Author + information
- Received September 20, 2018
- Revision received November 19, 2018
- Accepted November 27, 2018
- Published online February 25, 2019.
- Ali Alawieh, PhDa,b,
- Jan Vargas, MDb,
- Kyle M. Fargen, MDc,
- E. Farris Langley, BSa,
- Robert M. Starke, MDd,
- Reade De Leacy, MDe,
- Rano Chatterjee, MDf,
- Ansaar Rai, MDg,
- Travis Dumont, MDh,
- Peter Kan, MDi,
- David McCarthy, MDd,
- Fábio A. Nascimento, MDj,
- Jasmeet Singh, MDc,
- Lukas Vilella, MDc,
- Aquilla Turk, DOb and
- Alejandro M. Spiotta, MDb,∗ (, )@alex_spiotta
- aMedical Scientist Training Program, Medical University of South Carolina, Charleston, South Carolina
- bDepartment of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
- cDepartment of Neurological Surgery, Wake Forest University, Winston-Salem, North Carolina
- dDepartment of Neurological Surgery and Neuroradiology, University of Miami, Miami, Florida
- eDepartment of Neurosurgery, Mount Sinai Health System, New York, New York
- fDepartment of Radiology and Radiological Sciences, Medical University of South Carolina, Charleston, South Carolina
- gDepartments of Radiology, Neurology & Neurosurgery, West Virginia University, Morgantown, West Virginia
- hDepartment of Neurosurgery, University of Arizona, Tucson, Arizona
- iDepartment of Neurosurgery, Baylor College of Medicine, Houston, Texas
- jDepartment of Neurology, Baylor College of Medicine, Houston, Texas
- ↵∗Address for correspondence:
Dr. Alejandro Spiotta, Medical University of South Carolina, Department of Neurosurgery, 171 Ashley Avenue, Charleston, South Carolina 29425.
Background Endovascular thrombectomy (ET) for acute ischemic stroke is the current standard of care. Although successful ET has high efficacy in improving functional outcomes, the decision to abort a long procedure remains a challenge. Longer procedure time (PT) has been associated with lower rates of functional independence.
Objectives The objective of this study was to evaluate the impact of PT on outcomes and complications after ET using different techniques at a multicenter level and to define the risk of procedure extension in different patient cohorts.
Methods Patients undergoing ET with a stent retriever (SR) or a direct aspiration at first pass technique at 7 U.S. centers between June 2013 and February 2018 were reviewed from prospectively maintained databases that include baseline variables and technical and clinical outcomes. Multivariate analyses were used to assess impact of PT on 90-day modified Rankin scores, successful recanalization, post-procedural symptomatic hemorrhage (sICH), and complications.
Results The study included 1,359 patients and demonstrated a decreased likelihood of good functional outcomes (modified Rankin score 0 to 2) when PT extended beyond 30 min (p < 0.01). Rates of sICH and complications increased exponentially with PT (doubling rates of 26 and 50 min, respectively). The cumulative rate of successful recanalization and good outcomes plateaued after 60 min of PT. In patients with PT >30 min, fewer attempts predicted the success of ET and good outcomes (p < 0.01). Successful recanalization was achieved faster with the direct aspiration at first pass technique than in SR. The direct aspiration technique was more sensitive to PT than SR, and posterior stroke was more sensitive to PT than anterior stroke.
Conclusions Longer ET procedures lead to lower rates of functional independence and higher rates of sICH and complications. Exceeding 60 min or 3 attempts should trigger careful assessment of futility and risks of continuing the procedure.
Dr. Fargen has served as a consultant for Cerebrotech. Dr. Starke has served as a consultant for Medtronic, Penumbra, and Abbott. Dr. De Leacy has served as a consultant for Penumbra and Cerenovus. Dr. Rai has served as a consultant for Stryker Neurovascular and Cerenovus. Dr. Kan has served as a consultant to Medtronic and Stryker Neurovascular. Dr. Turk has been a consultant for, received honoraria from, and served on speaker bureaus for Codman, Covidien, Penumbra, Microvention, Blockade, Pulsar Vascular, and Medtronic; has received research funding from Codman, Penumbra, Microvention, and Pulsar Vascular; and owns stock in Blockade and Pulsar Vascular. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Listen to this manuscript's audio summary by Editor-in-Chief Dr. Valentin Fuster on JACC.org.
- Received September 20, 2018.
- Revision received November 19, 2018.
- Accepted November 27, 2018.
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