considered as three of the trials were completed in China and Asians are known to have high rates of ICAD [ 40 ]. However, as mentioned, prior studies showed that patients with ICAD who received rescue treatment achieved similar rates of successful recanalization and favorable outcome, compared to patients without ICAD [ 16 , 39 , 41 ]. Data on the percentage of ICAD were not available in the BAOCHE trial and we were unable to compare outcomes of patients with ICAD and without ICAD in this meta-analysis.…”

“…40 However, as mentioned, prior studies showed that patients with ICAD who received rescue treatment achieved similar rates of successful recanalization and favorable outcome, compared to patients without ICAD. 16,39,41 Data on the percentage of ICAD were not available in the BAOCHE trial and we were unable to compare outcomes of patients with ICAD and without ICAD in this meta-analysis. Further subgroup data of treatment effect by sex, ethnicity, IVT, time window of treatment, pc-ASPECTS, and ICAD would be of interest in a patient-level meta-analysis.…”

Basilar artery occlusion management: Specialist perspectives from an international survey

“…The reader is referred to the primary report of the After the BEST of BASICS (ABBA) Survey investigators for detailed survey methodology. 11,13 Briefly, the survey was conducted between…”