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Prognostic Value of Thrombus Volume and the Interaction With First-Line Endovascular Treatment Device Choice
abstract
This abstract is available on the publisher's site.
Access this abstract nowBACKGROUND
A larger thrombus in patients with acute ischemic stroke might result in more complex endovascular treatment procedures, resulting in poorer patient outcomes. Current evidence on thrombus volume and length related to procedural and functional outcomes remains contradicting. This study aimed to assess the prognostic value of thrombus volume and thrombus length and whether this relationship differs between first-line stent retrievers and aspiration devices for endovascular treatment.
METHODS
In this multicenter retrospective cohort study, 670 of 3279 patients from the MR CLEAN Registry (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) for endovascularly treated large vessel occlusions were included. Thrombus volume (0.1 mL) and length (0.1 mm) based on manual segmentations and measurements were related to reperfusion grade (expanded Treatment in Cerebral Infarction score) after endovascular treatment, the number of retrieval attempts, symptomatic intracranial hemorrhage, and a shift for functional outcome at 90 days measured with the reverted ordinal modified Rankin Scale (odds ratio >1 implies a favorable outcome). Univariable and multivariable linear and logistic regression were used to report common odds ratios (cORs)/adjusted cOR and regression coefficients (B/aB) with 95% CIs. Furthermore, a multiplicative interaction term was used to analyze the relationship between first-line device choice, stent retrievers versus aspiration device, thrombus volume, and outcomes.
RESULTS
Thrombus volume was associated with functional outcome (adjusted cOR, 0.83 [95% CI, 0.71-0.97]) and number of retrieval attempts (aB, 0.16 [95% CI, 0.16-0.28]) but not with the other outcome measures. Thrombus length was only associated with functional independence (adjusted cOR, 0.45 [95% CI, 0.24-0.85]). Patients with more voluminous thrombi had worse functional outcomes if endovascular treatment was based on first-line stent retrievers (interaction cOR, 0.67 [95% CI, 0.50-0.89]; P=0.005; adjusted cOR, 0.74 [95% CI, 0.55-1.0]; P=0.04).
CONCLUSIONS
In this study, patients with a more voluminous thrombus required more endovascular thrombus retrieval attempts and had a worse functional outcome. Patients with a lengthier thrombus were less likely to achieve functional independence at 90 days. For more voluminous thrombi, first-line stent retrieval compared with first-line aspiration might be associated with worse functional outcome.
Additional Info
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Prognostic Value of Thrombus Volume and Interaction With First-Line Endovascular Treatment Device Choice
Stroke 2023 Mar 13;[EPub Ahead of Print], H van Voorst, AAE Bruggeman, J Andriessen, JW Hoving, PR Konduri, W Yang, M Kappelhof, N Arrarte Terreros, YBWEM Roos, WH van Zwam, A van der Lugt, A van der Hoorn, J Boiten, S Roosendaal, S Jenniskens, MWA Caan, HA Marquering, BJ Emmer, CBLM MajoieFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Clot composition, clot pathophysiology, anatomical access, endovascular device, pharmacological adjuncts, and procedural technique are factors that can impact the clinician’s ability to successfully remove a large-vessel occlusion thrombus in patients with acute ischemic stroke.1–9
In the March 2023 issue of Stroke, the results of a study that used data from the MR CLEAN registry to assess the effect of thrombus volume and length on patient outcomes, and as stratified by the first-line device strategy, were published. The study included patients from 2014 to 2017. Thrombus volume and length were measured on thin slices with three-dimensional software with co-registration by CT and CTA images. The authors found that patients with more voluminous thrombi required more retrieval attempts and had worse outcomes. Moreover, patients with more voluminous thrombi who underwent first-line stent retrieval fared worse compared with those who underwent first-line aspiration.
These interesting findings, some of which are confirmatory to those of other studies, do not suggest that contact aspiration should be favored over stent retriever use in patients with voluminous clots, considering the non-randomized design and the fact that several randomized controlled trials have shown no difference between contact aspiration and stent retrieval as the first-line technique.10,11 We do not know whether device strategies switched. The likelihood of first-attempt reperfusion or first-pass effect is reported by thrombus volume, and, hence, it is difficult to compare this study with other contemporary studies that looked at first-pass reperfusion.12,13 Contact aspiration and stent retriever device use have evolved since 2014–2017, with larger bore aspiration catheters now being tested and fourth-generation stent retrievers of longer length being used. The technique has also evolved, with the use of a combined stent retriever and contact aspiration technique.
Altogether, these findings indicate that, for practitioners who prefer to use contact aspiration first-line, these findings support the rationale to continue doing so in the setting of voluminous thrombi. For practitioners who prefer to use stent-retriever–based techniques, with or without an intermediate catheter, these findings may not be enough to change practice.
References