Number of Stent Retriever Passes Associated With Futile Recanalization in Acute Stroke

Abstract

Background and Purpose— Stent retriever (SR) thrombectomy has become the mainstay of treatment of acute intracranial large artery occlusion. However, it is still not much known about the optimal limit of SR attempts for favorable outcome. We evaluated whether a specific number of SR passes for futile recanalization can be determined. Methods— Patients who were treated with a SR as the first endovascular modality for their intracranial large artery occlusion in anterior circulation were retrospectively reviewed. The recanalization rate for each SR pass was calculated. The association between the number of SR passes and a patient’s functional outcome was analyzed. Results— A total of 467 patients were included. Successful recanalization by SR alone was achieved in 82.2% of patients. Recanalization rates got sequentially lower as the number of passes increased, and the recanalization rate achievable by ≥5 passes of the SR was 5.5%. In a multivariable analysis, functional outcomes were more favorable in patients with 1 to 4 passes of the SR than in patients without recanalization (odds ratio [OR] was 8.06 for 1 pass; OR 7.78 for 2 passes; OR 6.10 for 3 passes; OR 6.57 for 4 passes; all P <0.001). However, the functional outcomes of patients with ≥5 passes were not significantly more favorable than found among patients without recanalization (OR 1.70 with 95% CI, 0.42–6.90 for 5 passes, P =0.455; OR 0.33 with 0.02–5.70, P =0.445 for ≥6 passes). Conclusions— The likelihood of successful recanalization got sequentially lower as the number of SR passes increased. Five or more passes of the SR became futile in terms of the recanalization rate and functional outcomes.

Effect of the phenotype of the M1-middle cerebral artery occlusion on the recanalization rates in the ASTER trial

“…In fact, the effect of the recanalization grade should be considered in an integrated assessment that includes the procedure time, the complication rate, and the number of maneuvers. Therefore, it is reasonable to suggest that late recanalizations obtained after several maneuvers, although complete, could explain unfavorable clinical outcomes, as pointed out in previously published papers 20–22. A preliminary study investigated a potential correlation between the occlusion phenotype, defined as regular or irregular, and the recanalization grade according to SR and CA as first-line approach 14.…”

Effects of first pass recanalization on outcomes of contact aspiration thrombectomy

“…The likelihood of a favorable outcome decreased sequentially with an increasing number of stent retriever passes 4. The effect of the number of passes on clinical outcomes may be associated with PRT.…”

“…The effect of the number of passes on clinical outcomes may be associated with PRT. However, PRT may be affected by factors other than the number of device passes, such as access difficulty 4. Additionally, patients with multiple device passes may have more vessel damage than patients with FPR 24.…”

“…Endovascular thrombectomy (EVT) has been a standard treatment for acute stroke due to emergent large vessel occlusion (ELVO) since a number of randomized controlled trials (RCTs) showed the safety and efficacy of EVT 1 2. In addition, faster and higher grade of recanalization is consistently associated with good clinical outcomes 3–6…”

Unfavorable Vascular Anatomy during Endovascular Treatment of Stroke: Challenges and Bailout Strategies

“…10 In addition to prolonging procedure time, multiple device passes may promote arterial endothelial Mont´Alverne, et al Unfavorable Vascular Anatomy in MT injury, potentially reducing clinical efficacy while increasing the occurrence of adverse events. [11][12][13][14] The Highly Effective Reperfusion Using Multiple Endovascular Devices (HERMES) trials pooled analysis of the first five contemporary MT trials reported that the probability of functional independence (mRS 0-2) at 3 months declined from 64.1% with a symptom onset-to-reperfusion time of 180 minutes to 46.1% with a symptom onset-to-reperfusion time of 480 minutes. 15 The procedural time (PT) might represent a significant proportion of the onset-to-reperfusion time in technically challenging scenarios.…”