Aspiration versus stent-retriever first: a single center open-label randomized controlled trial on endovascular thrombectomy for acute large vessel occlusion stroke

Abstract

Background And Aims: There is ongoing debate regarding the optimal first-line technique for endovascular thrombectomy for acute ischemic stroke due to large vessel occlusion. We performed a randomized trial on aspiration-first versus stent-retriever-first thrombectomy in a single-center real-world setting serving an Asian (Hong Kong Chinese) population to compare their clinical efficacy, safety and cost-effectiveness. Methods: This is a single-center, prospective, open-label, randomized study comparing aspiration-first versus stent-retriever first thrombectomy. Eligible patients were randomized 1:1 to either aspiration-first or stent-retriever first, with rescue devices allowed after at least 2 failed attempts with the primary device. Patient recruitment began in October 2017 and was completed in September 2019. The primary outcome was mRS at 90 days, with secondary outcomes of TICI 2b/3 reperfusion rate, groin-to-perfusion time, procedural complications, total device cost, and mortality. Results: In total 58 patients were recruited (28 aspiration-first, 30 stent-retriever first) and were included in the final analysis. There were no significant differences in the demographics, stroke etiology and severity, and the use of IV thrombolytics between groups. Clinical outcomes between aspiration-first and stent-retriever first were comparable in terms of mRS 0–2 at 90 days (39.3% vs 33.3%, p = 0.42), TICI 2b/3 reperfusion (89.3% vs 86.7%, p = 1.00), groin-to-perfusion time (67 vs 88 minutes, p = 0.14) and mortality (10.7% vs 30%, p = 0.11). Aspiration-first approach was associated with less use of rescue strategy (28.6% vs 63.3%, p = 0.01) and a trend of lower total device cost (US$7,746 vs $9800, p = 0.06). Conclusions: Aspiration-first thrombectomy was non-inferior to stent-retriever first strategy and maybe more cost-efficient as a first-line thrombectomy technique in our population.