Effect of First‐Pass Reperfusion on Outcome After Endovascular Treatment for Ischemic Stroke
Authors: den Hartog Sanne J. , Zaidat Osama , Roozenbeek Bob , van Es Adriaan C. G. M. , Bruggeman Agnetha A. E. , Emmer Bart J. , Majoie Charles B. L. M. , van Zwam Wim H. , van den Wijngaard Ido R. , van Doormaal Pieter Jan , Lingsma Hester F. , Burke James F. , Dippel Diederik W. J. , van der Lugt Aad , Roos Yvo B. W. E. M. , van Oostenbrugge Robert J. , Boiten Jelis , Vos Jan Albert , Jansen Ivo G. H. , Mulder Maxim J. H. L. , Goldhoorn Robert‐Jan B. , Compagne Kars C. J. , Kappelhof Manon , Brouwer Josje , Hinsenveld Wouter H. , Coutinho Jonathan M. , Schonewille Wouter J. , Wermer Marieke J. H. , van Walderveen Marianne A. A. , Staals Julie , Hofmeijer Jeannette , Martens Jasper M. , Lycklama à Nijeholt Geert J. , de Bruijn Sebastiaan F. , van Dijk Lukas C. , van der Worp H. Bart , Lo Rob H. , van Dijk Ewoud J. , Boogaarts Hieronymus D. , de Vries J. , de Kort Paul L. M. , van Tuijl Julia , Peluso Jo P. , Fransen Puck , van den Berg Jan S. P. , van Hasselt Boudewijn A. A. M. , Aerden Leo A. M. , Dallinga René J. , Uyttenboogaart Maarten , Eschgi Omid , Bokkers Reinoud P. H. , Schreuder Tobien H. C. M. L. , Heijboer Roel J. J. , Keizer Koos , Yo Lonneke S. F. , den Hertog Heleen M. , Sturm Emiel J. C. , Brouwers Paul J. A. M. , Sprengers Marieke E. S. , Jenniskens Sjoerd F. M. , van den Berg René , Yoo Albert J. , Beenen Ludo F. M. , Postma Alida A. , Roosendaal Stefan D. , van der Kallen Bas F. W. , Bot Joost , Meijer Anton , Ghariq Elyas , van Proosdij Marc P. , Krietemeijer G. Menno , Gerrits Dick , Dinkelaar Wouter , Appelman Auke P. A. , Hammer Bas , Pegge Sjoert , van der Hoorn Anouk , Vinke Saman , Flach H. Zwenneke , el Ghannouti Naziha , Sterrenberg Martin , Pellikaan Wilma , Sprengers Rita , Elfrink Marjan , Simons Michelle , Vossers Marjolein , de Meris Joke , Vermeulen Tamara , Geerlings Annet , van Vemde Gina , Simons Tiny , Messchendorp Gert , Nicolaij Nynke , Bongenaar Hester , Bodde Karin , Kleijn Sandra , Lodico Jasmijn , Droste Hanneke , Wollaert Maureen , Verheesen Sabrina , Jeurrissen D. , Bos Erna , Drabbe Yvonne , Sandiman Michelle , Aaldering Nicoline , Zweedijk Berber , Vervoort Jocova , Ponjee Eva , Romviel Sharon , Kanselaar Karin , Barning Denn , Venema Esmee , Chalos Vicky , Geuskens Ralph R. , van Straaten Tim , Ergezen Saliha , Harmsma Roger R. M. , Muijres Daan , de Jong Anouk , Berkhemer Olvert A. , Boers Anna M. M. , Huguet J. , Groot P. F. C. , Mens Marieke A. , van Kranendonk Katinka R. , Treurniet Kilian M. , Tolhuisen Manon L. , Alves Heitor , Weterings Annick J. , Kirkels Eleonora L. F. , Voogd Eva J. H. F. , Schupp Lieve M. , Collette Sabine L. , Groot Adrien E. D. , LeCouffe Natalie E. , Konduri Praneeta R. , Prasetya Haryadi , Arrarte‐Terreros Nerea , Ramos Lucas A. 
Published: March 2021

Background
First‐pass reperfusion (FPR) is associated with favorable outcome after endovascular treatment. It is unknown whether this effect is independent of patient characteristics and whether FPR has better outcomes compared with excellent reperfusion (Expanded Thrombolysis in Cerebral Infarction [eTICI] 2C‐3) after multiple‐passes reperfusion. We aimed to evaluate the association between FPR and outcome with adjustment for patient, imaging, and treatment characteristics to single out the contribution of FPR.

Methods and Results
FPR was defined as eTICI 2C‐3 after 1 pass. Multivariable regression models were used to investigate characteristics associated with FPR and to investigate the effect of FPR on outcomes. We included 2686 patients of the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry. Factors associated with FPR were as follows: history of hyperlipidemia (adjusted odds ratio [OR], 1.05; 95% CI, 1.01–1.10), middle cerebral artery versus intracranial carotid artery occlusion (adjusted OR, 1.11; 95% CI, 1.06–1.16), and aspiration versus stent thrombectomy (adjusted OR, 1.07; 95% CI, 1.03–1.11). Interventionist experience increased the likelihood of FPR (adjusted OR, 1.03 per 50 patients previously treated; 95% CI, 1.01–1.06). Adjusted for patient, imaging, and treatment characteristics, FPR remained associated with a better 24‐hour National Institutes of Health Stroke Scale (NIHSS) score (−37%; 95% CI, −43% to −31%) and a better modified Rankin Scale (mRS) score at 3 months (adjusted common OR, 2.16; 95% CI, 1.83–2.54) compared with no FPR (multiple‐passes reperfusion+no excellent reperfusion), and compared with multiple‐passes reperfusion alone (24‐hour NIHSS score, (−23%; 95% CI, −31% to −14%), and mRS score (adjusted common OR, 1.45; 95% CI, 1.19–1.78)).

Conclusions
FPR compared with multiple‐passes reperfusion is associated with favorable outcome, independently of patient, imaging, and treatment characteristics. Factors associated with FPR were the experience of the interventionist, history of hyperlipidemia, location of occluded artery, and use of an aspiration device compared with stent thrombectomy.