CardioVascular and Interventional Radiology

, Volume 41, Issue 12, pp 1909–1916 | Cite as

Impact of Retriever Passes on Efficacy and Safety Outcomes of Acute Ischemic Stroke Treated with Mechanical Thrombectomy

  • Yongjie Bai
  • Jie Pu
  • Huaiming Wang
  • Dong Yang
  • Yonggang Hao
  • Haowen Xu
  • Meng Zhang
  • Yu Geng
  • Yue Wan
  • Wei Wang
  • Hao Zhang
  • Wenjie ZiEmail author
  • Xinfeng Liu
  • Gelin XuEmail author
  • for the ACTUAL Investigators
Clinical Investigation Stroke/Neurointerventions
Part of the following topical collections:
  1. Stroke/Neurointerventions


Background and Purpose

In patients with acute ischemic stroke treated with thrombectomy, additional retriever passes may increase the likelihood of recanalization, but also the risk of intracranial hemorrhage. This multicenter retrospective register study aimed to evaluate the impact of retriever passes on treatment efficacy and safety outcomes in patients treated with mechanical thrombectomy.

Materials and Methods

Patients with ischemic stroke due to large artery occlusion in anterior circulation and treated with mechanical thrombectomy were enrolled. The primary efficacy outcome was a favorable functional outcome defined as modified Rankin Scale score of 0–2 at 90 days. Major safety outcome was symptomatic intracranial hemorrhage (SICH) and mortality. Multivariate logistic regression was used to analyze the impact of retriever passes on efficacy and safety outcomes.


Of the 472 enrolled patients, the likelihood of favorable outcome declined in patients with more than three retriever passes (44.4% in patients with three passes, 26.3% with four passes, 14.8% with five or more passes). Multivariate logistic regression analysis identified three or less passes as an independent predictor for favorable functional outcomes (OR 2.44, 95% CI 1.10–5.45, P = 0.029). More than three passes was associated with an increased risk of SICH (OR 2.24, 95% CI 1.16–4.33, P = 0.016).


More than three retriever passes may increase the rate of recanalization, but not the likelihood of favorable functional outcomes in ischemic stroke patients treated with mechanical thrombectomy. Notably, multiple retriever passes may also increase the risk of intracranial hemorrhage.

Evidence-Based Medicine

Level of Evidence: Level 4, Case Series.


Ischemic stroke Mechanical thrombectomy Stent retriever Cerebral revascularization Intracranial hemorrhage 



Symptomatic intracranial hemorrhage


Modified thrombolysis in cerebral infarction


Modified Rankin Scale


Endovascular Treatment for Acute Anterior Circulation Ischemic Stroke Registry



We acknowledge Shuyan Lu, Ph.D., for her statistical assistance.


This study was partly funded by National Natural Science Foundation of China (Nos. 81571143, 81400993 and 81530038), Jiangsu Provincial Special Program of Medical Science (No. BL2013025) and Chinese Postdoctoral Science Fund (No. 2015M572815).

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

For this type of study, formal consent is not required.

Supplementary material

270_2018_2022_MOESM1_ESM.doc (185 kb)
Supplementary material 1 (DOC 185 kb)


  1. 1.
    Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372(1):11–20. Scholar
  2. 2.
    Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372(11):1009–18. Scholar
  3. 3.
    Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372(24):2296–306. Scholar
  4. 4.
    Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372(11):1019–30. Scholar
  5. 5.
    Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015;372(24):2285–95. Scholar
  6. 6.
    Kang DH, Kim YW, Hwang YH, Park SP, Kim YS, Baik SK. Instant reocclusion following mechanical thrombectomy of in situ thromboocclusion and the role of low-dose intra-arterial tirofiban. Cerebrovasc Dis. 2014;37(5):350–5. Scholar
  7. 7.
    Hao Y, Yang D, Wang H, Zi W, Zhang M, Geng Y, et al. Predictors for symptomatic intracranial hemorrhage after endovascular treatment of acute ischemic stroke. Stroke. 2017;48(5):1203–9. Scholar
  8. 8.
    Loh Y, Jahan R, McArthur DL, Shi ZS, Gonzalez NR, Duckwiler GR, et al. Recanalization rates decrease with increasing thrombectomy attempts. AJNR Am J Neuroradiol. 2010;31(5):935–9. Scholar
  9. 9.
    Kurre W, Aguilar-Perez M, Schmid E, Sperber W, Bazner H, Henkes H. Clinical experience with the pREset stent retriever for the treatment of acute ischemic stroke—a review of 271 consecutive cases. Neuroradiology. 2014;56(5):397–403. Scholar
  10. 10.
    Saver JL, Jahan R, Levy EI, Jovin TG, Baxter B, Nogueira RG, et al. Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial. Lancet. 2012;380(9849):1241–9. Scholar
  11. 11.
    Pereira VM, Gralla J, Davalos A, Bonafe A, Castano C, Chapot R, et al. Prospective, multicenter, single-arm study of mechanical thrombectomy using Solitaire Flow Restoration in acute ischemic stroke. Stroke. 2013;44(10):2802–7. Scholar
  12. 12.
    Nogueira RG, Lutsep HL, Gupta R, Jovin TG, Albers GW, Walker GA, et al. Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trial. Lancet. 2012;380(9849):1231–40. Scholar
  13. 13.
    Angermaier A, Michel P, Khaw AV, Kirsch M, Kessler C, Langner S. Intravenous thrombolysis and passes of thrombectomy as predictors for endovascular revascularization in ischemic stroke. J Stroke Cerebrovasc Dis. 2016;25(10):2488–95. Scholar
  14. 14.
    Matias-Guiu JA, Serna-Candel C, Matias-Guiu J. Stroke etiology determines effectiveness of retrievable stents. J Neurointerv Surg. 2014;6(2):e11. Scholar
  15. 15.
    Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke. 1993;24(1):35–41.CrossRefGoogle Scholar
  16. 16.
    Barber PA, Demchuk AM, Zhang J, Buchan AM. Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS Study Group. Alberta Stroke Programme Early CT Score. Lancet. 2000;355(9216):1670–4. Scholar
  17. 17.
    Zaidat OO, Yoo AJ, Khatri P, Tomsick TA, von Kummer R, Saver JL, et al. Recommendations on angiographic revascularization grading standards for acute ischemic stroke: a consensus statement. Stroke. 2013;44(9):2650–63. Scholar
  18. 18.
    Powers WJ, Derdeyn CP, Biller J, Coffey CS, Hoh BL, Jauch EC, et al. 2015 American Heart Association/American Stroke Association focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: a guideline for healthcare professionals From the American Heart Association/American Stroke Association. Stroke. 2015;46(10):3020–35. Scholar
  19. 19.
    Hann S, Chalouhi N, Starke R, Gandhe A, Koltz M, Theofanis T, et al. Comparison of neurologic and radiographic outcomes with Solitaire versus Merci/Penumbra systems for acute stroke intervention. Biomed Res Int. 2013;2013:715170. Scholar
  20. 20.
    von Kummer R, Broderick JP, Campbell BC, Demchuk A, Goyal M, Hill MD, et al. The Heidelberg Bleeding Classification: classification of bleeding events after ischemic stroke and reperfusion therapy. Stroke. 2015;46(10):2981–6. Scholar
  21. 21.
    Shi ZS, Liebeskind DS, Xiang B, Ge SG, Feng L, Albers GW, et al. Predictors of functional dependence despite successful revascularization in large-vessel occlusion strokes. Stroke. 2014;45(7):1977–84. Scholar
  22. 22.
    Gory B, Bresson D, Kessler I, Perrin ML, Guillaudeau A, Durand K, et al. Histopathologic evaluation of arterial wall response to 5 neurovascular mechanical thrombectomy devices in a swine model. AJNR Am J Neuroradiol. 2013;34(11):2192–8. Scholar
  23. 23.
    Kurre W, Vorlaender K, Aguilar-Perez M, Schmid E, Bazner H, Henkes H. Frequency and relevance of anterior cerebral artery embolism caused by mechanical thrombectomy of middle cerebral artery occlusion. AJNR Am J Neuroradiol. 2013;34(8):1606–11. Scholar
  24. 24.
    Chalumeau V, Blanc R, Redjem H, Ciccio G, Smajda S, Desilles JP, et al. Anterior cerebral artery embolism during thrombectomy increases disability and mortality. J Neurointerv Surg. 2018. Scholar
  25. 25.
    Khatri R, McKinney AM, Swenson B, Janardhan V. Blood-brain barrier, reperfusion injury, and hemorrhagic transformation in acute ischemic stroke. Neurology. 2012;79(13 Suppl 1):S52–7. Scholar
  26. 26.
    Renu A, Laredo C, Lopez-Rueda A, Llull L, Tudela R, San-Roman L, et al. Vessel wall enhancement and blood-cerebrospinal fluid barrier disruption after mechanical thrombectomy in acute ischemic stroke. Stroke. 2017;48(3):651–7. Scholar
  27. 27.
    Linfante I, Walker GR, Castonguay AC, Dabus G, Starosciak AK, Yoo AJ, et al. Predictors of mortality in acute ischemic stroke intervention: analysis of the North American Solitaire Acute Stroke Registry. Stroke. 2015;46(8):2305–8. Scholar
  28. 28.
    Linfante I, Starosciak AK, Walker GR, Dabus G, Castonguay AC, Gupta R, et al. Predictors of poor outcome despite recanalization: a multiple regression analysis of the NASA registry. J Neurointerv Surg. 2016;8(3):224–9. Scholar
  29. 29.
    Seker F, Pfaff J, Wolf M, Ringleb PA, Nagel S, Schonenberger S, et al. Correlation of thrombectomy maneuver count with recanalization success and clinical outcome in patients with ischemic stroke. AJNR Am J Neuroradiol. 2017;38(7):1368–71. Scholar
  30. 30.
    Zaidat OO, Castonguay AC, Gupta R, Sun CH, Martin C, Holloway WE, et al. North American Solitaire Stent Retriever Acute Stroke registry: post-marketing revascularization and clinical outcome results. J Neurointerv Surg. 2014;6(8):584–8. Scholar
  31. 31.
    Eesa M, Almekhlafi MA, Mitha AP, Wong JH, Goyal M. Manual aspiration thrombectomy through balloon-tipped guide catheter for rapid clot burden reduction in endovascular therapy for ICA L/T occlusion. Neuroradiology. 2012;54(11):1261–5. Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2018

Authors and Affiliations

  1. 1.Department of NeurologyJinling Clinical College of Nanjing Medical UniversityNanjingChina
  2. 2.Department of Neurology, First Affiliated Hospital, College of Clinical MedicineHenan University of Science and TechnologyLuoyangChina
  3. 3.Department of Neurology, Jinling HospitalSouthern Medical UniversityNanjingChina
  4. 4.Department of Neurology, Jinling HospitalMedical School of Nanjing UniversityNanjingChina
  5. 5.Department of Neurology89th Hospital of People’s Liberation ArmyWeifangChina
  6. 6.Department of Emergency MedicineFirst Affiliated Hospital of Soochow UniversitySuzhouChina
  7. 7.Department of Intervention NeuroradiologyFirst Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
  8. 8.Department of Neurology, Research Institute of Surgery, Daping HospitalThird Military Medical UniversityChongqingChina
  9. 9.Department of NeurologyZhejiang Provincial People’s HospitalHangzhouChina
  10. 10.Department of NeurologyHubei Zhongshan HospitalWuhanChina
  11. 11.Department of Radiology, First People’s Hospital of YangzhouYangzhou UniversityYangzhouChina
  12. 12.Department of Neurology, First People’s Hospital of HangzhouNanjing Medical UniversityHangzhouChina

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