Stent-retriever alone vs. combined technique with balloon guide catheter in large vessel occlusion stroke: A single center experience

Abstract

Background: Today, balloon guide catheters are widely used in thrombectomies. This study aimed to compare the demographic, angiographic, and clinical outcome parameters of thrombectomy for anterior circulation large vessel occlusion strokes (LVOS) using a first-line stent retriever (SR) alone with those of a thrombectomy using a technique combining a balloon guide catheter (BGC) with a distal access catheter (DAC) and an SR.

Methods: We retrospectively analyzed the data of patients who had experienced anterior circulation LVOS and underwent mechanical thrombectomy with a BGC at our stroke center between January 2015 and December 2022. The patients were divided into two groups based on the techniques used in the thrombectomy: a stent retriever alone (BGC+SR) and a combined approach (BGC+DAC+SR). Baseline characteristics, procedure details, angiographic results, and clinical outcomes were assessed. The primary clinical outcome in this study was the rate of functional independence (mRS score ≤2) at 90 days. The primary technical outcome was the rate of first pass effect (FPE), defined as achieving near complete/complete revascularization (modified thrombolysis in cerebral infarction [mTICI] 2c-3) after a single treatment pass. Secondary outcomes included mortality at 90 days, procedural complications, embolic complications, and symptomatic intracranial hemorrhage.

Results: Out of 234 patients, 137 (58.6%) were in the BGC +SR group, while 97 (41.4%) were in the BGC+SR+DAC group. Patients treated with BGC and SR alone were younger (median age 58 vs. 61 years, p=0.005) and had a higher prevalence of middle cerebral artery occlusions (M1 segment: 64.9% vs. 37.5%; M2 segment: 14.9% vs. 5.2%, p<0.001) compared to those in the combined group. The BCG+SR group had a greater incidence of cardioembolism and embolic stroke of undetermined source (49.3% vs. 41.1%, 26.5% vs. 12.6%, respectively, p=0.007). The median NIHSS of the entire population was 15 (IQR, 11–18), and 108 (46%) patients received intravenous thrombolytics before thrombectomy. The patients treated with the combined technique tended to have higher rates of FPE compared to those in the BGC+SR (47.4% vs. 35.8%, p=0.074) and higher rates of successful (≥mTICI 2b) and excellent (≥mTICI 2c) recanalization overall (93.8% vs. 90.5% p=0.504; 78.4% vs. 71.5%, p=0.306, respectively). The groups had similar rates of good clinical outcome (mRS 0-2) and mortality at 90 days (61.7% vs. 53.3%, p=0.21;14.3% vs. 18.7%, p=0.495, respectively) with comparable rates of complications. Multivariate analyses identified higher baseline Alberta Stroke Program Early CT scores (OR=1.19; 95% CI, 1.09–1.28) and middle cerebral artery M1 occlusion locations (OR=1.90; 95% CI, 1.45–2.42) as independent predictors of first-pass success.

Conclusion: In this study, treating acute ischemic strokes with an anterior system large vessel occlusion using a thrombectomy technique employing a BGC with an SR resulted in similar recanalization and FPE rates as using a technique employing a BGC in combination with an SR and a DAC. Both first-line strategy techniques had similar rates of good clinical outcome (mRS score ≤2) and mortality at 90 days.