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Thirteen years after the initial publication outlining the potential benefits of ADAPT (a direct aspiration first-pass technique) in stroke thrombectomy, the approach is being adopted by an increasing number of neurointerventionists and continues to evolve. Here, NeuroNews takes a closer look at the core principles, clinical data and firsthand experiences associated with the latest advancement of this technique: ADAPT 2.0.
As first author on the 2013 publication that debuted ADAPT, Aquilla Turk (Prisma Health, Greenville, USA) played a central role in introducing this revolutionary concept into the field of interventional stroke care.1 And, today, as Imperative Care’s chief medical officer, he continues to drive progress in aspiration thrombectomy.
Looking back in time, however, Turk recalls that serendipity—as opposed to problem-solving innovation—sparked the initial idea behind direct aspiration.
“We were doing a [thrombectomy] case and, when we pulled the stent retriever through the aspiration catheter, the stent retriever looked brand new,” he says. “But, the aspiration catheter was clogged up, so we pulled it out, and the clot was hanging out of the end of the catheter.”
From that happy accident—and following a handful of cases where Turk and his colleagues saw continued success in advancing an aspiration catheter to the face of the clot and extracting it without a stent retriever—the ADAPT concept snowballed. And, while the technique by no means worked in every case, Turk remembers thinking, “wow, we’ve never done anything this quickly and easily before” in stroke thrombectomy.
This being the neurointerventional space, however, things have progressed markedly over the subsequent decade, with a number of companies developing larger, more trackable catheters tailored specifically to the neurovasculature.
In Turk’s view, a key milestone in this evolution is ADAPT 2.0—a concept that he also describes as a premise upon which Imperative Care was founded. ADAPT 2.0 is the culmination of the company’s attempts to improve “every step along the way” in aspiration thrombectomy, from navigating past the aortic arch to reach the cerebral vessels, to trackability in more distal locations like the M2 segment of the middle cerebral artery (MCA), to engagement and ingestion of the clot itself, and even visualisation of the clot once it has been captured.
ADAPT 2.0 ultimately consists of three key components: 0.088-inch intracranial access, an asymmetric catheter tip, and continuous dual aspiration (CDAT).
Turk explains that the first of these components carries a myriad of potential advantages. By positioning an atraumatic 0.088-inch access catheter above the patient’s neck—meaning it is effectively “anchored” around one or more vessel curvatures at the base of the skull—operators have a stable platform from which to deliver aspiration catheters quickly and effectively to the target site to remove the clot and restore blood flow rapidly. Furthermore, Turk notes that, in his experience, this closer proximity to the target clot helps improve control during the procedure, and makes performing additional passes quicker and easier while also providing a degree of flow attenuation that may aid clot retrieval.
Next up is the asymmetric tip—a feature that, according to Turk, “really sets these catheters apart”, creating a 15% larger surface area that improves clot engagement and exerts a greater degree of force onto the clot during aspiration.2
“The asymmetric tip also alters the physics of how the clot is engaged,” he explains. “If you look at the vector forces that are influencing the clot, it essentially twists and torques the clot against the vessel wall, which helps to more easily break those forces that are present when a clot is embedded in an artery. In addition, whereas we see clots being pulled straight into the end of a conventional catheter and then ‘mushrooming’, the asymmetric design means the clot is almost being rotated and tumbled when it engages with the catheter tip, and I think that’s why we’re now seeing more frequent ingestion than we did before.”
CDAT, meanwhile, perhaps represents the most novel aspect of all within ADAPT 2.0, introducing a concept whereby two catheters—one housed within the other—both simultaneously generate aspiration throughout the procedure via a single vacuum source. This simple approach was designed to maximise clot ingestion without adding extra time and while maintaining procedural efficiency.
“There has been a stepwise evolution in aspiration thrombectomy and, with the combination of these novel innovations that lead to ADAPT 2.0, we’ve seen results that are notably better,” Turk comments, citing a significant reduction in the need for stent retrievers as well as fast procedure times in his own practice.
And, with results from the Imperative Trial now also available—having been published in the Journal of NeuroInterventional Surgery (JNIS) last year—Turk believes this latest data release “speaks for itself”. Based upon analyses of a cohort of 211 patients submitted to the US Food and Drug Administration (FDA) in support of clearance of the Zoom System, the study produced a median modified thrombolysis in cerebral infarction (mTICI) 2b–3 recanalisation time of 19 minutes and a symptomatic intracranial haemorrhage (sICH) rate of 0.9%, while 4.7% of cases required rescue therapy using a stent retriever.3
“These results show meaningful outcomes in all the important areas we’ve talked about, including speed, safety and efficiency,” Turk adds.
ADAPT 2.0 in the real world
While “a lot of important information” was undoubtedly generated by the original Imperative Trial, Maxim Mokin (University of South Florida, Tampa, USA) and his colleagues recently sought to move the needle once again by examining the real-world utility of ADAPT 2.0—doing so via a multicentre, retrospective review of 124 consecutive ischaemic stroke cases treated using the Zoom Stroke System (Imperative Care) and CDAT.
Mokin himself presented findings from this analysis at the 2025 Society of Vascular and Interventional Neurology (SVIN) annual meeting (19–22 November, Orlando, USA), reporting that—across an all-comers patient population with a “very diverse” range of occlusion locations—researchers observed a “remarkable” median procedure time of 17 minutes and a median of one pass per procedure. These analyses also revealed rates of 97% and 80% for final mTICI 2b–3, and mTICI 2c–3, respectively.4
“As an operator, I want to be fast,” Mokin says. “I want to treat a stroke in the shortest amount of time possible because we know very well from prior literature that, the longer the procedure takes, the more damage we then see in terms of clinical recovery. In this series, we achieved a first-pass effect in more than half of the patients, and the procedures were extremely fast—and, in my experience, the two tend to correlate. If you have a procedure that requires an average of one pass and only takes 17 minutes, how can you get faster than that?”
Additionally, while the true clinical ramifications of attaining mTICI 2b–3 versus 2c–3 recanalisation are not fully known, achieving high rates for both remains of paramount importance in every thrombectomy treatment.
“Ideally, we want a procedure that is fast, with the minimal number of passes, and that provides complete or near-complete reperfusion; you really want to nail all three in every case, where possible, rather than settling for one or two,” Mokin explains.
Following on from these positive early indications, the prospective ADAPT 2.0 Study has now begun enrolment, with Mokin serving as co-national principal investigator alongside David Fiorella (Stony Brook Medicine, Stony Brook, USA), Shahram Majidi (Mount Sinai, New York, USA) and Justin Mascitelli (UT Health San Antonio, San Antonio, USA). Investigators expect to enrol a maximum of 750 patients across up to 50 US sites, with rates of mTICI 2c–3 recanalisation and embolisation to new territory (ENT) being among the study’s primary endpoints of interest.
“The prospective study is anticipated to be important in terms of validating our findings, and showing us what is happening in the real world on a daily basis,” Mokin adds. “With independent, core-lab-adjudicated imaging analysis and independently adjudicated safety outcomes, we hope to define where the differences truly are, in which patients, and also with what types of occlusions. Our initial analysis wasn’t that granular, partly because of the sample size, which was decent but not powered for those small details; it was about proving feasibility and looking for that early signal.”
Another finding Mokin is eager to examine further in the prospective study is something that was initially found within the analysis he presented at SVIN 2025: the fact that 27% of cases saw clots ingested into both the inner (smaller) and outer (larger) aspiration catheters during CDAT, while an additional 9% saw clots ingested into the larger, outer catheters alone.6 For Mokin, this begs the question of what would have happened in these patients if they had only been treated with traditional, single-catheter aspiration. In his view, at best, many would likely require additional passes and may still fail to achieve sufficient recanalisation; at worst, “that clot is heading deeper into the brain”.
“Once you start seeing those clots in the outer [catheter] quite frequently, you realise how many you could’ve missed without it,” Mokin continues. “One could argue, 9% is only a single-digit number, is it really a big deal? My answer would be yes; for the sake of a simple modification that actually makes your life easier, you are capturing clots in 9% of cases where you would otherwise have to do another pass. In this day and age, given how good our thrombectomy devices are now, 9% is huge.”
This early-stage yet intriguing outcome also highlights the potential benefits that may be carried by CDAT—and ADAPT 2.0 more generally—according to Mokin.
“With CDAT, I no longer think of the guide catheter as simply providing access; it becomes a more active component as an aspiration catheter, working in conjunction with the inner catheter to provide dual aspiration, “he explains. “CDAT is intended to make the aspiration you would normally achieve with a single catheter more effective, and more adaptable across different anatomies and clot types, because you have an extra safety basket. And it’s not forcing you to use a new tool—it’s allowing you to leverage a setup that you already have. In my experience, it’s reliable and simple to do, and you can use the same setup for almost every case [with the main exception being tandem occlusions]. That’s why I became a believer.”
An optimised thrombectomy setup
Earlier this year, Imperative Care launched the Zoom 4S catheter—a new product intended to facilitate thrombectomy treatments in more distal locations, further expanding the capabilities of the company’s Zoom Stroke System alongside its existing Zoom 88 and Zoom 7X catheters. As it pertains to ADAPT 2.0, the larger Zoom 88 catheter is used to provide intracranial access and administer aspiration in proximal locations, with the midsized Zoom 7X and smaller Zoom 4S catheter allowing physicians to advance more distally where required.
Among the key advantages of this setup is the fact the operator has all three catheters at their disposal from the outset of any given case. That is according to Josh Abecassis (University of Louisville, Louisville, USA) who is one of many physicians now employing this triumvirate of catheters—dubbed the ‘Zoom Stack’—in clinical practice.
“I really like the fact that, right out of the gate, I have a single stack with three different catheters available for aspirating a broad range of clot locations,” he reports. “It’s not uncommon that you get some fragmentation when you initially aspirate the clot, and I like having a smaller catheter readily available rather than having to get another device out in order to go up and do another pass.”
Between the increased support offered by Zoom 88, the trackability of Zoom 7X thanks to its self-orienting tip, and the Zoom 4S’s ability to both act as a rail for advancing the larger catheters and extract clots in more distal locations “as needed”, Abecassis feels the Zoom Stack represents a dependable setup that is well-suited to the unpredictability of ischaemic stroke care.
“The main thing that Zoom has revolutionised—in my opinion—is that it sets you up for success in tackling severe tortuosity and really complex anatomies in a way that [has been challenging] with conventional catheters,” he adds. “Zoom has absolutely enhanced our success rates in complex and more basic anatomies, but the results are much more palpable in the complex cases because they’re the ones that have historically made us suffer.”
The ever-growing uptake of tenecteplase—a simpler and potentially more effective alternative to alteplase—for intravenous thrombolysis, while advantageous overall, represents one of the many variables that makes modern interventional stroke care so challenging. Tenecteplase is known to be associated with increased clot migration versus alteplase, with a JNIS paper from March 2026 revealing that this “frequent and time-related” consequence may hinder recanalisation rates associated with thrombectomy.5
“This fragmentation phenomenon is not common, but it’s not necessarily that rare either,” Abecassis notes, citing observations from his own practice. “I think it makes an even stronger case for having multiple tools at your fingertips in every case. I’ve had cases where I thought I would need to use an 0.071-inch or 0.088-inch catheter to treat an M1 but, when I do the run, I see that there are actually multiple M2s, because the clot has fragmented and migrated. In those cases, I have been able to easily adjust my plan and use the Zoom 4S—with or without the Zoom 7X as an intermediate catheter.”
For Abecassis, the take-home message on the Zoom Stack—and, by extension, the ADAPT 2.0 technique he utilises alongside it—relates to its versatility, and the “impressive” results it has produced across the full gamut of stroke cases. And, echoing Mokin’s advocacy for a standardised setup incorporating CDAT and ADAPT 2.0 due to the fact that “you never know when it might help you out”, Abecassis believes “you have to be prepared for unexpected findings” when treating ischaemic strokes.
“The 0.088-inch intracranial access would be the foundation of ADAPT 2.0 and, to me, it’s probably the most important thing because of how much it changes the procedure for the better,” he adds. “We know about the theoretical benefits of the asymmetric tip due to the increased surface area but, in reality, it’s just a question of how often you’re having to do a second pass with the same catheter or switch to a different aspiration catheter—and I can tell you that the incidence of us having to do this with the Zoom 7X is very low, in our experience.”
And, similarly to Mokin, Abecassis ultimately feels that—with further technical developments and much more clinical evidence on the horizon—Turk and colleagues’ seminal work that helped propel aspiration thrombectomy forward remains a long way from the end of its journey.
“I’m a big believer in ADAPT 2.0,” he concludes. “I think it goes hand in hand with the Zoom technologies, but I also think it creates a framework for future innovation. I don’t think ADAPT had evolved very much since its initial inception and description nearly 15 years ago but, now, there’s nothing stopping us thinking about what ADAPT 3.0 or ADAPT 4.0 might look like. It’s incredibly refreshing to see how much we’re innovating in this space.”
References:
- Turk A S, Spiotta A, Frei D et al. Initial clinical experience with the ADAPT technique: a direct aspiration first pass technique for stroke thrombectomy. J NeuroInterv Surg. 2014; 6(3): 231–7.
- Data on file at Imperative Care
- Zoom System instructions for use (IFU): LBL002069.A
- Mokin M. Society of Vascular and Interventional Neurology annual meeting. 2025, 19–22 Nov; Orlando, USA [cited 4 May 2026].
- Tessier G, Gerschenfeld G, Cortese J et al. When lysis moves the target: thrombus migration after tenecteplase and its impact on endovascular recanalization. J NeuroInterv Surg. Published online first: 4 Mar 2026. DOI: 10.1136/jnis-2025-024846.
Notes: Individual trials are not directly comparable, and data is presented for observational purposes only. Imperative Care products referenced in this article are approved for use in the United States only and are not approved or available for sale outside the United States.
Important Safety Information
U.S. – Rx only. The Zoom System, when used with the Zoom Aspiration Pump (or equivalent vacuum pump), is indicated for use in the revascularization of patients with acute ischemic stroke secondary to intracranial large vessel occlusive disease (within the internal carotid, middle cerebral – M1 and M2 segments, basilar, and vertebral arteries) within 8 hours of last known well. Patients who are ineligible for intravenous thrombolytic drug therapy or who have not responded to thrombolytic drug therapy are candidates for treatment. There are no known contraindications.
For complete product information including the Zoom System devices, Zoom portfolio, indications, contraindications, warnings, precautions and adverse events, see product IFU included in product packaging, contact Customer Service at +1-408-502-7548, [email protected] or visit bit.ly/3yWkfEJ.
Maxim Mokin and Josh Abecassis are paid consultants for Imperative Care. M003275.A
