2006 First-Pass Success: Always Effective in Low ASPECTS, Only Timely Effective in High

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INTRODUCTION: First-Pass Effect (FPE), complete reperfusion on the first endovascular thrombectomy (EVT) attempt, is a powerful predictor of favorable outcomes in large vessel occlusion strokes. However, the clinical benefit of both EVT and FPE diminishes as procedure time (PT) increases. While patients with low Alberta Stroke Program Early CT Scores (ASPECTS) were historically excluded from major trials, six randomized controlled studies have now established the safety and efficacy of EVT in this high-risk population. As these vulnerable strokes carry limited tissue reserve and narrow therapeutic margins, optimizing procedural efficiency has become critical. METHODS: This retrospective analysis included EVT patients from 37 centers across the US and internationally. The primary endpoint was a good functional outcome, defined by 90-day modified Rankin Scale scores of 0-3. First pass success (FPS, defined as 1 pass vs ≥2 passes) was the primary study exposure, while PT was the secondary exposure, evaluated in both low ASPECTS and ASPECTS 6-10 subgroups. Youden's index determined the PT cut-off. Adjusted logistic regression models assessed the interaction between PT and FPS, with adjustments for confounders. Propensity score matching (PSM) compared FPS impacts within ≤35-minute and >35-minute PT groups for both low and high ASPECT subgroups. RESULTS: Of the 5,880 patients analyzed, 590 (10%) presented with low ASPECTS (0–5). First-Pass Effect (FPE) was independently associated with higher odds of good functional outcome (adjusted odds ratio [aOR]: 3.17, 95% CI: 2.04–5.20; P < 0.01). Procedure time (PT) was inversely associated with outcomes, with 35 minutes identified as the optimal cut-off beyond which clinical benefit declined (P < 0.01). A significant interaction between PT and FPE was observed in patients with ASPECTS 6–10 (P for interaction < 0.01), but not in the low ASPECTS group (P = 0.73). in ASPECTS 6–10 patients, those achieving FPE within 35 minutes had a 16.5% higher predicted probability of good outcome compared to those requiring multiple passes (73.2% vs. 56.7%; P = 0.001). However, this difference was no longer significant when PT exceeded 35 minutes (P = 0.55). In contrast, among low ASPECTS patients, FPE remained beneficial regardless of procedure duration. The odds of good outcome were significantly higher in FPE cases both within ≤35 minutes (aOR: 2.76; 95% CI: 1.45–3.31; P = 0.03) and beyond 35 minutes (aOR: 1.56; 95% CI: 1.11–2.32; P = 0.02). CONCLUSIONS: In conclusion, FPE offers time-sensitive benefits in ASPECTS 6–10, losing impact beyond 35 minutes. In low ASPECTS patients, however, FPE remains a strong predictor of good outcomes, even with prolonged procedure duration. These findings highlight the need to optimize thrombectomy techniques that improve FPE rates in this high-risk group, where its clinical value persists despite extended procedural times.

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