First‐Line Stent Retriever Versus Contact Aspiration or Combined Technique for Endovascular Therapy of Posterior Cerebral Artery Occlusion Stroke: The PLATO Study

Well, which one got to 100% recovery? Oh you incompetently didn't measure that, did you?  First pass effect is not something survivors care about, so why the fuck aren't you measuring survivor wants? Like 100% recovery?

“What's measured, improves.” So said management legend and author Peter F. Drucker 

First‐Line Stent Retriever Versus Contact Aspiration or Combined Technique for Endovascular Therapy of Posterior Cerebral Artery Occlusion Stroke: The PLATO Study

Thanh N. Nguyen,

Mohamad Abdalkader,

Muhammad M. Qureshi,

Patrik Michel,

Davide Strambo,

Daniel Strbian,

Christian Herweh,

Markus A. Möhlenbruch,

Silja Räty,

… See all authors

Originally published18 Nov 2023https://doi.org/10.1161/SVIN.123.001004Stroke: Vascular and Interventional Neurology. 2024;4:e001004

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Abstract

Background

The optimal reperfusion technique in patients with isolated posterior cerebral artery (PCA) occlusion is uncertain. We compared clinical and technical outcomes with first‐line stent retriever (SR), contact aspiration (CA), or combined techniques in patients with isolated PCA occlusion.

Methods

This international case–control study was conducted at 30 sites in Europe and North America and included consecutive patients with isolated PCA occlusion presenting within 24 hours of time last seen well from January 2015 to August 2022. The primary outcome was the first‐pass effect (FPE), defined as expanded Treatment in Cerebral Infarction (TICI) 2c/3 on the first pass. Patients treated with SR, CA, or combined technique were compared with multivariable logistic regression.

Results

There were 326 patients who met inclusion criteria, 56.1% male, median age 75 (interquartile range 65–82) years, and median National Institutes of Health Stroke Scale score 8 (5–12). Occlusion segments were PCA‐P1 (53.1%), P2 (40.5%), and other (6.4%). Intravenous thrombolysis was administered in 39.6%. First‐line technique was SR, CA, and combined technique in 43 (13.2%), 106 (32.5%), and 177 (54.3%) patients, respectively; FPE was achieved in 62.8%, 42.5%, and 39.6%, respectively. FPE was lower in patients treated with first‐line CA or combined technique compared with SR (CA versus SR: adjusted odds ratio 0.45 [0.19–1.06]; P=0.07; combined versus SR: adjusted odds ratio 0.35 [0.016–0.80]; P=0.01). There were lower odds of functional independence (modified Rankin scale score 0–2) in the first‐line CA versus SR alone group (adjusted odds ratio 0.52 [0.28–0.95]; P=0.04). FPE was associated with higher rates of favorable outcomes (modified Rankin scale score 0–2: 58% versus 43.4%; P=0.01; modified Rankin scale score 0–1: 36.6% versus 25.8%; P=0.05). Overall, symptomatic intracranial hemorrhage was present in 5.6% (18/326) and mortality in 10.9% (35/326) without difference between first‐line technique.

Conclusion

In patients with isolated PCA occlusion, SR was associated with a higher rate of FPE compared with CA or combined techniques with no difference in final successful reperfusion. Functional independence at 90 days was more likely with first‐line SR compared with CA. FPE was associated with better 90‐day clinical outcomes.

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First-pass effect in patients with acute vertebrobasilar artery occlusion undergoing thrombectomy: insights from the PERSIST registry

When you enter the ER you'll have to ask your doctor if they will guarantee a first pass success. Your responsibility!

First-pass effect in patients with acute vertebrobasilar artery occlusion undergoing thrombectomy: insights from the PERSIST registry

Xianjun Huang https://orcid.org/0000-0003-2646-982X, Chu Chen, […], and Wen Sun sunwen_medneuro@163.com+7View all authors and affiliations

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https://doi.org/10.1177/17562864221139595

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Abstract

Background:

Achieving rapid and complete vascular recanalization in patients with acute large vessel occlusion can significantly improve patients’ prognosis.

Objective:

We aimed to investigate the potential contribution of the first-pass effect (FPE) to the clinical outcome of patients with acute vertebrobasilar artery occlusion (VBAO).

Methods:

We retrospectively analyzed the data of patients who underwent endovascular thrombectomy (EVT) caused by VBAO in a multicentered retrospective registry dataset. FPE was defined as successful recanalization [modified thrombolysis in cerebral infarction (mTICI) 2b/3 as modified FPE (mFPE); mTICI 3 as true FPE (tFPE)] after one pass of the device without rescue therapy. The baseline characteristics and procedural and clinical outcomes were analyzed. Multivariate analysis was used to explore the predictors of FPE and the relationship between FPE and 90-day prognosis.

Results:

A total of 508 patients (age, 63.7 ± 13.1 years, male, 71.6%) were finally included, 29.9% (152/508) of whom achieved mFPE, and 21.1% (107/508) of whom achieved tFPE. FPE was significantly associated with improved clinical outcomes, regardless of mFPE [odds ratio (OR): 0.601, 95% confidence interval (CI): 0.370–0.977, p = 0.040] and tFPE (OR: 0.547, 95% CI: 0.318–0.940, p = 0.029). The use of contact aspiration, favorable collateral status, cardioembolic etiology, and basilar artery occlusion were statistically significant predictors of mFPE and tFPE, whereas hypertension was a negative predictor. Intravenous (IV) recombinant tissue plasminogen activator (rt-PA) prior to EVT was a positive predictor of mFPE but not of tFPE.

Conclusion:

FPE was associated with significantly favorable outcomes in EVT patients with VBAO. The predictors of FPE include infarct etiology, the site of occlusion, collateral status, EVT strategies, and IV rt-PA bridging strategies.

Trial registration number:

URL: http://www.chictr.org.cn/; Unique identifier: ChiCTR2000033211.

Introduction

Posterior circulation stroke occurs in approximately one-fifth of all ischemic strokes,¹ which are supplied by the vertebrobasilar artery and result in severe disability or death in nearly two-thirds of patients.² Previously, several randomized controlled studies have shown that endovascular thrombectomy (EVT) was a safe and effective treatment for large vessel occlusion stroke (LVOS) in the anterior circulation up to 24 h from stroke onset.^3,4 However, among patients with stroke from vertebrobasilar artery occlusion (VBAO), EVT treatment showed inconsistent results. Previous clinical trials failed to show significant advantages over medical therapy.^5,6 However, the ATTENTION (EndovAscular TreaTmENT for acute basilar artery occlusION) study recently published at the European Stroke Conference showed that EVT was significantly better than medical therapy [an adjusted risk ratio of 2.1, 95% confidence interval (CI): 1.5–3.0]. One important reason was a significantly higher proportion of ‘futile’ reperfusion.⁷

Achieving successful reperfusion of the target vessel occlusion is critical for improving patients’ prognosis. However, reperfusion can be achieved in single or multiple passes.⁸ Multiple passes are associated with a prolonged procedure time and aggravated arterial endothelial injury.⁹ Therefore, the concept of the first-pass effect (FPE) or modified FPE (mFPE) was introduced, which implies that ideally, EVT should achieve successful reperfusion [modified thrombolysis in cerebral infarction (mTICI) 2b/3] after a single pass.^8,10 Several previous studies have investigated the clinical value and predictors of FPE in the treatment of EVT in patients with anterior circulation LVOS.^11,12 Furthermore, a recent study showed that first-pass mTICI 2b/3 reperfusion was the only treatment-related factor predictive of clinical outcome.¹² Therefore, it is important to identify the predictors associated with first-pass reperfusion in the posterior circulation stroke.¹³

To address this question, we conducted a study comparing the baseline characteristics and clinical outcomes of patients with FPE with those of the remainder of the cohort. The aim was to identify factors that may influence the achievement of FPE in EVT patients with VBAO and the relationship between FPE and prognosis.

 

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First pass effect in posterior circulation occlusions: Analysis from the CICAT registry

When you enter the emergency room you'll have to demand your doctor accomplish the thrombectomy in one pass or they better have followup protocols that restore functionality to the same that would have occurred in one pass.

First pass effect in posterior circulation occlusions: Analysis from the CICAT registry

Mikel Terceño https://orcid.org/0000-0001-5532-5329 mterceno.girona.ics@gencat.cat, Yolanda Silva, […], Saima Bashir, Ángel Chamorro https://orcid.org/0000-0003-0493-5340, Natalia Pérez de la Ossa, María Hernandez-Pérez https://orcid.org/0000-0001-8279-7954, Carlos Castaño, Pol Camps-Renom https://orcid.org/0000-0001-6587-6271, Denisse Wenger, Pere Cardona, Carlos Molina, Ana Rodríguez-Campello, David Cánovas, Francisco Purroy https://orcid.org/0000-0002-1808-5968, Mercè Salvat-Plana https://orcid.org/0000-0003-0994-6567, Joaquín Serena, and on behalf of the Catalan Stroke Code and Reperfusion Consortium (Cat-SCR), +14 -14View all authors and affiliations

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https://doi.org/10.1177/17474930221089772

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Abstract

Background:

The first pass effect (FPE) is an independent predictor of functional independence in patients with large vessel occlusion in anterior circulation ischemic strokes. However, whether it predicts outcome in posterior circulation large vessel occlusion (PC-LVO) is uncertain. We aimed to study the frequency, characteristics, and predictors of FPE and its association with clinical outcomes in PC-LVO.

Method:

We performed an analysis from the prospective CICAT Registry. All patients with PC-LVO who underwent endovascular therapy between January 2016 and January 2020 were included. A centrally assessed clinical follow-up was performed at 3 months by blinded investigators. FPE was defined as the achievement of modified Thrombolysis In Cerebral Infarction 3 in a single pass of the endovascular thrombectomy device, and multi-pass effect (MPE) if it was achieved in more than one pass. A multivariable analysis was performed to identify whether FPE is an independent predictor of functional independence defined as a modified Rankin Score of 0–2.

Results:

We analyzed data from 265 patients in who FPE was achieved in 105 (39.6%). Patients with FPE were more likely to achieve functional independence compared to the non-FPE group (52.4% vs 25.1%, p < .001) and the MPE group (52.4% vs 26.7%, p < .001). FPE was independently associated with functional independence (adjusted odds ratio (aOR): 2.10, 95% confidence interval (CI) 1.01-4.37) but MPE was not (aOR: 0.92, 95% CI 0.40-2.13). Independent predictors of FPE were the use of direct aspiration, embolic mechanism of stroke, and the absence of general anesthesia (GA) use.

Conclusions:

FPE is an independent predictor of functional independence in PC-LVO and was associated with a significantly better outcome than MPE.

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References

1. Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke 2007; 38(3): 967–973.

Walrus large bore guide catheter impact on recanalization first pass effect and outcomes: the WICkED study

With no reporting on 100% recovery you can't tell how good this is. Recanalization is an intermediate step that survivors don't give a shit about.  Your reference to functional independence is just using your fucking tyranny of low expectations to justify failure.

 Walrus large bore guide catheter impact on recanalization first pass effect and outcomes: the WICkED study

1. Gustavo M Cortez1,2,
2. Raymond D Turner3,
3. http://orcid.org/0000-0001-6827-6650Andre Monteiro4,
4. Ajit S Puri5,
5. http://orcid.org/0000-0002-9519-0059Adnan H Siddiqui4,
6. http://orcid.org/0000-0001-5489-2524J Mocco6,
7. http://orcid.org/0000-0001-7164-1479Jan Vargas3,
8. Anna L Kuhn5,
9. Shahram Majidi6,
10. M Imran Chaudry3,
11. http://orcid.org/0000-0002-9126-2932Amin Aghaebrahim1,
12. Aquilla S Turk3,
13. Eric Sauvageau1,
14. http://orcid.org/0000-0001-7195-5806Ricardo A Hanel1

1. Correspondence to Dr Ricardo A Hanel, Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA; rhanel@lyerlyneuro.com

Abstract

Background The use of a balloon-guide catheter (BGC) in acute stroke treatment has been widely adopted after demonstrating optimized procedure metrics and outcomes. Initial technical constraints of previous devices included catheter stiffness and smaller inner diameters. We aim to evaluate the performance and safety of the Walrus BGC, a variable stiffness catheter with a large bore 0.087 inch inner diameter (ID), via the the WICkED study (Walrus Large Bore guide Catheter Impact on reCanalization first pass Effect anD outcomes).

Methods This is a retrospective, site adjudicated, multicenter study on consecutive patients with large vessel occlusion treated with the Walrus BGC. Baseline characteristics, procedural outcomes and functional outcomes were analyzed.

Results A total of 338 patients met the inclusion criteria. The Walrus was successfully tracked into distal vasculature and allowed therapeutic device delivery in all but 3 cases (0.9%). Large aspiration catheters ≥0.070 inch ID were used in 71.9% of cases. Stent retriever thrombectomy was used as the first-line modality in 59.2% and thromboaspiration in 40.8% of cases. The successful recanalization rate (modified treatment in cerebral ischemia (mTICI) 2b/3) was 94.4%, with 64.8% of the patients achieving mTICI 2b/3 after the first pass. The Walrus-related adverse event rate was 0.6%, corresponding to two vessel dissections. Functional independence was 50% (126/252) and mortality 25% (63/252). Unfavorable outcomes were more likely in older patients, who had unsuccessful reperfusion, longer procedure times, and a higher mean number of passes.

Conclusion In acute ischemic stroke patients presenting with large vessel occlusion, the Walrus BGC demonstrated excellent navigability and safety profile, allowed the accommodation of leading large bore aspiration catheters, and demonstrated high vessel recanalization rates.

Data availability statement

Data are available upon reasonable request.

http://dx.doi.org/10.1136/neurintsurg-2021-017494

First-pass effect lowers costs in treatment of acute ischaemic stroke, study finds

You have got to be fucking kidding. Measuring COST RATHER THAN 100% RECOVERY! Do you really think survivors care about cost? Talk to them sometime, you are treating them, not your bottom line. 

First-pass effect lowers costs in treatment of acute ischaemic stroke, study finds

 

Osama Zaidat, lead author

A study published in the British Medical Journal (BMJ) has found that first-pass effect (FPE), restoring complete or near complete reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] 2c-[SM1] 3) in a single pass, used as an endovascular treatment of acute ischaemic stroke, not only provides better clinical results, but also lowers health costs. Researchers found a lower cost potential per stroke patient annually, in every country studied.

The objective of the study was to assess the economic impact of achieving complete or near complete reperfusion after FPE, compared with the need for multiple passes to achieve the same level of reperfusion.

Study authors noted that, “Complete reperfusion of brain tissue is the primary goal in treatment of acute ischaemic stroke. Rapid revascularisation is vital as reduced time from symptom onset to revascularisation is strongly correlated with improved clinical and functional outcomes. Complete revascularisation with mechanical thrombectomy, a cost-effective treatment for patients with acute stroke, might require multiple passes, which prolongs procedure time and increases the risk of arterial endothelial injury.”

The analysis of revascularisation in ischaemic stroke with emboTrap study (ARISE II study) is, a prospective, single-arm, international, multicentre clinical trial, investigating the efficacy and safety of the EmboTrap device (Cerenovus) in 227 treated patients. Patient level data from the ARISE II study was used to conduct post hoc analyses on patient outcomes. The target population were patients for whom mTICI 2c–3 was achieved (n=172). Therefore, the patients from this study were split into two groups. The first was the FPE group, patients for whom mTICI 2c–3 was achieved on the first pass. The second was the non-FPE group:, patients who only achieved mTICI 2c–3 after multiple passes. Data from the ARISE II study were used to establish baseline characteristics, clinical outcomes, and healthcare resources for both the FPE and non-FPE cohorts.

The researchers then used peer reviewed literature and public market research reports to calculate the cost consequence of FPE or non-FPE results, using a determinist approach from two different perspectives: , provider and payer. These data were country specific, looking at healthcare systems in the USA, France, Germany, Italy, Spain, Sweden, and the UK with two separate time horizons. The cost analysis was based on total hospital length of stay (LOS), days in the intensive care unit, standard bed days, and devices used during the procedure. This was calculated for both FPE and non-FPE groups, which was then applied to the country specific data, creating a cost estimate for both outcomes. Finally, total costs per patient in an acute care setting were calculated from a provider perspective.

From the ARISE II study, researchers found that 76% of patients received complete or near complete reperfusion; among these, 53% were in the FPE group. Investigators reported that a higher proportion of patients in the FPE group achieved good or functional outcomes compared with the non-FPE group. Additionally, patients in the FPE group required only a single EmboTrap device, whereas 35% of patients in the non-FPE group required at least one additional device.

With regard to cost, researchers found that FPE led to potential per-patient cost savings in every country studied (US$6575 for the USA, €1560 [US$1833] for France, €2202 [US$2587] for Germany, €2901 [US$3409] for Italy, €4548 [US$5343] for Spain, Kr 29 468 [US$3364] for Sweden, and £1751 [US$2285] for the UK. Furthermore, achieving FPE led to potential per-patient annual care cost savings in the first year after stroke in every country studied (US$4116 for the USA, €2131 [US$2503] for France, €701 [US$823] for Italy, Kr 13 333 for Sweden [US$1522], and £2132 [US$2783] for the UK.

Lead author of the study Osama Zaidat (Mercy Saint Vincent Medical Center, Toledo, USA), commented, “This article showed that in patients who achieved FPE with the EmboTrap clot retrieval Device, not only achieved a better clinical outcome with single attempt vessel opening, but also resulted were also associated with significant cost saving. This should focus the future clinical research and technical innovation on identifying the best approach, devices, and clot features that would lead to this important target.”

Hyperdense vessel sign as a potential guide for the choice of stent retriever versus contact aspiration as first-line thrombectomy strategy

Where the fuck is the preliminary protocol on this while you lazily didn't do your job well enough and had to call for further studies?

Hyperdense vessel sign as a potential guide for the choice of stent retriever versus contact aspiration as first-line thrombectomy strategy

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1. http://orcid.org/0000-0002-7393-9989Mahmoud H Mohammaden1,2,
2. Diogo C Haussen1,2,
3. http://orcid.org/0000-0002-9353-1219Catarina Perry da Camara1,2,
4. Leonardo Pisani1,2,
5. Marta Olive Gadea1,2,
6. Alhamza R Al-Bayati1,2,
7. Bernardo Liberato1,2,
8. Srikant Rangaraju1,2,
9. Michael R Frankel1,2,
10. Raul G Nogueira1,2

Author affiliations

Abstract

Background The first-pass effect (FPE) has emerged as a key metric for efficacy in mechanical thrombectomy (MT). The hyperdense vessel sign (HDVS) on non-contrast head CT (NCCT) indicates a higher clot content of red blood cells.

Objective To assess whether the HDVS could serve as an imaging biomarker for guiding first-line device selection in MT.

Methods A prospective MT database was reviewed for consecutive patients with anterior circulation large vessel occlusion stroke who underwent thrombectomy with stent retriever (SR) or contact aspiration (CA) as first-line therapy between January 2012 and November 2018. Pretreatment NCCT scans were evaluated for the presence of HDVS. The primary outcome was FPE (modified Thrombolysis in Cerebral Infarction score 2c/3). The primary analysis was the interaction between HDVS and thrombectomy modality on FPE. Secondary analyses aimed to evaluate the predictors of FPE.

Results A total of 779 patients qualified for the analysis. HDVS and FPE were reported in 473 (60.7%) and 286 (36.7%) patients, respectively. The presence of HDVS significantly modified the effect of thrombectomy modality on FPE (p=0.01), with patients with HDVS having a significantly higher rate of FPE with a SR (41.3% vs 22.2%, p=0.001; adjusted OR 2.11 (95% CI 1.20 to 3.70), p=0.009) and non-HDVS patients having a numerically better response to CA (41.4% vs 33.9%, p=0.28; adjusted OR 0.58 (95% CI 0.311 to 1.084), p=0.088). Age (OR 1.01 (95% CI 1.00 to 1.02), p=0.04) and balloon guide catheter (OR 2.08 (95% CI 1.24 to 3.47), p=0.005) were independent predictors of FPE in the overall population.

Conclusion Our data suggest that patients with HDVS may have a better response to SRs than CA for the FPE. Larger confirmatory prospective studies are warranted.

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http://dx.doi.org/10.1136/neurintsurg-2020-016005

New Benchmark to Measure Angiographic Success of Recanalization in Ischemic Stroke Patients Undergoing Thrombectomy

Stupid, stupid, stupid. The goal is 100% recovery, NOT just first pass revascularization. No wonder we never get anywhere in stroke, we don't even attempt the correct goal. I don't care how fucking hard that goal is. Try recovering from a stroke with NO protocols, completely on your own.  
https://journals.heart.org/bloggingstroke/2018/07/18/new-benchmark-to-measure-angiographic-success-of-recanalization-in-ischemic-stroke-patients-undergoing-thrombectomy/?platform=hootsuite

Muhammad Zeeshan Memon, MD

Zaidat OO, Castonguay AC, Linfante I, Gupta R, Martin CO, Holloway WE, et al. First Pass Effect: A New Measure for Stroke Thrombectomy Devices. Stroke. 2018
Currently, the American Heart Association/American Stroke Association recommends mechanical thrombectomy as the standard of care for acute stroke patients with proximal artery occlusions. Multiple studies have shown complete or near-complete reperfusion achieved in a timely manner leads to improved clinical outcomes and reduced adverse effects; however, complete reperfusion is achieved in <50% of cases, and often requires many thrombectomy attempts and the use of multiple devices. This not only delays time to achieve recanalization, but also incurs additional risk of vessel spasm, injury, and rupture. Design improvement of mechanical thrombectomy devices, particularly the advent of stent retrievers, has improved recanalization rates and decreased the complication rates leading to this notion that achieving complete revascularization with a single pass should be the new angiographic goal.

In the March 2018 issue of Stroke, Zaidat et al introduced and evaluated a new metric for thrombectomy devices, the first pass effect (FPE). They studied FPE with the Solitaire FR device within a large cohort of patients from the North American Solitaire Acute Stroke (NASA) Registry database from March 2012 to February 2013 at 24 North American medical centers. They defined FPE as: (1) single pass/use of the device; (2) complete revascularization of the large vessel occlusion and its downstream territory (Modified Thrombolysis in Cerebral Infarction [mTICI] 3); and (3) no use of rescue therapy. They reported clinical and angiographic outcomes of patients between FPE and non-FPE populations.
Three hundred fifty-four patients were included in the NASA registry, out of which 25.1% achieved FPE. The study demonstrated that the FPE patients had significantly better 90-day clinical outcomes than those in the non-FPE population (mRS score <=2 61.3% versus 35.3%; P=0.01; odds ratio, 1.7; 95% confidence interval, 1.1–2.7). 90-day mortality rate (16%) and symptomatic intracranial hemorrhage rate (5.6%) was significantly lower in the FPE group compared with the non-FPE cohort. Predictors of achieving FPE were the use of balloon guided catheters, whereas the ICA terminus occlusion predicted failure to achieve FPE.
Despite these interesting findings, this study had several limitations. First, the study was not designed to study FPE rather report an observation from their registry. Secondly, the study had a small number of patients treated with the combined aspiration and stent retriever thrombectomy or aspiration-first approach, making it hard to distinguish the effect of this combination approach vs. FPE only. The authors hinted at the potential benefit of the aspiration-first approach in achieving rapid and high rate of FPE from a single attempt, but left it to future studies to address this. Nevertheless, Dr. Zaidat’s study findings reiterate the importance of early and complete reperfusion in acute ischemic stroke patients and establish FPE as a potential benchmark to measure the angiographic efficacy and a possible surrogate for clinical efficacy for emerging thrombectomy devices.