Futile complete recanalization: patients characteristics and its time course

Abstract

As the goal of mechanical thrombectomy is shifting toward mTICI-3 rather than mTICI-2b, we sought to clarify the limitation of the effect of mTICI-3. A post-hoc analysis of a registry of large-vessel occlusion stroke from 46 centers was conducted. Among 2,420 registered patients, 725 patients with anterior circulation occlusion who achieved successful reperfusion were analyzed. We compared outcomes between patients with mTICI-3 and mTICI-2b, and investigated how the effect of mTICI-3 changed according to baseline characteristics and time course. The proportion of patients with favorable outcomes (mRS 0-2 at day 90) was higher among patients with mTICI-3 compared to those with mTICI-2b (adjusted OR, 2.10; 95% CI, 1.49-2.97). There was no heterogeneity in the effect of mTICI-3 with respect to age, neurological deficit, alteplase use, occluded vessels, or infarct size. mTICI-3 was associated with favorable outcomes when the puncture-to-reperfusion time was <80 minutes (adjusted OR, 2.28; 95% CI, 1.52-3.41), but not when the puncture-to-reperfusion time was ≥80 minutes. A significant heterogeneity was found in the effect of mTICI-3 reperfusion across the puncture-toreperfusion time subgroups (p for interaction = 0.025). Until when operators should continue the procedure after mTICI-2b has been achieved, needs to be studied.

Machine learning to predict futile recanalization of large vessel occlusion before and after endovascular thrombectomy

“…Although the technical expertise of the operator is important, the increased number of passages may be due to some uncontrollable factors such as increased clot fragmentation with distal embolization or accumulated endothelial damage (27). In addition, the impact of the groin to recanalization and the number of passages on futile recanalization supports the conclusion of previous studies that an angiographic recanalization does not necessarily lead to functional independence if it was achieved at the expense of longer procedural times (28).…”

Factors associated with early reperfusion improvement after intra-arterial fibrinolytics as rescue for mechanical thrombectomy

“…28,29 On the other hand, recent analyses from the RESCUE-Japan 2 Registry suggested that mTICI 3 versus mTICI 2b was associated with favorable outcomes only when puncture to reperfusion time was <80 min. 30 In this analysis, the association of EARI with higher rates of functional independence was relatively homogenous across subgroups (including different time intervals from symptom onset to IAF) with one exception. Although not significant on interaction analyses, there was a tendency of the association being attenuated in patients with moderate to severe ischemia as opposed to those without or only minor ischemic changes on admission.…”

Successful reperfusion in relation to the number of passes: comparing outcomes of first pass expanded Treatment In Cerebral Ischemia (eTICI) 2B with multiple-pass eTICI 3

“…In general, increasing the number of passes and increasing the treatment time to achieve successful reperfusion were shown to lead to worse functional outcome 1 6–12. This trend to worse functional outcome was also seen when excellent or complete reperfusion (eTICI 2C/3) was reached 6 13. However, in patients with complete reperfusion a decline in the odds of post-stroke functional independence was only seen if more than three passes were necessary to achieve this result, while in patients with a final eTICI score of 2B this decline had already occurred if more than two passes were necessary 6.…”

“…However, in patients with complete reperfusion a decline in the odds of post-stroke functional independence was only seen if more than three passes were necessary to achieve this result, while in patients with a final eTICI score of 2B this decline had already occurred if more than two passes were necessary 6. Prolonged procedure time, greater infarct volumes, increased clot fragmentation with distal embolization, and accumulated endothelial damage after multiple passes are possible explanations for this negative effect of an increasing number of passes on functional outcome 13–16…”

“…As such, too many additional attempts could ultimately outweigh the benefit of an improved reperfusion grade. Previous studies have indeed found that the positive effect on functional outcome of reaching excellent/complete reperfusion over good reperfusion diminishes with an increasing number of passes and prolonged procedure time 6 13. Greater infarct volumes, increased clot fragmentation with distal embolization, and accumulated endothelial damage after multiple passes are possible explanations for this negative association between increasing number of passes and functional outcome 13–16…”