Thrombectomy in basilar artery occlusions: impact of number of passes and futile reperfusion

Abstract

BackgroundThe number of mechanical thrombectomy (MT) passes is strongly associated with angiographic reperfusion as well as clinical outcomes in patients with anterior circulation ischemic stroke. However, these associations have not been analyzed in patients with basilar artery occlusion (BAO). We investigated the influence of the number of MT passes on the degree of reperfusion and clinical outcomes, and compared outcome after ≤3 passes versus >3 passes.MethodsWe used data from the prospective multicentric Endovascular Treatment in Ischemic Stroke (ETIS) Registry at 18 sites in France. Patients with BAO treated with MT were included. The primary outcome was a favorable outcome, defined as a modified Rankin Scale score of 0–3 at 90 days. We fit mixed multiple regression models, with center as a random effect.ResultsWe included 275 patients. Successful recanalization (modified Thrombolysis In Cerebral Infarction (mTICI) 2b-3) was achieved in 88.4%, and 41.8% had a favorable outcome. The odds ratio for favorable outcome with each pass above 1 was 0.41 (95% CI 0.23 to 0.73) and for recanalization (mTICI 2b-3) it was 0.70 (95% CI 0.57 to 0.87). In patients with ≤3 passes, the rate of favorable outcome in recanalized versus non-recanalized patients was 50.5% versus 10.0% (p=0.001), while in those with >3 passes it was 16.7% versus 15.2% (p=0.901).ConclusionsWe found that BAO patients had a significant relationship between the number of MT passes and both recanalization and favorable functional outcome. We further found that the benefit of recanalization in BAO patients was significant only when recanalization was achieved within three passes, encouraging at least three passes before stopping the procedure.

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

“…36 Treatment failure is a significant concern for all EVT methods with failure to achieve recanalization observed in approximately 10%-15% of BAO patients. 16,37 Similar to anterior LVO stroke, the first-pass effect 38,39 is observed in BAO occlusion 40 with the odds of failed recanalization and subsequent poor neurological outcome increasing for every additional pass. The benefits of EVT in BAO may be attenuated when more than 3 passes are required for recanalization.…”

“…The benefits of EVT in BAO may be attenuated when more than 3 passes are required for recanalization. 37 Angioplasty with or without stenting has been demonstrated to prevent unsuccessful EVT in patients after the failure of another technique. 41,42 In 1 retrospective study of patients who underwent EVT for BAO, angioplasty prevented treatment failure in 65 of 188 successfully reperfused patients.…”

Futile Recanalization After Endovascular Treatment in Patients With Acute Basilar Artery Occlusion

“…Moreover, LeCouffe et al 28 The post hoc analysis of Endovascular Treatment in Ischemic Stroke registry has found that stent retriever passes ≤3 were benefit for patients with basilar artery occlusion, but those >3 did not; however, patients included in this study were all within 24 hours from onset to puncture time. 29 In our subgroup analysis, patients were divided into the early time window and the late time window groups according to onset to puncture time. Notably, we found that stent retriever passes were associated with futile recanalization in patients with late time windows, but there was no significant difference between stent retriever passes and futile recanalization in patients with the early time windows.…”

“…[IQR], 63 [54-71] years vs 65 [58-74] years; P = .02), had a higher systolic blood pressure on admission (median[IQR], 146 mm Hg vs 151 [135-169] mm Hg; P = .03), higher neutrophil-to-lymphocyte ratio (NLR) (median [IQR], 6.3 [4.1-10.2] vs 9.2[5.8-13.4]; P < .001), higher baseline NIHSS score (median [IQR], 18[11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27] vs 30[21][22][23][24][25][26][27][28][29][30][31][32][33][34]; P < .001), lower baseline pc-ASPECTS score (median [IQR], 9[8][9][10] vs 8[6][7][8][9]; P < .001), lower PC-CS score (median [IQR], 5[4][5][6] vs 4 [3-6]; P < .001), and longer puncture to recanalization time (PTR) (median [IQR], 87 [62-128] minutes vs 110 [11-155] minutes; P < .001). In addition, the proportions of patients with diabetes mellitus (87 of 328 patients [26.5%] vs 21 of 194 patients [16.0%]; P = .005), coronary heart disease (59 of 328 patients [18.0%] vs 21 of 194 patients [10.8%]; P = .03), and symptomatic intracranial hemorrhage (24 of 328 patients [7.4%] vs 3 of 194 patients [1.5%]; P = .004) in the futile recanalization group were higher than those in the meaningful recanalization group.…”

Predictors of futile recanalization in basilar artery occlusion patients undergoing endovascular treatment: a post hoc analysis of the ATTENTION trial

“…Compared with incomplete reperfusion, complete reperfusion ( 18 ), especially the first pass to achieve complete reperfusion, which is called the first pass effect ( 19 – 21 ), is related to better outcomes. De Havenon et al’s study also showed that the benefit of recanalization in BAO patients was significantly decreased when recanalization was achieved after more than three attempts ( 22 ). However, in our study, we did not observe a correlation between the first-pass effect and clinical outcome, and this phenomenon was also observed in another study ( 6 , 8 ).…”