ADAPT a safe and simple technique for ischaemic stroke thrombectomy

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A direct aspiration first pass technique (ADAPT) with a large bore aspiration catheter has been shown to be “fast, safe, simple and effective method” for acute ischaemic stroke thrombectomy. The results were published in the Journal of of NeuroInterventional Surgery.

The authors of the ADAPT FAST study (Aquilla S Turk, Medical University of South Carolina, USA and colleagues) note that aspiration thrombectomy using the Penumbra system (Penumbra) and stent retrievers is effective for vessel revascularisation but has “yielded only modest clinical results.”

Therefore, Turk and colleagues used the novel ADPAT technique as their first approach for thrombectomy and report the follow-up of their initial experience. Patients who were included in the study (98 with 100 occlusions) had large vessel, cerebral vessel occlusion with a viable penumbra and a less than one-third ischaemic vascular territory.

Turk et al state that during the study period, the 5MAX ACE became available therefore they also compared the performance of the 5MAX ACE and the 5MAX (Penumbra).

The degree of vessel occlusion was measured before and after the procedure and defined in the modified Thrombolysis and Cerebral Infarction (TICI) classification. Successful recanalisation was defined as TICI score ≥2b post-treatment. Procedure time was classed as from the time of groin access to at least TICI 2b revascularisation.

The overall successful recanalisation rate (TICI 2b–3) was 95%. The average time to recanalisation was 36.6 minutes (SD=26.4 minutes). The aspiration component of the ADAPT technique successfully recanalised occluded vessels 78% of the time and when it was used as a standalone technique the average time to recanalisation was 31.6 minutes (SD=23.3 minutes). The authors add that, in cases where an adjunctive device, such as a stent retriever was used, the time to revascularisation was longer (p<0.0001; average time 56.8 minutes; SD=29.1 minutes).

Overall the 5MAX catheter was used in 44 cases, the 5MAX ACE was used in 44 cases, the 3MAX (Penumbra) in six cases, in four cases the Navien 058 (EV3, Covidien) and in one case the Neuron 088 MAX (Penumbra). TICI 2b or 3 revascularisation with aspiration alone was achieved in 75% of cases where the 5MAX was used vs. 82% (p=0.44) when a 5MAX ACE was used.

The National Institutes of Health Stroke Scale (NIHSS) at presentation was 17.3 (median 17; SD=6.4) and was improved to 7.3 (median 4; SD=7.5).

The authors report that there were no incidences of postprocedure spontaneous intracranial haemorrhage. They add that, compared with the outcomes of the stent retriever data reported, ADAPT has similar rates of good functional outcome (mRS 0–2), mortality and device-related complications.

Modified Rankin Scale score (mRS) was reported in 81 patients with 40% achieving a mRS score of 0–2, and in 20% of cases an score of 6 at three-month follow-up was achieved.

In 78% of cases, according to Turk et al, where ADAPT alone was successful, 47% of patients achieved a mRS score on 0–2 and 14% has a score of 6. Where a stent retriever was used with ADAPT (or was unsuccessful), 18% achieved mRS 0–2 and 35% achieved a score of 6.

Concluding, the authors say that catheter aspiration thrombectomy is an effective, novel technique to achieve revascularisation as a first-line therapy. It has previously only been reported as a bailout after failure of traditional revascularisation techniques.

They say that ADAPT is made possible because of the availability of newer, flexible, atraumatic, large bore aspiration catheters and add that their “multicentre series supports the hypothesis that, in comparison with modern thrombectomy devices, ADAPT is a fast, simple, efficient and safe strategy to achieve revascularisation in patients with acute ischaemic stroke secondary to large vessel occlusion.”