Sex-Based Efficacy of Endovascular Thrombectomy Techniques in LVO Stroke: A Multicenter Registry Analysis

Sex differences in stroke cause, vessel anatomy, and thrombus composition are well established, yet whether these factors influence the efficacy of specific endovascular thrombectomy (EVT) techniques remains unknown. Here, we investigate sex-based differences in reperfusion outcomes across EVT techniques.

Consecutive patients with anterior circulation large vessel occlusion including intracranial internal carotid artery and the M1 and M2 segments of the middle cerebral artery treated with EVT across 4 comprehensive stroke centers in the Greater Houston area (January 2021 to June 2024) were included from a prospectively maintained registry. EVT techniques were categorized as stent retriever, contact aspiration, or combined technique. The primary outcome was the first-pass effect (modified Thrombolysis in Cerebral Infarction 2c/3 after 1 pass). Secondary outcomes included achieving modified Thrombolysis in Cerebral Infarction 2c/3 within 2 passes, 90-day modified Rankin Scale score (0-2), intracerebral hemorrhage, symptomatic intracerebral hemorrhage, and mortality. Multivariable logistic regressions were used for binary outcomes adjusted for age, National Institutes of Health Stroke Scale score, atrial fibrillation, smoking, and prior thrombolysis. Linear regression was used for the number of thrombectomy passes.

Among 724 patients that met inclusion criteria, 47% were female patients, the median age was 68 (interquartile range, 54-78) years, and the National Institutes of Health Stroke Scale score was 16 (interquartile range, 11-21). Presentation characteristics were balanced except for a greater rate of atrial fibrillation in female patients (23.0% versus 16.6%; P<0.05) and lower rates of intravenous thrombolysis in female patients (31% versus 40%; P<0.05). EVT techniques were comparable between sexes. The first-pass effect across the cohort was similar (female versus male patients, 37.9% versus 36.3%). In female patients, contact aspiration yielded higher odds of first-pass effect (adjusted odds ratio, 2.17 [1.07-4.35]) and modified Thrombolysis in Cerebral Infarction 2c/3 within 2 passes (adjusted odds ratio, 2.63 [1.32-5.26]) versus stent retriever, with fewer passes overall (β, 0.28; P<0.05). No difference in reperfusion outcomes was seen between EVT techniques in the male patients subgroup. Among patients receiving stent retriever as their first pass, female sex was associated with lower odds of achieving reperfusion within 2 passes (adjusted odds ratio, 0.43 [0.19-0.99]).

This multicenter analysis provides the first evidence that EVT technique performance differs by sex. In female patients, contact aspiration achieved superior reperfusion with fewer passes than stent retriever. These findings highlight the importance of sex-stratified EVT trials and support individualized, precision-based device selection in acute ischemic stroke.