Reasons for Reperfusion Failures in Stent-Retriever-Based Thrombectomy: Registry Analysis and Proposal of a Classification System

Kaesmacher, Johannes; Gralla, Jan; Mosimann, Pascal J.; Zibold, Felix; Heldner, Mirjam Rachel; Piechowiak, Eike Immo; Dobrocky, Tomas; Arnold, Marcel; Fischer, Urs; Mordasini, Pasquale

doi:10.3174/ajnr.a5759

Cited by 72 publications

(85 citation statements)

References 47 publications

(49 reference statements)

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“…Several retrospective investigations concerning failing thrombectomy were published in recent months [13,14]. In our study, we were able to detect success rates of 83.2% at our center.…”

Section: Discussionsupporting

confidence: 53%

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Why we fail: mechanisms and co-factors of unsuccessful thrombectomy in acute ischemic stroke

et al. 2020

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Purpose Mechanical thrombectomy (MT) is an effective treatment for patients suffering from acute ischemic stroke. However, recanalization fails in about 16.5% of interventions. We report our experience with unsuccessful MT and analyze technical reasons plus patient-related parameters for failure. Methods Five hundred ninety-six patients with acute ischemic stroke in the anterior circulation and intention to perform MT with an aspiration catheter and/or stent retriever were analyzed. Failure was defined as 0, 1, or 2a on the mTICI scale. Patients with failing MT were analyzed for interventional progress and compared to patients with successful intervention, whereby parameters included demographics, medical history, stroke presentation, and treatment.Results One hundred of the 596 (16.8%) interventions failed. In 20 cases, thrombus could not be accessed or passed with the device. Peripheral arterial occlusive disease is common in those patients. In 80 patients, true stent retriever failure occurred. In this group, coagulation disorders are associated with poor results, whereas atrial fibrillation is associated with success.The administration of intravenous thrombolysis and intake of nitric oxide donors are associated with recanalization success. Intervention duration was significantly longer in the failing group. Conclusion In 20% of failing MT, thrombus cannot be reached/passed. Direct carotid puncture or surgical arterial access could be considered in these cases.In 80% of failing interventions, thrombus can be passed with the device, but the occluded vessel cannot be recanalized. Rescue techniques can be an option. Development of new devices and techniques is necessary to improve recanalization rates. Assessment of pre-existing illness could sensitize for occurring complications.

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“…Several retrospective investigations concerning failing thrombectomy were published in recent months [13,14]. In our study, we were able to detect success rates of 83.2% at our center.…”

Section: Discussionsupporting

confidence: 53%

“…A major problem when comparing different studies is the heterogeneous definition of success. In particular, a reperfusion result of mTICI 2a is sometimes regarded as success, sometimes as failure [6,13,14,18,19].…”

Section: Discussionmentioning

confidence: 99%

Why we fail: mechanisms and co-factors of unsuccessful thrombectomy in acute ischemic stroke

et al. 2020

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“…Trial and observational evidence suggests that there is a technical failure rate (TICI 0–2a) of 14–41% whether using a stent retriever and balloon guide catheter, distal aspiration catheter, or a combination of techniques 1–12. As well as intracranial access failure, thrombus extraction failure is responsible in approximately 40% of unsuccessful procedures 16. The natural history of non-recanalized ELVO stroke is poor,35 and equally, those patients suffering procedural failure commonly fair poorly also.…”

Section: Discussionmentioning

confidence: 99%

“…A number of factors impact on technical success, including intracranial access failure and thrombus extraction failure. The latter has been shown to be responsible for nearly half of unsuccessful procedures 16. Multiple variables are likely to govern device–thrombus interaction17 but patient factors associated with thrombectomy failure include fibrin rich18 or calcific emboli,19 intracranial atherosclerotic disease (ICAD),20 and vessel morphology 21…”

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confidence: 99%

A systematic review and meta-analysis of observational evidence for the use of bailout self-expandable stents following failed anterior circulation stroke thrombectomy

Wareham

Flood

Phan³

et al. 2018

J NeuroIntervent Surg

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BackgroundThe crucial role of thrombectomy in the management of emergent large vessel occlusive stroke is not disputed but there is a technical failure rate in a significant minority of patients whose outcomes are often poor. Our objective was to perform a systematic review and meta-analysis to assess the safety and efficacy of permanent self-expandable stent deployment as a bailout procedure in cases of failed anterior circulation thrombectomy.MethodsTwo independent reviewers searched the Pubmed (Medline) database for studies reporting outcomes following failed endovascular thrombectomy with subsequent rescue therapy employing self-expandable stents.ResultsEight studies (one prospective, seven retrospective) originating from Europe, Asia, and America comprising 160 patients met the inclusion criteria. Estimated baseline National Institutes of Health Stroke Scale score was 17.1 (95% CI 15.7 to 18.4). Following failed thrombetcomy and stent deployment, the rate of favorable outcome (modified Rankin Scale score 0–2) was 43% (95% CI 34% to 53%). Pooled mortality was 21% (95% CI 13% to 33%). Successful recanalization (Thrombolysis in Cerebral Infarction (TICI) 2b–3 or Thrombolysis in Myocardial Infarction (TIMI) 2–3) was 71% (95% CI 63% to 77%). Symptomatic intracerebral hemorrhage was seen in 12% (95% CI 7% to 18%). The Solitaire stent (Medtronic) was the most commonly deployed stent following failed thrombectomy attempts (66%; 95% CI 31% to 89%). Pre- or post-stent angioplasty was performed in 39%of patients (95% CI 29% to 48%). Glycoprotein IIb/IIIa inhibitors were used in 89% (95% CI 71% to 97%). 95% of patients received postprocedural antiplatelet therapy.ConclusionA rescue stent procedure seems reasonable as a last resort following failed thrombectomy but currently the level of evidence is limited. Prospective registries may aid in guiding future recommendations.

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“…The median NIHSS score on admission was 16 (14)(15)(16)(17)(18)(19)(20). The median mRS score at day 90 was 6 (4)(5)(6). A good clinical outcome was observed in only 3 patients (5.7%).…”

Section: Early Termination Vs Multiple Reperfusion Attemptsmentioning

confidence: 95%

Factors Associated with Failure of Reperfusion in Endovascular Therapy for Acute Ischemic Stroke

Flottmann

Broocks²,

Faizy

et al. 2020

Clin Neuroradiol

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Aim In acute large vessel occlusions, endovascular therapy (EVT) achieves flow restoration in the majority of cases; however, EVT fails to achieve sufficient reperfusion in a substantial minority of patients. This study aimed to identify predictors of failed reperfusion. Methods In this study 2211 patients from the German Stroke Registry who received EVT for anterior circulation stroke were retrospectively analyzed. Failure of reperfusion was defined as thrombolysis in cerebral infarction (TICI) grades 0/1/2a, and sufficient reperfusion as TICI 2b/3. In 1629 patients with complete datasets, associations between failure of reperfusion and baseline clinical data, comorbidities, location of occlusion, and procedural data were assessed with multiple logistic regression. Results Failure of reperfusion occurred in 371 patients (16.8%) and was associated with the following locations of occlusion: cervical internal carotid artery (ICA, adjusted odds ratio, OR 2.01, 95% confidence interval, CI 1.08-3.69), intracranial ICA without carotid T occlusion (adjusted OR 1.79, 95% CI 1.05-2.98), and M2 segment (adjusted OR 1.86, 95% CI 1.21-2.84). Failed reperfusion was also associated with cervical ICA stenosis (>70% stenosis, adjusted OR 2.90, 95% CI 1.69-4.97), stroke of other determined etiology by TOAST (Trial of ORG 10172 in acute stroke treatment) criteria (e.g. nonatherosclerotic vasculopathies, adjusted OR 2.73, 95% CI 1.36-5.39), and treatment given outside the usual working hours (adjusted OR 1.41, 95% CI 1.07-1.86). Successful reperfusion was associated with higher Alberta stroke program early CT score (ASPECTS) on initial imaging (adjusted OR 0.85, 95% CI 0.79-0.92), treatment with the patient under general anesthesia (adjusted OR 0.72, 95% CI 0.54-0.96), and concomitant ICA stenting in patients with ICA stenosis (adjusted OR 0.20,). The authors Hannes Leischner and Caspar Brekenfeld contributed equally to the manuscript. Electronic supplementary material The online version of this article (https://doi.F. Flottmann et al. ConclusionSeveral factors are associated with failure of reperfusion, most notably occlusions of the proximal ICA and low ASPECTS on admission. Conversely, stent placement in the proximal ICA was associated with reperfusion success.

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Reasons for Reperfusion Failures in Stent-Retriever-Based Thrombectomy: Registry Analysis and Proposal of a Classification System

Cited by 72 publications

References 47 publications

Why we fail: mechanisms and co-factors of unsuccessful thrombectomy in acute ischemic stroke

Why we fail: mechanisms and co-factors of unsuccessful thrombectomy in acute ischemic stroke

A systematic review and meta-analysis of observational evidence for the use of bailout self-expandable stents following failed anterior circulation stroke thrombectomy

Factors Associated with Failure of Reperfusion in Endovascular Therapy for Acute Ischemic Stroke

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