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Effect of Thrombectomy With Combined Contact Aspiration and Stent Retriever vs Stent Retriever Alone on Revascularization in Patients With Acute Ischemic Stroke and Large Vessel OcclusionThe ASTER2 Randomized Clinical Trial

Educational Objective
To understand the goals of mechanical thrombectomy for treatment of anterior circulation large vessel occlusion stroke.
1 Credit CME
Key Points

Question  Among patients with acute ischemic stroke and large vessel occlusion, does an initial thrombectomy technique consisting of contact aspiration and stent retriever combined improve the reperfusion rate compared with stent retriever alone?

Findings  In this randomized clinical trial that included 408 patients, the rate of near-total or total reperfusion on the extended Thrombolysis in Cerebral Infarction scale of 2c or 3 (eTICI 2c/3) at the end of the endovascular procedure was not significantly different in the combined contact aspiration and stent retriever group compared with the stent retriever alone group (64.5% vs 57.9%; adjusted odds ratio, 1.33).

Meaning  Among patients with acute ischemic stroke due to large vessel occlusion, an initial thrombectomy technique consisting of contact aspiration and stent retriever combined did not significantly improve the rate of near-total or total (eTICI 2c/3) reperfusion at the end of the endovascular procedure as compared with stent retriever alone.

Abstract

Importance  Mechanical thrombectomy using a stent retriever or contact aspiration is widely used for treatment of patients with acute ischemic stroke due to anterior circulation large vessel occlusion, but the additional benefit of combining contact aspiration with stent retriever is uncertain.

Objective  To determine whether mechanical thrombectomy for treatment of anterior circulation large vessel occlusion stroke with initial contact aspiration and stent retriever combined results in better final angiographic outcome than with standard stent retriever alone.

Design, Setting, and Participants  This trial was a multicenter randomized, open-label, blinded end point evaluation that enrolled 408 patients from October 16, 2017, to May 29, 2018, in 11 French comprehensive stroke centers, with a 12-month outcome follow-up. Patients with a large vessel occlusion in the anterior circulation were included up to 8 hours after symptom onset. The final date of follow-up was June, 19, 2019.

Interventions  Patients were randomly assigned (1:1 allocation) to receive initial thrombectomy with contact aspiration and stent retriever combined (205) or stent retriever alone (203).

Main Outcomes and Measures  The primary outcome was the rate of expanded Thrombolysis In Cerebral Infarction score of 2c or 3 (eTICI 2c/3; ie, scores indicate near-total and total reperfusion grades) at the end of the procedure.

Results  Among the 408 patients who were randomized, 3 were excluded, and 405 (99.3%) patients (mean age, 73 years; 220 [54%] women and 185 [46%] men) were included in the primary analysis. The rate of eTICI 2c/3 at the end of the endovascular procedure was not significantly different between the 2 thrombectomy groups (64.5% [131 of 203 patients] for contact aspiration and stent retriever combined vs 57.9% [117 of 202 patients] for stent retriever alone; risk difference, 6.6% [95% CI, –3.0% to 16.2%]; adjusted odds ratio [OR], 1.33 [95% CI, 0.88 to 1.99]; P = .17). Of 14 prespecified secondary efficacy end points, 12 showed no significant difference. A higher rate of successful reperfusion was achieved in the contact aspiration combined with stent retriever group vs the stent retriever alone group (eTICI 2b50/2c/3, 86.2% vs 72.3%; adjusted OR, 2.54 [95% CI, 1.51 to 4.28]; P < .001) and of near-total or total reperfusion (eTICI 2c/3, 59.6% vs 49.5%; adjusted OR, 1.52 [95% CI, 1.02 to 2.27]; P = .04) after the assigned initial intervention alone.

Conclusions and Relevance  Among patients with acute ischemic stroke due to large vessel occlusion, an initial thrombectomy technique consisting of contact aspiration and stent retriever combined, compared with stent retriever alone, did not significantly improve the rate of near-total or total reperfusion (eTICI 2c/3) at the end of the endovascular procedure, although the trial may have been underpowered to detect smaller differences between groups.

Trial Registration  ClinicalTrials.gov Identifier: NCT03290885

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Article Information

Corresponding Author: Bertrand Lapergue, MD, PhD, Stroke Center Neurology Division, Hôpital Foch, 40 Rue Worth, Suresnes, France, 92150 (b.lapergue@hopital-foch.org).

Accepted for Publication: July 30, 2021.

Author Contributions: Drs Piotin and Lapergue had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Lapergue, Blanc, Consoli, Renaud, Labreuche.

Acquisition, analysis, or interpretation of data: Lapergue, Costalat, Desal, Saleme, Spelle, Marnat, Shotar, Eugene, Mazighi, Houdart, Consoli, Rodesch, Bourcier, Bracard, Duhamel, Maacha, Lopez, Labreuche, Gory, Piotin.

Drafting of the manuscript: Lapergue, Blanc, Desal, Rodesch, Labreuche, Piotin.

Critical revision of the manuscript for important intellectual content: Lapergue, Blanc, Costalat, Saleme, Spelle, Marnat, Shotar, Eugene, Mazighi, Houdart, Consoli, Bourcier, Bracard, Duhamel, Maacha, Lopez, Renaud, Gory, Piotin.

Statistical analysis: Duhamel, Labreuche.

Obtained funding: Lapergue, Renaud.

Administrative, technical, or material support: Lapergue, Costalat, Saleme, SPELLE, Marnat, Houdart, Maacha, Lopez, Renaud.

Supervision: Lapergue, Blanc, Costalat, Consoli, Bourcier, Maacha, Gory, Piotin.

Other: Shotar.

Conflict of Interest Disclosures: Dr Lapergue reported grants from Stryker Neurovascular, Penumbra, Balt, and MicroVention during the conduct of the study; and nonfinancial support for travel from Medtronic and personal fees for speaker honoraria from Penumbra outside the submitted work. Dr Costalat reported grants from Medronic, Stryker, Cerenovus, Balt, and MicroVention outside the submitted work. Dr Spelle reported personal fees from MicroVention, Medtronic, and Balt; and other (hospital grant) from Philips outside the submitted work. Dr Marnat reported personal fees (for paid lectures) from Medtronic and MicroVention outside the submitted work. Dr Eugene reported personal fees from Biomodex outside the submitted work. Dr Mazighi reported personal fees (for consulting) from Acticor Biotech, Air Liquide, Boerhinger Ingelheim, Servier, Medtronic, and Amgen; and personal fees (for paid lectures) from Servier, Amgen, Medtronic, and AstraZeneca outside the submitted work. Dr Bracard reports personal fees from General Electric Medical Systems and nonfinancial support from MicroVention Europe outside the submitted work. Dr Renaud reported grants from the French health ministry Programme Hospitalier Recherche Clinique (PHRC), MicroVention, Penumbra, and Stryker during the conduct of the study. Dr Piotin received institutional grants from Stryker, Medtronic, MicroVention and Balt outside the submitted work. No other disclosures were reported.

Funding/Support: This research was sponsored by Foch Hospital, University of Versailles Saint-Quentin-en-Yvelines. Research grants were provided by Penumbra, Stryker, MicroVention, and by PHRC (PHRC-N-17-0292).

Role of the Funder/Sponsor: The study sponsors were not involved in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Nonauthor Collaborators List: See Supplement 4.

Data Sharing Statement: See Supplement 5.

Additional Contributions: We thank Malek Ben Maacha, MSc, clinical research associate (Department of Diagnostic and Interventional Neuroradiology, Rothschild Foundation, Paris, France) for serving as the main clinical research associate for the trial and Mary Osborne-Pellegrin, PhD, INSERM 1148, Paris, France, for help in editing the final draft of the manuscript. Neither individual received compensation for their work related to this study.

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