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Research ArticleNeurointervention
Open Access

Comparison of Aspiration versus Stent Retriever Thrombectomy as the Preferred Strategy for Patients with Acute Terminal Internal Carotid Artery Occlusion: A Propensity Score Matching Analysis

P.F. Xing, P.F. Yang, Z.F. Li, L. Zhang, H.J. Shen, Y.X. Zhang, Y.W. Zhang and J.M. Liu
American Journal of Neuroradiology February 2020, DOI: https://doi.org/10.3174/ajnr.A6414
P.F. Xing
aFrom the Department of Stroke Center, Changhai Hospital, Second Military Medical University, Shanghai, China.
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P.F. Yang
aFrom the Department of Stroke Center, Changhai Hospital, Second Military Medical University, Shanghai, China.
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Z.F. Li
aFrom the Department of Stroke Center, Changhai Hospital, Second Military Medical University, Shanghai, China.
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L. Zhang
aFrom the Department of Stroke Center, Changhai Hospital, Second Military Medical University, Shanghai, China.
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H.J. Shen
aFrom the Department of Stroke Center, Changhai Hospital, Second Military Medical University, Shanghai, China.
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Y.X. Zhang
aFrom the Department of Stroke Center, Changhai Hospital, Second Military Medical University, Shanghai, China.
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Y.W. Zhang
aFrom the Department of Stroke Center, Changhai Hospital, Second Military Medical University, Shanghai, China.
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J.M. Liu
aFrom the Department of Stroke Center, Changhai Hospital, Second Military Medical University, Shanghai, China.
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  • FIG 1.
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    FIG 1.

    A, AT. Preprocedure CTA of the head indicated that the terminal end of the right ICA was occluded and that the blood flow from the left ICA was supplied to the right anterior cerebral artery and to the ostium of the A1 segment (white arrow) through the anterior communicating artery. B and C, DSA of the right ICA confirmed that the terminal ICA was occluded. D, A collateral blood supply was present from the posterior cerebral artery to the temporal lobe. E and F, A 6F Sofia Plus 125 cm (0.070 inch) catheter connected to a Penumbra pump was inserted into the terminal ICA via roadmap imaging and was placed beyond the face of the thrombus (white arrows). G and H, The ICA was recanalized, with eTICI 3 after 1-pass AT, and a supraclinoid segment aneurysm was present (H, black arrow).

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    FIG 2.

    SRT. A, A preprocedure CTA of the head indicated that the terminal end of the left ICA was occluded and that the blood flow from the right ICA was supplied to the left anterior cerebral artery and to the ostium of the A1 segment (white arrow) through the anterior communicating artery. B, DSA of the left common carotid artery revealed that the left ICA was occluded (black arrow). C, DSA of the right ICA indicated similar results to (A) CTA, and no collateral blood supply was observed from the (D) posterior to the anterior circulation. E, DSA of the intermediate catheter (long black arrow) and guide catheter (short black arrow) demonstrated that the left carotid terminus was occluded, whereas the cervical ICA was not occluded (pseudo-occlusion) compared with that of image B. F, DSA was performed via the microcatheter crossing the occluded segment and the MCA was patent. G, A Solitaire FR 6 × 30 mm stent was used and inserted into the 6F Sofia Plus 125-cm catheter, which was advanced closer to the thrombus for local aspiration after the stent-retriever removal. H, The ICA was recanalized to eTICI 3 after a 1-pass SRT.

  • FIG 3.
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    FIG 3.

    The eTICI grade distribution. The breakdown of the eTICI grade of the (A and C) AT and SRT groups in the overall sample and the (B and D) PSM sample. The grades included 0, 1, 2a, 2b, 2c, and 3, with 0 indicating no revascularization; 1 thrombus reduction without any revascularization of distal arteries; 2a, <50% revascularization; 2b, 50%–89% revascularization; 2c, 90%–99% revacularization; and 3 complete revascularization. A, The distribution of the final eTICI grade in the overall sample. Significant differences were noted between the AT and SRT groups in the overall sample in the successful revascularization rates (eTICI 2b–3: OR 1.23 [95% CI, 1.10–1.38]; eTICI 2c–3: OR 4.62 [95% CI, 1.72–12.43]; and eTICI 3: OR 3.05 [95% CI, 1.32–7.06]). B, The distribution of the final eTICI grade in the PSM sample. In the PSM sample, the groups did not significantly differ with regard to the eTICI 2b–3 (OR 1.11 [95% CI, 0.99–1.25]). C, The distribution of the first pass to eTICI 2b, 2c, and 3 in the overall sample. No significant differences were noted between the groups with regard to the first-pass revascularization rates (for eTICI 2b–3, 2c–3, or 3). D, The distribution of the first pass to eTICI 2b, 2c, and 3 in the PSM sample. In the PSM sample, the rate of eTICI 2c–3 in the AT group was higher than that in the SRT group (OR 3.05 [95% CI, 1.00–3.93]).

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    Table 1:

    Baseline characteristics of raw and PSM data of the 2 groups

    Overall SamplePSM Sample
    AT Group (n = 40)SRT Group (n = 69)OR (95% CI)PAT Group (n = 30)SRT Group (n = 30)OR (95% CI)P
    Sex, male, n (%)21 (52.5)28 (40.6)1.62 (0.74–3.54).22813 (43.3)11 (36.7)1.32 (0.47–3.72).598
    Age, mean ± SD, y68.3 ± 14.069.5 ± 9.2NA.63169.2 ± 14.069.4 ± 7.9NA.946
    Pre-NIHSS score, median (IQR)21 (15–23)19 (16–22)NA.16021 (15–22)18 (16–22)NA.342
    Stroke etiology
        Cardioembolic, n (%)37 (92.5)57 (82.6)2.60 (0.69–9.82).24828 (93.3)25 (83.3)2.80 (0.50–15.73).421
        Large vessel atherosclerosis, n (%)1 (2.5)10 (14.5)0.15 (0.02–1.23).0941 (3.3)2 (6.7)0.48 (0.04–5.63).999
        Other etiology, n (%)2 (5.0)2 (2.9)1.76 (0.24–13.02).9731 (3.3)3 (10.0)0.31 (0.03–3.17).605
    Onset to puncture time, median (IQR), min288 (180–480)240 (169–314)NA.061250 (161–338)243 (174–338)NA.859
    ASITN/SIRs grade, median (IQR)2 (1–2)2 (1–2)NA.6772 (1–2)2 (1–2)NA.839
    Baseline ASPECTS, median (IQR)7 (5–8)7 (6–8)NA.1107 (5–8)6 (5–7)NA.711
    ASPECTS <6, n (%)12 (30.0)27 (39.1)0.67 (0.29–1.53).3389 (30.0)11 (36.7)0.74 (0.25–2.18).584
    • Note:—SD indicates standard deviation; IQR, interquartile range (25%–75%); NA, not applicable.

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    Table 2:

    Procedural details and clinical outcomes of the 2 groups

    Overall SamplePSM Sample
    AT Group (n = 40)SRT Group (n = 69)OR (95% CI)PAT Group (n = 30)SRT Group (n = 30)OR (95% CI)P
    eTICI 2b–3, n (%)40 (100)56 (81.2)1.23 (1.10–1.38).00230 (100)27 (90.0)1.11 (0.99–1.25).237
    eTICI 2c–3, n (%)34 (85.0)38 (55.1)4.62 (1.72–12.43).00126 (86.7)15 (50.0)6.50 (1.82–23.21).006
    eTICI 3, n (%)29 (72.5)32 (46.4)3.05 (1.32–7.06).00822 (73.3)11 (36.7)4.75 (1.58–14.25).004
    First pass to eTICI 2b–3, n (%)10 (25.0)15 (21.7)1.20 (0.48–3.00).6969 (30.0)9 (30.0)1.00 (0.33–3.02).999
    First pass to eTICI 2c–3, n (%)10 (25.0)12 (17.4)1.58 (0.61–4.01).3409 (30.0)6 (20.0)3.05 (1.00–3.93).044
    First pass to eTICI 3, n (%)8 (20.0)11 (15.9)1.32 (0.48–3.61).5908 (26.7)5 (16.7)1.82 (0.52–6.38).347
    No. passes of thrombectomy, median (IQR)2 (2–3.7)3 (2–4)NA.9002 (1–3)2.5 (1–3)NA.367
    Rescue treatment, n (%)6 (15.0)8 (11.6)1.35 (0.43–4.20).6085 (16.7)6 (20.0)0.80 (0.22–2.97).739
    PRT, median (IQR) (min)46 (24–68)83 (55–120)NA.00138 (22–56)69 (45–120)NA.001
    Onset to reperfusion time, median (IQR) (min)355 (222–550)337 (264–420)NA.900249 (205–391)344 (248–450)NA.145
    Use of rtPA, n (%)12 (30.0)33 (47.8)0.47 (0.21–1.07).06811 (36.7)15 (50.0)0.58 (0.19–1.59).297
    Administration of GPI, n (%)2 (5.0)10 (14.5)0.31 (0.06–1.50).2271 (3.3)3 (10.0)0.31 (0.03–3.17).605
    Balloon angioplasty, n (%)1 (2.5)2 (2.9)0.86 (0.08–9.78).9991 (3.3)2 (6.7)0.48 (0.04–5.63).999
    Stent placement, n (%)0 (0)5 (7.2)0.33 (0.04–2.91).1560 (0)2 (6.7)1.07 (0.97–1.18).492
    IV heparin, n (%)28 (70.0)36 (52.2)2.14 (0.94–4.88).06819 (63.3)15 (50.0)1.73 (0.62–4.85).297
    mRS score 0–1 at 90 days, n (%)13 (32.5)15 (21.7)1.73 (0.72–4.16).21511 (36.7)5 (16.7)2.90 (0.86–9.75).080
    mRS score 0–2 at 90 days, n (%)17 (42.5)22 (31.9)1.92 (0.86–4.25).26515 (50.0)9 (30.0)2.33 (0.81–6.73).114
    mRS score 3–5 at 90 days, n (%)17 (42.5)35 (50.7)0.72 (0.33–1.57).40710 (33.3)16 (53.3)0.44 (0.15–1.24).118
    • Note:—NA indicates not applicable; GPI, glycoprotein IIb/IIIa receptor inhibitor.

    • View popup
    Table 3:

    Adverse events after mechanical thrombectomy in the 2 groups

    Overall SamplePSM Sample
    AT Group, n (%) (n = 40)SRT Group, n (%) (n = 69)OR (95% CI)PAT Group, n (%) (n = 30)SRT Group, n (%) (n = 30)OR (95% CI)P
    Overall adverse events21 (52.5)50 (72.5)0.42 (0.19–0.95).03514 (46.7)20 (66.7)0.44 (0.15–1.24).118
    Any ICH12 (30.0)28 (40.6)0.63 (0.27–1.44).2696 (20.0)14 (46.7)0.29 (0.09–0.90).028
    Symptomatic ICH4 (10.0)14 (20.3)0.44 (0.13–1.43).2603 (10.0)8 (26.7)0.31 (0.07–1.29).182
    Downstream territory embolism17 (42.5)31 (44.9)0.91 (0.41–1.99).80611 (36.7)11 (36.7)1.00 (0.35–2.86).999
    Malignant cerebral edema4 (10.0)19 (27.5)0.29 (0.09–0.93).0504 (13.3)5 (16.7)0.77 (0.19–3.20).999
    All-cause mortality at 90 days6 (15.0)12 (17.4)0.84 (0.29–2.44).7466 (20.0)6 (20.0)1.00 (0.28–3.54).999
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P.F. Xing, P.F. Yang, Z.F. Li, L. Zhang, H.J. Shen, Y.X. Zhang, Y.W. Zhang, J.M. Liu
Comparison of Aspiration versus Stent Retriever Thrombectomy as the Preferred Strategy for Patients with Acute Terminal Internal Carotid Artery Occlusion: A Propensity Score Matching Analysis
American Journal of Neuroradiology Feb 2020, DOI: 10.3174/ajnr.A6414

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Comparison of Aspiration versus Stent Retriever Thrombectomy as the Preferred Strategy for Patients with Acute Terminal Internal Carotid Artery Occlusion: A Propensity Score Matching Analysis
P.F. Xing, P.F. Yang, Z.F. Li, L. Zhang, H.J. Shen, Y.X. Zhang, Y.W. Zhang, J.M. Liu
American Journal of Neuroradiology Feb 2020, DOI: 10.3174/ajnr.A6414
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