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Updated: Nov 20, 2025
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Good Clinical Outcome Decreases With Number of Retrieval Attempts in Stroke Thrombectomy: Beyond the First-Pass
Fabian Flottmann1, Caspar Brekenfeld1, Gabriel Broocks1
1Department of Diagnostic and Interventional Neuroradiology (F.F., C.B., G.B., H.L., R.M., T.D.F., J.F.), University Medical Center Hamburg-Eppendorf, Germany.
Insights
For acute ischemic stroke, achieving reperfusion through endovascular therapy within three attempts significantly improves patient outcomes. More retrieval attempts correlate with lower odds of good clinical recovery.
Area of Science:
- Neurology
- Interventional Cardiology
- Vascular Surgery
Background:
- Endovascular therapy is the standard treatment for acute ischemic stroke caused by large-vessel occlusion.
- Multiple retrieval attempts are often necessary to achieve successful reperfusion.
- The impact of the number of retrieval attempts on clinical outcomes requires further quantification.
Purpose of the Study:
- To assess the influence of the number of retrieval attempts in endovascular therapy on clinical outcomes in patients with acute ischemic stroke.
- To analyze the association between successful reperfusion and functional independence at 90 days post-stroke.
Main Methods:
- An observational cohort study analyzed 1225 patients from the German Stroke Registry (June 2015-April 2018).
- Patients with acute anterior circulation stroke undergoing endovascular therapy were included.
- Multivariate mixed-effects models were used to determine the odds of functional independence (modified Rankin Scale score 0-2) at 90 days, adjusting for confounders and center effects.
Main Results:
- The odds of achieving a good clinical outcome decreased with each additional retrieval attempt.
- The first retrieval attempt showed the highest odds of good outcome (aOR, 6.45 [95% CI, 4.0-10.4]).
- Subsequent attempts also demonstrated significant odds of good outcome, though decreasing (second: aOR, 4.56 [95% CI, 2.7-7.7]; third: aOR, 3.16 [95% CI, 1.8-5.6]).
Conclusions:
- Successful reperfusion within three retrieval attempts in endovascular therapy for anterior circulation stroke is linked to better clinical outcomes.
- Performing at least three retrieval attempts is recommended to maximize the chances of successful reperfusion and improve patient prognosis.
- This study highlights the importance of procedural persistence in achieving reperfusion for acute ischemic stroke.
Background And Purpose:
Endovascular therapy is the standard of care in the treatment of acute ischemic stroke due to large-vessel occlusion. Often, more than one retrieval attempt is needed to achieve reperfusion. We aimed to quantify the influence of endovascular therapy on clinical outcome depending on the number of retrievals needed for successful reperfusion in a large multi-center cohort.
Methods:
For this observational cohort study, 2611 patients from the prospective German Stroke Registry included between June 2015 and April 2018 were analyzed. Patients who received endovascular therapy for acute anterior circulation stroke with known admission National Institutes of Health Stroke Scale score and Alberta Stroke Program Early CT Score, final Thrombolysis in Cerebral Infarction score, and number of retrievals were included. Successful reperfusion was defined as a Thrombolysis in Cerebral Infarction score of 2b or 3. The primary outcome was defined as functional independence (modified Rankin Scale score of 0-2) at day 90. Multivariate mixed-effects models were used to adjust for cluster effects of the participating centers and confounders.
Results:
The inclusion criteria were met by 1225 patients. The odds of good clinical outcome decreased with every retrieval attempt required for successful reperfusion: the first retrieval had the highest odds of good clinical outcome (adjusted odds ratio, 6.45 [95% CI, 4.0-10.4]), followed by the second attempt (adjusted odds ratio, 4.56 [95% CI, 2.7-7.7]), and finally the third (adjusted odds ratio, 3.16 [95% CI, 1.8-5.6]).
Conclusions:
Successful reperfusion within the first 3 retrieval attempts is associated with improved clinical outcome compared with patients without reperfusion. We conclude that at least 3 retrieval attempts should be performed in endovascular therapy of anterior circulation strokes. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03356392.
