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First-line contact aspiration not superior to stent retriever for successful revascularization in ischemic stroke
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First-line thrombectomy with contact aspiration, as compared with a first-line stent retriever technique, did not increase successful revascularization at the end of the procedure among patients with acute ischemic stroke in the anterior circulation, according to new data published in JAMA.
For the randomized, open-label, blinded-endpoint ASTER trial, Bernard Lapergue, MD, PhD, from the University of Versailles and Saint Quentin en Yvelines, Foch Hospital, Suresnes, France, and colleagues randomly assigned 381 patients (mean age, 70 years; 46% women) with acute ischemic stroke and large vessel occlusion in the anterior circulation to first-line contact aspiration (ADAPT [A Direct Aspiration, First Pass Technique], Penumbra; n = 192) or first-line stent retriever (n = 189) prior to mechanical thrombectomy. The most common stent retriever devices used were Solitaire (Medtronic) and Trevo (Stryker). All patients presented within 6 hours of symptom onset and were treated at one of eight comprehensive stroke centers from 2015 to 2016 in France.
The primary outcome was successful revascularization, defined by a modified Thrombolysis in Cerebral Infarction score of 2b or 3.
Overall, 363 patients completed the trial.
The researchers found no significant difference in successful revascularization with first-line contact aspiration vs. stent retriever (85.4% vs. 83.1%; OR = 1.2; 95% CI, 0.68-2.1), with a risk difference of 2.4% (95% CI, –5.4 to 9.7). Additionally, rescue treatment after first-line strategy (32.8% vs. 23.8%; OR = 1.57; 95% CI, 0.99-2.47) and total number of revascularization attempts (median, 2 vs. 2; P = .84) did not differ between groups.
Clinical outcomes were also similar between treatment groups. The mean change in NIH Stroke Scale score was –4.8 points with first-line contact aspiration (95% CI, –6.1 to –3.6) vs. –5.2 points with first-line stent retriever (95%, –6.5 to –3.9), with a mean difference of 0.38 points (95% CI, –1.42 to 2.18) between groups. Similarly, there was no difference in the proportion of patients who were functionally independent, as measured by modified Rankin Scale score assessment at 3 months (45.3% vs. 50%; OR = 0.83; 95% CI, 0.54-1.26).
Patients in both groups had similar rates of adverse events, including intracranial hemorrhage (46%) and procedure-related events (6%).
“The hypothesis of this trial was that use of first-line contact aspiration would increase the rate of successful revascularization by 15% compared with a first-line stent retriever (superiority design), so, although contact aspiration was not superior to stent retriever in achieving successful recanalization, this study was not designed to claim equivalence or noninferiority of these strategies,” the researchers wrote. “Furthermore, although the contact aspiration group did not achieve a 15% increase in successful revascularization, a smaller yet potentially clinically significant difference in revascularization rate cannot be fully excluded.”
The researchers also noted that, despite a lack of differences between treatment groups in clinical outcomes, the trial was underpowered to detect differences. – by Melissa Foster
Disclosures: Penumbra provided an unrestricted research grant. One author reports consulting for Acticor and Servier; receiving funding for teaching from Amgen and Pfizer; and receiving travel reimbursement from Bayer, Boehringer Ingelheim and Zeneca. Piotin reports receiving grants from Balt, Medtronic, Microvention and Stryker.
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