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In acute ischaemic stroke, fast and complete recanalisation of the occluded vessel is associated with improved outcomes. While morbidity and mortality in these patients can be high, achieving complete or near-complete reperfusion has been associated with significant clinical benefit and reduced adverse effects. Here, Professor Vincent Costalat, head of the department of Interventional Neuroradiology at Gui de Chauliac University Hospital, Montpellier, France, speaks to NeuroNews about how evolving technologies are permitting improved rates of revascularisation and clinical outcomes through achieving the first-pass effect.
What is the first-pass effect and how is this driving innovation in the treatment of acute ischaemic stroke?
The first-pass effect is the clinical benefit induced by a quick and fast recanalisation after the first-pass of a thrombectomy device. We know now that when we repeat the attempt in a patient, we are increasing the risk of collateral infarction, of vessel dissection and, in addition to this, we are increasing the time of the treatment. A recent publication from the Embotrap ARISE 2 study found that, independent of the time and the complication rate, opening the vessel immediately after one pass shows clear benefit to the patients.
What is its impact on patient outcomes and mortality rates?
The mortality rate in stroke management depends on the severity of the stroke that you are managing. So, the severity of the patient at presentation would be the strongest prognostic factor. The success of recanalisation will dramatically reduce the mortality rate of the patients, and achieving a first-pass is a guarantee of reducing the final infarct core.
What are the usual success rates?
The usual success rates for recanalisation will depend on both operator and centre experience. From what we can see in the literature, the first data published in 2014 were around 60% of thrombolysis in cerebral infarction (TICI) 2b/3, in the context of low experience. In more recent literature testing the latest technology, recanalisation rates are now around 85% of TICI 2b/3.
What are the different mechanisms currently used to remove a clot in the first-pass?
The technique to remove a clot in the first pass will also vary depending on the operator and centre experience. But, in Montpellier for example, we tend to use a maximalist approach, using a balloon guide catheter, an intermittent catheter, and next-generation stents—like the Embotrap for example. This allows us to achieve more complete recanalisation after only one pass.
In terms of real-world cases using Embotrap II, could you describe a typical patient’s status pre-intervention?
In general, the patients that present with a large artery occlusion have an average NIHSS (National Institutes of Health Stroke Scale) score of around 17. The average necrotic core may vary a lot between patients. With Embotrap you can treat any patient, from almost any location. The device is one size in diameter and length, and will allow you to treat vessels from M2 (of the middle cerebral artery) up to the carotid.
Why would you choose to use the Embotrap II device?
An advantage of Embotrap II is the basket end at the tip of the device, which may be used to grab some fragment of the clot during the retrieval manoeuvre. This makes the Embotrap II a little different from the other stents today. Regarding the in silico study we did in our department using Embotrap II, we have carried out up to 150 consecutive thrombectomy cases that demonstrate that the device has the ability to reduce the rate of collateral infarction compared to other devices and increase the complete recanalisation rate.
This was an in silico study of course, and while it did not reach full significance, the results were in favour of a trend. From what we experienced, the device performed really well at safely removingthe thrombus in one pass. In addition, the outcome of the Embotrap II ARISE 2 study was very promising, one of the best in the literature to date. We also have to understand that there is a learning curve, where the later studies tend to show better results than the earlier studies because of the learning curve in the community using the thrombectomy devices. But, we have to admit that the Embotrap II trial results were very encouraging, and Embotrap II is now one of our three major stentrievers used daily in the department.
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