Thrombectomy with combo of contact aspiration and stent retriever has no additional benefit in stroke patients: JAMA

France: Thrombectomy with combined contact aspiration and stent retriever versus stent retriever alone did not significantly improve the reperfusion rate in patients with acute ischemic stroke due to large vessel occlusion, show results from additional benefit trial. However, according to the authors, the trial may have been underpowered to detect smaller differences between groups. The study findings are published in the Journal of the American Medical Association. 

According to the study, an initial thrombectomy technique with a combo of aspiration and stent retriever did not significantly improve the rate of near-total or total reperfusion (eTICI 2c/3) at the end of the endovascular procedure. 

Mechanical thrombectomy is a type of minimally invasive procedure popularly used to treat blockages and ischemic strokes. Mechanical thrombectomy using a stent retriever or contact aspiration is widely used for the treatment of patients with acute ischemic stroke due to anterior circulation large vessel occlusion. However, there is uncertainty regarding the additional benefit of combining contact aspiration with a stent retriever. 

Against the above background, Bertrand Lapergue, the University of Versailles and Saint Quentin en Yvelines, Foch Hospital, Suresnes, France, and colleagues aimed to evaluate whether mechanical thrombectomy for treatment of anterior circulation large vessel occlusion stroke with initial contact aspiration and stent retriever combined results in the better final angiographic outcome than with standard stent retriever alone.

The study was designed as a multicenter randomized, open-label, blinded endpoint evaluation that included 408 patients from October 16, 2017, to May 29, 2018, in 11 French comprehensive stroke centers, with a 12-month outcome follow-up. Patients with a large vessel occlusion in the anterior circulation were included up to 8 hours after symptom onset. The final date of follow-up was June 19, 2019. Patients were randomly assigned (1:1 allocation) to receive initial thrombectomy with contact aspiration and stent retriever combined (205) or stent retriever alone (203).

Out of 408 patients who were randomized, 3 were excluded, and 405 (99.3%) patients (mean age, 73 years; 220 [54%] women and 185 [46%] men) were included in the primary analysis.

The results of the study were

• The rate of eTICI 2c/3 at the end of the endovascular procedure was not significantly different between the 2 thrombectomy groups (64.5% [131 of 203 patients] for contact aspiration and stent retriever combined vs 57.9% [117 of 202 patients] for stent retriever alone.

• Risk difference, 6.6%; adjusted odds ratio [OR], 1.33).

• Of 14 prespecified secondary efficacy endpoints, 12 showed no significant difference. A higher rate of successful reperfusion was achieved in the contact aspiration combined with stent retriever group vs the stent retriever alone group (eTICI 2b50/2c/3, 86.2% vs 72.3%; adjusted OR, 2.54.

• Near-total or total reperfusion (eTICI 2c/3, 59.6% vs 49.5%; adjusted OR, 1.52) after the assigned initial intervention alone.

Dr Lapergue and team concluded that "Among patients with acute ischemic stroke due to large vessel occlusion, an initial thrombectomy technique consisting of contact aspiration and stent retriever combined, compared with stent retriever alone, did not significantly improve the rate of near-total or total reperfusion (eTICI 2c/3) at the end of the endovascular procedure, although the trial may have been underpowered to detect smaller differences between groups."

Reference:

Lapergue B, Blanc R, Costalat V, et al. Effect of Thrombectomy With Combined Contact Aspiration and Stent Retriever vs Stent Retriever Alone on Revascularization in Patients With Acute Ischemic Stroke and Large Vessel Occlusion: The ASTER2 Randomized Clinical Trial. JAMA. 2021;326(12):1158–1169. doi:10.1001/jama.2021.13827