First Line Thrombectomy Devices in Intracranial Atherosclerotic Disease: An analysis of the RESCUE-ICAS registry

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Abstract Introduction Managing atherosclerotic large vessel occlusion is procedurally challenging. Prior literature pertaining to technical considerations remain heterogenous and further research is necessary to highlight important differences. As such, first-line thrombectomy technique remains an active area of debate with respect to rate of recanalization, need for rescue stenting, and hemorrhagic complications. Methods This is a pre-planned analysis of the prospective RESCUE-ICAS registry which included atherosclerotic large vessel occlusions treated with mechanical thrombectomy from 25 sites. Patients were excluded if they had missing data on first-line technique or primary outcomes. Patients were dichotomized into two cohorts based on whether their first-line thrombectomy technique was with aspiration alone or a stentriever (SR). Primary procedural outcome was first-pass effect while primary safety outcome was mortality at 90 days. Propensity score matching and inverse probability weighted analysis were performed with respect to primary and secondary outcomes. Results 419 were patients included in this analysis with 266 and 153 patients in the aspiration and stentriever cohorts, respectively. The cohort’s mean age was 68 (SD ±13) years, and the majority of patients were white (59%) and male (62%). There were no significant baseline demographic differences between cohorts; however, ICA occlusions were more common in the stentriever cohort (52% vs 31%), while MCA occlusions were more frequent in the aspiration cohort (35% vs 15%). In the un-adjusted model, first pass effect was higher in stentriever versus aspiration (35.3% vs 23.7%, p = 0.01) with equivalent mortality rates (31% vs 26%, p = 0.31). Distal embolization rates were higher in the aspiration cohort (9.8% vs 3.9%, p = 0.03), yet aspiration was associated with lower composited procedural complications (6% vs 11%, p = 0.01). Propensity score matching and weighted analysis demonstrated that differences in primary clinical efficacy and safety outcomes were insignificant between cohorts. Conclusion In patients with atherosclerotic large vessel occlusions, first line stentriever utilization was associated with higher first-pass effect rates, lower rates of distal embolization and shorter procedural length compared to aspiration. However, no clinical outcome difference was appreciated between the two groups and aspiration was associated with lower complication rates.

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