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
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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