Aspiration Versus Stent‐Retriever as First‐Line Endovascular Therapy Technique for Primary Medium and Distal Intracranial Occlusions: A Propensity‐Score Matched Multicenter Analysis
Authors: Siegler James E. , Shaikh Hamza , Khalife Jane , Oak Solomon , Zhang Linda , Abdalkader Mohamad , Klein Piers , Nguyen Thanh N. , Kass‐Hout Tareq , Morsi Rami Z. , Heit Jeremy J. , Regenhardt Robert W. , Diestro Jose Danilo Bengzon , Cancelliere Nicole M. , Ghozy Sherief , Sweid Ahmad , Naamani Kareem El , Amllay Abdelaziz , Meyer Lukas , Dusart Anne , Bellante Flavio , Forestier Géraud , Rouchaud Aymeric , Saleme Suzana , Mounayer Charbel , Fiehler Jens , Kühn Anna Luisa , Puri Ajit S. , Dyzmann Christian , Kan Peter T. , Colasurdo Marco , Marnat Gaultier , Berge Jérôme , Barreau Xavier , Sibon Igor , Nedelcu Simona , Henninger Nils , Marotta Thomas R. , Das Alvin S. , Stapleton Christopher J. , Rabinov James D. , Ota Takahiro , Dofuku Shogo , Yeo Leonard L.L. , Tan Benjamin Y.Q. , Martinez‐Gutierrez Juan Carlos , Salazar‐Marioni Sergio , Sheth Sunil A. , Renieri Leonardo , Capirossi Carolina , Mowla Ashkan , Tjoumakaris Stavropoula I. , Jabbour Pascal , Khandelwal Priyank , Biswas Arundhati , Clarençon Frédéric , Elhorany Mahmoud , Premat Kevin , Valente Iacopo , Pedicelli Alessandro , Filipe João Pedro , Varela Ricardo , Quintero‐Consuegra Miguel , Gonzalez Nestor R. , Möhlenbruch Markus A. , Jesser Jessica , Costalat Vincent , Schiphorst Adrien ter , Yedavalli Vivek , Harker Pablo , Chervak Lina M. , Aziz Yasmin , Bullrich Maria Bres , Sposato Luciano , Gory Benjamin , Hecker Constantin , Killer‐Oberpfalzer Monika , Griessenauer Christoph J. , Thomas Ajith J. , Hsieh Cheng‐Yang , Liebeskind David S. , Radu Răzvan Alexandru , Alexandre Andrea M. , Tancredi Illario , Faizy Tobias D. , Fahed Robert , Weyland Charlotte , Patel Aman B. , Pereira Vitor Mendes , Lubicz Boris , Guenego Adrien , Dmytriw Adam A. ,   MAD‐MT Consortium
Published: July 2023

Background
For acute proximal intracranial artery occlusions, contact aspiration may be more effective than stent‐retriever for first‐line reperfusion therapy. Due to the lack of data regarding medium vessel occlusion thrombectomy, we evaluated outcomes according to first‐line technique in a large, multicenter registry.

Methods
Imaging, procedural, and clinical outcomes of patients with acute proximal medium vessel occlusions (M2, A1, or P1) or distal medium vessel occlusions (M3, A2, P2, or further) treated at 37 sites in 10 countries were analyzed according to first‐line endovascular technique (stent‐retriever versus aspiration). Multivariable logistic regression and propensity‐score matching were used to estimate the odds of the primary outcome, expanded Thrombolysis in Cerebral Infarction score of 2b–3 (“successful recanalization”), as well as secondary outcomes (first‐pass effect, expanded Thrombolysis in Cerebral Infarction 2c‐3, intracerebral hemorrhage, and 90‐day modified Rankin scale, 90‐day mortality) between treatment groups.

Results

Of the 440 included patients (44.5% stent‐retriever versus 55.5% aspiration), those treated with stent‐retriever had lower baseline Alberta Stroke Program Early Computed Tomography Scale scores (median 8 versus 9;
P
<0.01), higher National Institutes of Health Stroke Scale scores (median 13 versus 11;
P
=0.02), and nonsignificantly fewer medium‐distal occlusions (M3, A2, P2, or other: 17.4% versus 23.8%;
P
=0.10). Use of a stent‐retriever was associated with 15% lower odds of successful recanalization (odds ratio [OR], 0.85; [95% CI 0.74–0.98];
P
=0.02), but this was not significant after multivariable adjustment in the total cohort (adjusted OR, 0.88; [95% CI 0.72–1.09];
P
=0.24), or in the propensity‐score matched cohort (n=105 in each group) (adjusted OR, 0.94; [95% CI 0.75–1.18];
P
=0.60). There was no significant association between technique and secondary outcomes in the propensity‐score matched adjusted models.

Conclusion
In this large, diverse, multinational medium vessel occlusion cohort, we found no significant difference in imaging or clinical outcomes with aspiration versus stent‐retriever thrombectomy.