Comparative efficacy and safety of various mechanical thrombectomy strategies for patients with acute ischemic stroke: a Bayesian network meta-analysis

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Comparative efficacy and safety of various mechanical thrombectomy strategies for patients with acute ischemic stroke: a Bayesian network meta-analysis

Jiahao Meng, Zeya Yan, […], and Gang Chen+9View all authors and affiliations

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https://doi.org/10.1177/17562864231181180

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  • Introduction
  • Methods
  • Results
  • Discussion
  • Conclusion
  • Acknowledgments
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Abstract

Background:

Stent retriever, contact aspiration, and combined treatment are crucial mechanical thrombectomy strategies for patients with acute ischemic stroke (AIS).

Objectives:

The aim of this study was to compare and rank three different mechanical thrombectomy strategies for AIS due to large vessel occlusion by means of a Bayesian network meta-analysis.

Design:

A systematic review and Bayesian network meta-analysis based on PRISMA guidelines.

Data sources and methods:

Relevant randomized controlled trials (RCTs) were identified in Embase, MEDLINE, the Cochrane Library database, and Clinicaltrials.gov from inception to 15 March 2022. We used random effect models to estimate corresponding odds ratios (ORs) and rank probabilities using pairwise and Bayesian network meta-analysis. We applied the grading of recommendations assessment, development, and evaluation (GRADE) methodology to rate the certainty of evidence.

Results:

We identified 10 RCTs enrolling 2098 participants. As for modified Rankin Scale (mRS) 0–2, moderate certainty evidence established all mechanical thrombectomy strategies that were more effective than standard medical treatment [combined: log OR 0.9288, 95% credibility intervals (CrI) 0.1268–1.7246; contact aspiration: log OR 0.9507, 95% CrI 0.3361–1.5688; stent retriever: log OR 1.0919, 95% CrI 0.6127–1.5702]. The same applied to mRS 0–3 (combined: log OR 0.9603, 95% CrI 0.2122–1.7157; contact aspiration: log OR 0.7554, 95% CrI 0.1769–1.3279; stent retriever: log OR 1.0046, 95% CrI 0.6001–1.4789). Combined treatment was superior to stent retriever in substantial reperfusion (log OR 0.8921, 95% CrI 0.2105–1.5907, high certainty). Stent retriever had the highest probability of being optimal for mRS 0–2 and mRS 0–3. Standard medical treatment had the lowest risk of subarachnoid hemorrhage. For all other outcomes, combined treatment was most likely the best treatment.

Conclusion:

Our results indicated that, with the exception of functional outcome, combined treatment might be the outstanding strategy. Apart from subarachnoid hemorrhage, all three mechanical thrombectomy strategies proved better strategies than standard medical treatment.

Registration:

PROSPERO (CRD42022351878).

Introduction

Stroke is one of the leading causes of death and disability globally.¹ Meanwhile, it is the most significant contributor to neurological disability-adjusted life-years.² Acute ischemic stroke (AIS) accounts for approximately 90% of strokes per year.³ Until now, recanalization treatment involving intravenous thrombolysis and mechanical thrombectomy has been supported by class I level A recommendation as treatment strategies for AIS.⁴

Previous research demonstrates that mechanical thrombectomy can significantly reduce disability and improve clinical outcomes for patients with AIS compared with standard medical treatment.^5,6 Even the guidelines have recommended mechanical thrombectomy for large vessel occlusion in the anterior circulation up to 24 h from symptom onset.^4,7 Nevertheless, the benefits of successful revascularization using various mechanical thrombectomy strategies as the first-line therapy approach remain uncertain to date. For mechanical thrombectomy, previous guidelines recommended a stent retriever as the first-line approach.⁷ Meanwhile, contact aspiration has gained growing acceptance. In the 2019 updated guidelines, contact aspiration and stent retriever are considered as equally crucial.⁴ Contact aspiration is also proposed to shorten the time for successful reperfusion and reduce the total cost of hospitalization.⁸ However, three randomized controlled trials (RCTs), including ASTER,⁹ COMPASS,¹⁰ and a study by Tsang et al.,¹¹ confirmed that stent retriever compared with contact aspiration did not result in a greater functional outcome or higher successful revascularization rate. In accordance with several retrospective studies, contact aspiration combined with stent retriever can boost revascularization rate and may have a synergistic effect.^12,13 Nogueira et al.¹⁴ observed combined treatment versus contact aspiration alone did not significantly improve efficacy and safety outcomes. Furthermore, the ASTER2 trial revealed that stent retriever was non-inferior to combined treatment.¹⁵

As a result, clinicians and patients were perplexed by the selection of treatment strategies. Few RCTs directly compared multiple mechanical thrombectomy strategies to our knowledge. Moreover, previous researches were either conventional pairwise meta-analysis¹⁶ or network meta-analysis¹⁷ that excluded combined treatment and were published early. In this study, we systematically evaluated three different mechanical thrombectomy strategies. We conducted the pairwise meta-analysis and first Bayesian network meta-analysis to, directly and indirectly, compare their efficacy and safety as the first-line approach for the treatment of patients with AIS.

 

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