Extended endovascular thrombectomy times lead to increased brain bleeding

Longer endovascular thrombectomy procedures for acute ischemic stroke may lead to decreased rates of functional independence and increased symptomatic intracerebral hemorrhage and complications, according to findings published in the Journal of the American College of Cardiology.

Ali Alawieh, PhD, of the Medical Scientist Training Program and the department of neurosurgery at the Medical University of South Carolina, and colleagues sought to evaluate the effect of longer procedure times on outcomes and complications after endovascular thrombectomy using different techniques while defining the risks of procedure extension in different patient cohorts.

“Prior studies have shown that for mechanical thrombectomy, the procedural time has a profound impact on patient outcomes,” Alawieh and colleagues wrote. “Extended procedures resulted in increased incidence of complications, increased cost and worse outcomes.”

The researchers analyzed data of patients who underwent endovascular thrombectomy (n = 1,359; mean age, 67 years; 51% women) with a stent retriever or a direct aspiration first-pass technique (ADAPT) at seven U.S. centers from June 2013 to February 2018.

Multivariate analyses were used to assess the effect of procedure time on 90-day modified Rankin Scale scores, successful recanalization, postprocedural symptomatic hemorrhage and complications.

Alawieh and colleagues identified a decreased likeliness of good functional outcomes, defined as modified Rankin Scale score 0 to 2, when procedure time extended beyond 30 minutes (P < .01).

Symptomatic hemorrhage and complication rates rose exponentially as procedure time increased, according to the researchers.

The cumulative rate of successful recanalization and good outcomes plateaued after 60 minutes of procedure time. In patients with procedure time greater than 30 minutes, fewer attempts predicted success of endovascular therapy and good outcomes (P < .01), the researchers wrote.

Successful recanalization was achieved faster with ADAPT than with a stent retriever, Alawieh and colleagues wrote.

The direct aspiration technique was more sensitive to procedure time than stent retriever, and posterior stroke was more closely correlated with procedure time than anterior stroke.

Exceeding 60 minutes or three attempts “should trigger careful assessment of futility and risks of continuing the procedure,” Alawieh and colleagues wrote.

In a related editorial, Nestor R. Gonzalez, MD, from the department of neurosurgery at Cedars-Sinai Medical Center, wrote: “The authors should be congratulated for this contribution to the understanding of the factors involved in the success of the current techniques used for the management of acute ischemic stroke. Further analysis of these valuable data will likely help to define the points of futility and assist in refining the application of endovascular thrombectomy.” – by Earl Holland Jr.

Disclosures: Alawieh and Gonzalez report no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

Longer endovascular thrombectomy procedures for acute ischemic stroke may lead to decreased rates of functional independence and increased symptomatic intracerebral hemorrhage and complications, according to findings published in the Journal of the American College of Cardiology.

Ali Alawieh, PhD, of the Medical Scientist Training Program and the department of neurosurgery at the Medical University of South Carolina, and colleagues sought to evaluate the effect of longer procedure times on outcomes and complications after endovascular thrombectomy using different techniques while defining the risks of procedure extension in different patient cohorts.

“Prior studies have shown that for mechanical thrombectomy, the procedural time has a profound impact on patient outcomes,” Alawieh and colleagues wrote. “Extended procedures resulted in increased incidence of complications, increased cost and worse outcomes.”

The researchers analyzed data of patients who underwent endovascular thrombectomy (n = 1,359; mean age, 67 years; 51% women) with a stent retriever or a direct aspiration first-pass technique (ADAPT) at seven U.S. centers from June 2013 to February 2018.

Multivariate analyses were used to assess the effect of procedure time on 90-day modified Rankin Scale scores, successful recanalization, postprocedural symptomatic hemorrhage and complications.

Alawieh and colleagues identified a decreased likeliness of good functional outcomes, defined as modified Rankin Scale score 0 to 2, when procedure time extended beyond 30 minutes (P < .01).

Symptomatic hemorrhage and complication rates rose exponentially as procedure time increased, according to the researchers.

The cumulative rate of successful recanalization and good outcomes plateaued after 60 minutes of procedure time. In patients with procedure time greater than 30 minutes, fewer attempts predicted success of endovascular therapy and good outcomes (P < .01), the researchers wrote.

Successful recanalization was achieved faster with ADAPT than with a stent retriever, Alawieh and colleagues wrote.

The direct aspiration technique was more sensitive to procedure time than stent retriever, and posterior stroke was more closely correlated with procedure time than anterior stroke.

Exceeding 60 minutes or three attempts “should trigger careful assessment of futility and risks of continuing the procedure,” Alawieh and colleagues wrote.

In a related editorial, Nestor R. Gonzalez, MD, from the department of neurosurgery at Cedars-Sinai Medical Center, wrote: “The authors should be congratulated for this contribution to the understanding of the factors involved in the success of the current techniques used for the management of acute ischemic stroke. Further analysis of these valuable data will likely help to define the points of futility and assist in refining the application of endovascular thrombectomy.” – by Earl Holland Jr.

Disclosures: Alawieh and Gonzalez report no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.