Number of Passes of Endovascular Therapy for Stroke With a Large Ischemic Core: Secondary Analysis of RESCUE-Japan LIMIT

Abstract

BACKGROUND: The increased risk of intracranial hemorrhage with multiple passes in endovascular therapy (EVT) for large vessel occlusion with a large ischemic core is a concern. We explored the effect of the number of EVT passes on patients in a randomized clinical trial. METHODS: This post hoc study was the secondary analysis of RESCUE-Japan LIMIT, which was a randomized clinical trial comparing EVT and medical treatment alone for large vessel occlusion with large ischemic core. We grouped patients according to the number of passes with successful reperfusion (modified Thrombolysis in Cerebral Infarction score, ≥2b) in 1, 2, and 3 to 7 passes and failed reperfusion (modified Thrombolysis in Cerebral Infarction score, 0–2a) after any pass in the EVT group, and these groups were compared with medical treatment group. The primary outcome was modified Rankin Scale score of 0 to 3 at 90 days. Secondary outcomes were improvement in National Institutes of Health Stroke Scale score of ≥8 at 48 hours, mortality at 90 days, symptomatic intracranial hemorrhage, and any intracranial hemorrhage within 48 hours. RESULTS: The number of patients who received EVT with successful reperfusion after 1, 2, and 3 to 7 passes and failed reperfusion were 44, 23, 19, and 14, respectively, and 102 received medical treatment alone. The adjusted odds ratios (95% CIs) for the primary outcome relative to medical treatment were 5.52 (2.23–14.28) after 1 pass, 6.45 (2.22–19.30) after 2 passes, 1.03 (0.15–4.48) after 3 to 7 passes, and 1.17 (0.16–5.37) if reperfusion failed. The adjusted odds ratios (95% CIs) for any intracranial hemorrhage within 48 hours relative to medical treatment were 1.88 (0.90–3.93) after 1 pass, 5.14 (1.97–14.72) after 2 passes, 3.00 (1.09–8.58) after 3 to 7 passes, and 6.16 (1.87–24.27) if reperfusion failed. CONCLUSIONS: The successful reperfusion within 2 passes was associated with better clinical outcomes. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03702413.

Endovascular therapy in acute ischaemic stroke with large infarction with matched or mismatched clinical-radiological severities: a post-hoc analysis of the ANGEL-ASPECT trial

“…Moreover, there have been secondary analyses of these trials indicating specific subgroups of patients who may or may not benefit from EVT than medical management alone. 11 , 12 …”

The Dilemma of Incomplete Reperfusion After Thrombectomy for Ischemic Stroke

“…1 However, longer duration of the intervention and multiple passes are associated with increased chances of adverse outcomes. 2 Intervention teams will face a dilemma when, after several attempts, the occluding thromboembolus is removed, but a more peripherally located vessel is still occluded. Should they attempt to open this distal arterial branch, with the aim to prevent a persistent perfusion deficit (PPD), at the risk of perforation and other complications associated with a prolonged procedure, or should they wait and hope for delayed reperfusion (DR)?…”