A Medical University of South Carolina study report promising 90-day outcomes for stroke patients with large-vessel clots who underwent thrombectomy or clot removal using the direct-aspiration, first pass technique (ADAPT).
Approximately 58% of stroke patients with a large-vessel clot removed using the technique achieved a good outcome at 90 days, defined as a Modified Rankin Score (mRS) of 0 to 2.
ADAPT aims to remove the clot in its entirety with a large-diameter aspiration catheter in a single pass. In contrast, stent retrievers, currently considered standard of care, frequently fragment the clot for removal and can require several passes.
ADAPT was developed by MUSC Health neuro-endovascular surgeons Dr M Imran Chaudry, Dr Alejandro M Spiotta, Dr Aquilla S Turk and Dr Raymond D Turner. MUSC Health neurosurgery resident Dr Jan Vargas, is first author on the article.
“The goal in ADAPT is to take the largest-bore catheter available up to the blood clot and put suction where it’s blocked and pull it out of the head to reestablish flow in that blood vessel,” said Turk. If the first-pass attempt is unsuccessful, stent retrievers can still be used to remove the clot.
Investigators report the results of a retrospective study of 191 consecutive patients with acute ischemic stroke who underwent ADAPT at MUSC Health. In 94.2% of patients, blood vessels were successfully opened – by direct aspiration alone in 145 cases and by the additional use of stent retrievers in another 43 cases. Good outcomes at 90 days (mRS, 0-2) were achieved in 57.7% of patients who were successfully revascularized with aspiration alone and in 43.2% of those who also required a stent retriever. The average time required to reopen the blocked blood vessels was 37.3 minutes – 29.6 minutes for direct aspiration alone and 61.4 minutes for cases that also required stent retrievers. Patients presented for thrombectomy on average 7.8 hours after stroke onset.
These results confirm the promise of ADAPT, which was first described by the MUSC Health team in a seminal 2014 article. Since the publication of that article, a number of single-centre series studies have reported impressive recanalisation times (the time it takes to open the blood vessel) and good neurological outcomes with ADAPT using a large-bore catheter, suggesting that it could offer an alternative approach to stent retrievers for mechanical thrombectomy.
Stent retrievers have been considered standard of care for stroke patients since the publication in the October 2015 issue of Stroke of a scientific statement on thrombectomy by the American Heart Association. That statement recommended rapid clot removal in addition to tissue plasminogen activator (tPA), a clot-busting drug that can minimize stroke complications if administered in a tight time window. The recommendation was based on the promising findings of five large clinical trials comparing treatment with tPA alone versus treatment with tPA plus thrombectomy using stent retrievers in large-vessel clots: MR CLEAN, EXTEND-IA, ESCAPE, SWIFT PRIME, and REVASCAT.
A definitive answer as to whether ADAPT could likewise become standard of care for stroke patients with large-vessel clots will require clinical trials comparing the efficacy of the direct aspiration technique versus stent retrievers in this population of stroke patients.
The MUSC Health neuro-endovascular surgery team is currently running the COMPASS trial (COMParison of ASpiration vs Stent retriever as first-line approach; Clinicaltrials.gov identifier NCT02466893) in conjunction with colleagues Dr J Mocco of Mount Sinai and Dr Adnan Siddiqui of the University of Buffalo. The trial is randomising patients to either ADAPT or a stent retriever as the initial thrombectomy technique. The trial, scheduled to enrol 270 patients, has enrolled 90 patients in the past year at ten sites in the US.
Introduction: The direct aspiration first pass technique (ADAPT) has been introduced as a simple and fast method for achieving good angiographic and clinical outcomes using large bore aspiration catheters for the treatment of acute ischemic stroke (AIS). We present a single center’s long term experience with ADAPT.
Methods: Retrospective analysis of a database was gathered on patients undergoing stroke thrombectomy with ADAPT at a stroke center. Speciﬁc parameters captured included age, gender, National Institutes of Health Stroke Scale (NIHSS) score at presentation, time to presentation from last normal, and modiﬁed Rankin Scale (mRS) score at the 90 day follow-up. Radiological and angiographic imaging was reviewed to document the location of the vascular occlusion, Thrombolysis in Cerebral Infarction (TICI) ﬂow postprocedure, and procedural complications.
Results:191 consecutive patients who suffered an AIS treated with ADAPT were reviewed; 91 were women, and mean age was 67 years. Patients presented with a mean NIHSS score of 15.4, and 71 patients received intravenous tissue plasminogen activator. The average time from onset to puncture was 7.8 h. The average time for recanalization was 37.3 min. TICI 2B or better recanalization was achieved in 180 (94.2%) patients. 98 (54.1%) patients had an mRS of 0–2 at 90 days. Direct aspiration alone was performed in 145 cases, and 43 cases required the additional use of a stent retriever. There was no significant difference in presenting NIHSS score, average time to presentation, average mRS at 90 days, or 90 day mortality between the two groups. Time to recanalization was 29.6 min for direct aspiration compared with 61.4 min in cases that required adjunct devices (p=0.00000201). 79 (57.7%) patients who underwent direct aspiration only achieved a good outcome at 90 days (mRS 0–2) compared with 19 (43.2%) who underwent adjunct therapies (p=0.12).
Conclusions: ADAPT is an effective method to achieve good clinical and angiographic outcomes, and serves as a useful firstline method for revascularization.
Jan Vargas, Alejandro Spiotta, Kyle Fargen, Raymond Turner, Imran Chaudry, Aquilla Turk
Introduction: Conventional Onyx embolization of cerebral arteriovenous malformations (AVMs) requires lengthy procedure and fluoroscopy times to form an adequate ‘proximal plug’ which allows forward nidal penetration while preventing reflux and non-targeted embolization. We review our experience with balloon-augmented Onyx embolization of cerebral AVMs using a dual-lumen balloon catheter technique designed to minimize these challenges.
Methods: Retrospectively acquired data for all balloon-augmented cerebral AVM embolizations performed between 2011 and 2014 were obtained from four tertiary care centers. For each procedure, at least one Scepter C balloon catheter was advanced into the AVM arterial pedicle of interest and Onyx embolization was performed through the inner lumen after balloon inflation via the outer lumen.
Results: Twenty patients underwent embolization with the balloon-augmented technique over 24 discreet treatment episodes. There were 37 total arterial pedicles embolized with the balloon-augmented technique, a mean of 1.9 per patient (range 1–5). The treated AVMs were heterogeneous in their location and size (mean 3.3±1.6 cm). Mean fluoroscopy time for each procedure was 48±26 min (28 min per embolized pedicle). Two Scepter C balloon catheter-related complications (8.3% of embolization sessions, 5.4% of pedicles embolized) were observed: an intraprocedural rupture of a feeding pedicle and fracture and retention of a catheter fragment.
Conclusions:This multicenter experience represents the largest reported series of balloon-augmented Onyx embolization of cerebral AVMs. The technique appears safe and effective in the treatment of AVMs, allowing more efficient and controlled injection of Onyx with a decreased risk of reflux and decreased fluoroscopy times.
Alejandro M Spiotta, Robert F James, Stephen R Lowe, Jan Vargas, Aquilla S Turk, M Imran Chaudry, Tarun Bhalla, Rashid M Janjua, John J Delaney, Stacey Quintero-Wolfe, Raymond D Turner