Direct aspiration as good as stent retriever as first-line strategy in acute ischemic stroke

Patients with a large vessel occlusion stroke (LVO) do just as well when treated with a direct aspiration first pass (ADAPT) approach as those treated with a stent retriever first-line (SRFL) approach, according to findings presented at the International Stroke Conference in Los Angeles, CA. Currently, stent retrievers are the standard of care for mechanical thrombectomy in patients suffering acute ischemic stroke.

The finding comes from a prospective, randomized, open-label clinical trial known as COMPASS (COMparison of direct ASpiration vs Stent retrieval), which compared ADAPT with SRFL in 270 adult patients with acute ischemic stroke.

The data strongly demonstrate “that the two approaches are clinically equivalent,” said J Mocco, MD, MS, vice chair of neurosurgery and director of the Cerebrovascular Center for the Mount Sinai Health System, who presented the findings at the conference. “COMPASS is the first trial designed to compare patient functional outcome between these treatment approaches, and we found that patients do equally well with either treatment.”

Both procedures are initiated by inserting a guide catheter into the femoral artery and advancing it into the brain under imaging. With the aspiration approach, a large-bore catheter is inserted and advanced into the proximal area of the clot, which is then suctioned out. The stent retriever approach involves introducing a wire cage device to trap and remove the clot.

COMPASS enrolled patients within 6 hours of symptom onset who presented to one of six participating high-volume centers. To be eligible, patients had to have a National Institutes of Health Stroke Scale score >5, a large-vessel proximal occlusion (distal internal carotid artery through middle cerebral artery bifurcation), and a prestroke modified Rankin Scale (mRS) score of 0 to 1.

Primary outcome was the degree of functional independence, defined as a score of 0 to 2 on the mRS. The ADAPT technique was found to be noninferior to stent retrievers, with 52% of patients treated with aspiration achieving the primary endpoint compared with 49% of patients treated with stent retrievers.

Aspiration showed a nonsignificant trend toward faster reperfusion, with a 10-minute advantage. The final rates of reperfusion success were comparable at 92% with ADAPT and 89% with stent retrievers. The percentage of patients achieving full reperfusion—defined as Thrombolysis in Cerebral Infarction of grade 3—was 38% for the ADAPT arm and 29% for the stent retriever arm.

The rates of secondary safety endpoints, including embolization in new territory and symptomatic intracranial hemorrhage, were not significantly different between the two approaches.

Results from this new study show that an aspiration-first strategy is at least as effective as using retrievable stents, and suggest that it may even be faster.

“This study is very exciting because it shows that there are other ways to open the arteries that are just as effective and perhaps, less expensive,” Dr. Mocco said. “Whether you approach the brain clot with suction or whether you approach it with trapping and pulling it out, patients do equally well. Stroke is a massive disease that is prevalent across the globe, so finding ways to provide these therapies to patients who need it in a cost-effective manner is going to be another great step forward in medicine.”