Should a 'Three Strikes' Rule Apply to Stroke Thrombectomy?

What is so bad about this is that your doctors have NOTHING TO GET YOU 100% RECOVERED regardless of the success or failure of clot retrieval.

 

Should a 'Three Strikes' Rule Apply to Stroke Thrombectomy?

Reconsider forging ahead with repeated clot retrieval attempts, study suggests

by Nicole Lou, Staff Writer, MedPage Today June 23, 2021

Operators considering multiple clot retrieval attempts in mechanical thrombectomy may need to take a step back, a retrospective study suggested.

With each additional attempt, there was a greater incidence of emboli moving to a new territory, reflecting potential clot fragmentation, and an accompanying increase in infarct growth, reported researchers led by Wagih Ben Hassen, MD, of Sainte-Anne Hospital and the University of Paris Descartes.

Infarct growth was in turn an independent predictor of worse functional outcome (modified Rankin Scale [mRS] score >2) at 3 months (adjusted OR 1.05 per 1-mL increase, 95% CI 1.02-1.07), the group noted in Neurology.

It was important that the study found more retrieval attempts to be associated with emboli in new territories and larger infarct growth independently of procedural time, commented Johanna Fifi, MD, of the Icahn School of Medicine at Mount Sinai in New York City, who was not involved in the study.

"The key take home for me is that in thrombectomy, your first attempt at retrieval should be optimized as much as possible -- the techniques for doing this are still under debate. The new standard for judging thrombectomy technical outcome [will] be the so-called 'first pass effect' -- what percentage of the time can you get the vessel open on the first attempt," she wrote in an email to MedPage Today.

However, "caution is needed when using retrieval attempt metrics as prognostic predictors," the study authors noted, adding that 45% of patients still had a favorable outcome when successful recanalization was achieved after a third clot retrieval attempt.

"Successful recanalization, even after multiple attempts is still better than no recanalization," the group emphasized.

"Consequently, in our opinion, it is irrelevant to suggest some sort of 'three strikes law' for endovascular procedures in [acute ischemic stroke due to large vessel occlusion], and one should rather draw attention to the potential impact of multiple [clot retrieval attempts] and encourage operators to use the best technique available to achieve full recanalization with a minimal number of maneuvers," wrote Ben Hassen and colleagues.

Fifi said she agreed with the authors' recommendations against a limit to retrieval attempts. "Multiple randomized trials have shown the tremendous efficacy of thrombectomy for [emergent large vessel occlusion] stroke; and there is sufficient data to say that an open vessel is better than a closed one for the patients," she noted.

Seemant Chaturvedi, MD, of the University of Maryland School of Medicine in Baltimore, said that a "three strikes" rule is "reasonable in the majority of patients, but care must always be individualized."

"In younger patients with embolic-appearing occlusions, going beyond three attempts can at times be useful," he told MedPage Today, noting that factors such as underlying high-grade intracranial stenosis or vasculopathy can lead to multiple retrieval attempts in thrombectomy.

Ben Hassen and colleagues based their study on two registries of stroke patients who underwent mechanical thrombectomy in 2o16-2019 at one of two French comprehensive stroke centers. The study included 419 patients who achieved successful recanalization (i.e., expanded Thrombolysis in Cerebral Infarction Scale scores 2b, 2c, or 3).

Successful recanalization was achieved after one clot retrieval attempt in 53.5% of patients, two attempts in 25.5%, three attempts in 11.7%, and four or more attempts in 9.3%.

The investigators acknowledged the potential for confounding in their retrospective study. Moreover, 12% of 90-day mRS scores were missing, they said.

"These findings highlight the need for a randomized trial to define the appropriate therapeutic strategy when a first clot retrieval attempt is unsuccessful," they concluded.

• 

  Nicole Lou is a reporter for MedPage Today, where she covers cardiology news and other developments in medicine. Follow

Disclosures

Ben Hassen reported no disclosures.

Fifi reported consultant work for Stryker, Penumbra, and Cerenovus, and stock in Imperative Care.

Chaturvedi reported no disclosures.

Primary Source

Neurology

Source Reference: Ben Hassen W, et al "Impact of repeated clot retrieval attempts on infarct growth and outcome after ischemic stroke" Neurology 2021; DOI: 10.1212/WNL.0000000000012321.

 

More than one clot retrieval attempt after stroke causes decline in functional outcomes

 What is so bad about this is that your doctors have NOTHING TO GET YOU 100% RECOVERED  regardless of the success or failure of clot retrieval. Of course your doctors and hospital don't bother telling you they are complete failures in everything to do in stroke. Ask for their statistics proving success, you'll find neither statistics nor success.

More than one clot retrieval attempt after stroke causes decline in functional outcomes

Repeated attempts to retrieve a clot in patients with acute stroke increased both the rate of emboli to new territory and infarct growth volume, with an impact on functional outcomes even when recanalization was successful.

Researchers published the findings in Neurology.

Repeated attempts to retrieve a clot in patients with acute stroke correlated with worse functional outcomes, according to findings published in Neurology. Source: Adobe Stock

“These findings highlight the need for a study to determine the appropriate strategy to use when the first attempt at retrieving a blood clot is unsuccessful, since each additional attempt reduced the odds of a favorable outcome,” Wagih Ben Hassen, MD, of the French National Institute for Health and Medical Research in Paris, said in a press release.

Research recently identified the number of clot retrieval attempts as a marker of clinical outcome, regardless of final recanalization success, with a “detrimental” effect of more clot retrieval attempts on 3-month functional outcomes, whereas the ability to achieve complete recanalization on the first clot retrieval attempt correlated with a favorable outcome and reduced mortality. However, the impact of more clot retrieval attempts on functional outcomes “is not straightforward and has not yet been explained,” according to the researchers.

“Additional [clot retrieval attempts] could result in an increased per procedural clot fragmentation, leading to emboli to new (initially unaffected) territory, associated with [infarct growth] and potentially explaining the detrimental effect of [clot retrieval attempts] on functional outcome,” Hassen and colleagues wrote. “In this study, we aimed to elucidate the link between the number of [clot retrieval attempts] and the functional outcome in a successfully recanalized population.”

The researchers obtained data from two pooled, multicentric prospective registries of patients with consecutive anterior acute ischemic stroke caused by large vessel occlusion who were treated with mechanical thrombectomy between January 2016 and January 2019. Specifically, Hassen and colleagues included patients who received pretreatment and post-treatment at 24 hours with diffusion-weighted imaging and successful recanalization, which was defined as expanded Thrombolysis in Cerebral Infarction Scale (eTICI) scores of 2B, 2C or 3. They evaluated emboli to new territory and measured infarct growth using voxel-based segmentation after diffusion-weighted imaging coregistration. Hassen and colleagues also examined correlations between the number of clot retrieval attempts, emboli to new territory, infarct growth and outcomes at 3 months.

The study included 419 patients in whom successful recanalization was achieved (43.9% men; mean age, 68 years).

Hassen and colleagues found that emboli to new territory “strongly correlated” with a greater number of clot retrieval attempts, with 23 cases (5.5%) in the entire study population, two cases (1%) in the group with one clot retrieval attempt, three cases (2.8%) in the group with two clot retrieval attempts, seven cases (14.3%) in the group with three clot retrieval attempts and 11 cases (28.2%) in the group with four or more clot retrieval attempts.

Patients with emboli to new territory experienced higher infarct growth volume compared with the group with no emboli to new territory (P = .01). Patients with one clot retrieval attempt demonstrated the lowest infarct growth volume (P = .001) and the lowest rates of emboli to new territory (P = .01). Infarct growth increased linearly with the number of clot retrieval attempts, according to the study results.

“In multivariable linear regression, number of [clot retrieval attempts] and [emboli to new territory] were associated with [infarct growth] among poor collateral status, blood glucose level and initial NIH [stroke scale] score independently from time metrics (procedure time or onset-to-recanalization time),” Hassen and colleagues wrote.

Poor functional outcome, which the researchers defined as a 3-month modified Rankin scale score of greater than 2, increased with each new clot retrieval attempt, according to the study results. Specifically, symptomatic intracranial hemorrhage rates rose with the number of clot retrieval attempts; patients with one retrieval attempt had the lowest rate of symptomatic intracranial hemorrhage (5.8%), compared with rates of 8.4% in the group with two clot retrieval attempts, 6.1% in the group with three clot retrieval attempts and 10% in the group with four or more clot retrieval attempts. Favorable functional outcomes also declined with each additional clot retrieval attempt among the group of patients who were successfully recanalized. Infarct growth served as an independent predictor of unfavorable outcomes (OR = 1.05) per 1 mL increase in infract growth, according to binary logistic regression analysis.

“Achieving successful removal of blood clots and clearing these blood vessels with the fewest number of attempts, and ideally with a single pass, appears to be the new goal,” Ben Hassen said in the press release. “This underlines the need to develop a new generation of devices designed to increase the rate of complete success at the first attempt.”

Reference:

American Academy of Neurology. After stroke, more than one try to remove blood clots may be tied to worse outcome. Available at: https://www.aan.com/PressRoom/Home/PressRelease/4904. Accessed June 23, 2021.