Endovascular Thrombectomy Technique Optimization: A SVIN Registry Analysis

Achieving excellent recanalization (Modified Thrombolysis in Cerebral Infarction 2c/3) in fewer attempts improves clinical outcomes. Previous studies suggest that switching techniques after a failed first pass may enhance reperfusion rates. This study evaluates whether technique switching improves subsequent reperfusion in a large multicenter registry.

We analyzed retrospective and prospective SVIN (Society of Vascular and Interventional Neurology) registry data from 12 US centers (October 2014-December 2021) involving endovascular therapy for M1 or internal carotid artery-terminus (ICA-T) occlusions. Patients with at least 2 recanalization attempts using stent retriever (SR), contact aspiration (CA), or combined technique (CT) were included. Primary outcome was the likelihood of achieving TICI 2c/3 reperfusion with or without technique switching on the second pass. Secondary outcomes included the likelihood of final TICI 2c/3 stratified by the technique and occlusion location.

Among 2893 endovascular therapy treatments, 1089 patients (37.6%) had successful reperfusion after the first pass. First-pass TICI 2c/3 rates for ICA-T occlusions were 36.0% with SR, 23.6% with CA, and 35.8% with CT; for M1 occlusions, the rates were 38.8% with SR, 39.3% with CA, and 38.6% with CT. A total of 1420 treatments included at least 2 passes. ICA-T occlusions occurred in 20.4% and M1 occlusions in 79.6%. In multivariable analysis, in M1 occlusions, switching from CT to alternative technique after a failed first pass significantly increased the odds of achieving TICI 2c/3 after the second pass (adjusted odds ratio, 2.08 [95% CI, 1.18-3.67]). Patients who had 2 failed attempts using CA had significantly higher odds of achieving final TICI 2c/3 compared with those with 2 failed passes using the SR technique (adjusted odds ratio 1.65, [95% CI, 1.09-2.51]).

In M1-middle cerebral artery occlusion, switching from CT to SR or CA was associated with an improvement in TICI2c/3 rates on the second pass. In addition, after 2 failed passes with CA, additional passes increased the odds of achieving complete reperfusion compared with SR.