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Effect of Bridging Thrombolysis on the Efficacy of Stent Retriever Thrombectomy Techniques

Insights from the SWIFT-DIRECT trial

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Abstract

Background

There are little available data regarding the influence of intravenous thrombolysis (IVT) on the efficacy of different first line endovascular treatment (EVT) techniques.

Methods

We used the dataset of the SWIFT-DIRECT trial which randomized 408 patients to IVT + EVT or EVT alone at 48 international sites. The protocol required the use of a stent retriever (SR), but concomitant use of a balloon guide catheter (BGC) and/or distal aspiration (DA) catheter was left to the discretion of the operators. Four first line techniques were applied in the study population: SR, SR + BGC, SR + DA, SR + DA + BGC. To assess whether the effect of allocation to IVT + EVT versus EVT alone was modified by the first line technique, interaction models were fitted for predefined outcomes. The primary outcome was first pass mTICI 2c‑3 reperfusion (FPR).

Results

This study included 385 patients of whom 172 were treated with SR + DA, 121 with SR + DA + BGC, 57 with SR + BGC and 35 with SR. There was no evidence that the effect of IVT + EVT versus EVT alone would be modified by the choice of first line technique; however, allocation to IVT + EVT increased the odds of FPR by a factor of 1.68 (95% confidence interval, CI 1.11–2.54).

Conclusion

This post hoc analysis does not suggest treatment effect heterogeneity of IVT + EVT vs EVT alone in different stent retriever techniques but provides evidence for increased FPR if bridging IVT is administered before stent retriever thrombectomy.

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Abbreviations

ESO:

European Stroke Organization

EVT:

Endovascular treatment

IQR:

Interquartile range

IVT:

Intravenous thrombolysis

mRS:

Modified Rankin scale

MT:

Mechanical thrombectomy

mTICI:

Post-interventional modified thrombolysis in cerebral infarction score

NIHSS:

National Institutes of Health Stroke Scale

SWIFT-DIRECT:

Solitaire with the intention for thrombectomy plus intravenous t‑PA versus DIRECT solitaire stent retriever thrombectomy in acute anterior circulation stroke

References

  1. Zi W, Qiu Z, Li F, Sang H, Wu D, Luo W, et al. Effect of endovascular treatment alone vs intravenous alteplase plus endovascular treatment on functional independence in patients with acute ischemic stroke: the DEVT randomized clinical trial. JAMA. 2021;325(3):234–43. https://doi.org/10.1001/jama.2020.23523.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Yang P, Zhang Y, Zhang L, Zhang Y, Treurniet KM, Chen W, et al. Endovascular thrombectomy with or without intravenous alteplase in acute stroke. N Engl J Med. 2020;382(21):1981–93. https://doi.org/10.1056/NEJMoa2001123.

    Article  CAS  PubMed  Google Scholar 

  3. Suzuki K, Matsumaru Y, Takeuchi M, Morimoto M, Kanazawa R, Takayama Y, et al. Effect of mechanical thrombectomy without vs with intravenous thrombolysis on functional outcome among patients with acute ischemic stroke: the SKIP randomized clinical trial. JAMA. 2021;325(3):244–53. https://doi.org/10.1001/jama.2020.23522.

    Article  PubMed  PubMed Central  Google Scholar 

  4. LeCouffe NE, Kappelhof M, Treurniet KM, Rinkel LA, Bruggeman AE, Berkhemer OA, et al. A randomized trial of intravenous alteplase before endovascular treatment for stroke. N Engl J Med. 2021;385(20):1833–44. https://doi.org/10.1056/NEJMoa2107727.

    Article  CAS  PubMed  Google Scholar 

  5. Fischer U, Kaesmacher J, Strbian D, Eker O, Cognard C, Plattner PS, et al. Thrombectomy alone versus intravenous alteplase plus thrombectomy in patients with stroke: an open-label, blinded-outcome, randomised non-inferiority trial. Lancet. 2022;400(10346):104–15. https://doi.org/10.1016/S0140-6736(22)00537-2.

    Article  CAS  PubMed  Google Scholar 

  6. Mitchell PJ, Yan B, Churilov L, Dowling RJ, Bush SJ, Bivard A, et al. Endovascular thrombectomy versus standard bridging thrombolytic with endovascular thrombectomy within 4·5 h of stroke onset: an open-label, blinded-endpoint, randomised non-inferiority trial. Lancet. 2022;400(10346):116–25. https://doi.org/10.1016/S0140-6736(22)00564-5.

    Article  CAS  PubMed  Google Scholar 

  7. Kaesmacher J, Mujanovic A, Treurniet K, Kappelhof M, Meinel TR, Yang P, et al. Perceived acceptable uncertainty regarding comparability of endovascular treatment alone versus intravenous thrombolysis plus endovascular treatment. J NeuroIntervent Surg. 2022; https://doi.org/10.1136/neurintsurg-2022-018665.

    Article  Google Scholar 

  8. Turc G, Tsivgoulis G, Audebert HJ, Boogaarts H, Bhogal P, De Marchis GM, et al. European Stroke Organisation (ESO)–European Society for Minimally Invasive Neurological Therapy (ESMINT) expedited recommendation on indication for intravenous thrombolysis before mechanical thrombectomy in patients with acute ischemic stroke and anterior circulation large vessel occlusion. J NeuroIntervent Surg. 2022;14(3):209–27. https://doi.org/10.1136/neurintsurg-2021-018589.

    Article  Google Scholar 

  9. Mokin M, Waqas M, Fifi JT, De Leacy R, Fiorella D, Levy EI, et al. Intravenous alteplase has different effects on the efficacy of aspiration and stent retriever thrombectomy: analysis of the COMPASS trial. J NeuroIntervent Surg. 2021; https://doi.org/10.1136/neurintsurg-2021-017943.

    Article  Google Scholar 

  10. Shigeta K, Suzuki K, Matsumaru Y, Takeuchi M, Morimoto M, Kanazawa R, et al. Intravenous alteplase is associated with first pass effect in stent-retriever but not ADAPT thrombectomy. Clin Neuroradiol. 2022;32(1):153–62. https://doi.org/10.1007/s00062-021-01085-3.

    Article  PubMed  Google Scholar 

  11. Rinkel LA, Treurniet KM, Nieboer D, Kappelhof M, LeCouffe NE, Bruggeman AAE, et al. Effect of intravenous alteplase treatment on first-line stent retriever versus aspiration alone during endovascular treatment. Stroke. 2022. https://doi.org/10.1161/STROKEAHA.121.038390.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Kaesmacher J, Dobrocky T, Heldner MR, Bellwald S, Mosimann PJ, Mordasini P, et al. Systematic review and meta-analysis on outcome differences among patients with TICI2b versus TICI3 reperfusions: success revisited. J Neurol Neurosurg Psychiatry. 2018;89(9):910–7. https://doi.org/10.1136/jnnp-2017-317602.

    Article  PubMed  Google Scholar 

  13. Zaidat OO, Castonguay AC, Linfante I, Gupta R, Martin CO, Holloway WE, et al. First pass effect: a new measure for stroke thrombectomy devices. Stroke. 2018;49(3):660–6. https://doi.org/10.1161/strokeaha.117.020315.

    Article  PubMed  Google Scholar 

  14. Bourcier R, Saleme S, Labreuche J, Mazighi M, Fahed R, Blanc R, et al. More than three passes of stent retriever is an independent predictor of parenchymal hematoma in acute ischemic stroke. J NeuroIntervent Surg. 2019;11(7):625–9. https://doi.org/10.1136/neurintsurg-2018-014380.

    Article  Google Scholar 

  15. Kaesmacher J, Maegerlein C, Kaesmacher M, Zimmer C, Poppert H, Friedrich B, et al. Thrombus migration in the middle cerebral artery: incidence, imaging signs, and impact on success of endovascular thrombectomy. J Am Heart Assoc. 2017; https://doi.org/10.1161/jaha.116.005149.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Kaesmacher J, Giarrusso M, Zibold F, Mosimann PJ, Dobrocky T, Piechowiak E, et al. Rates and quality of preinterventional reperfusion in patients with direct access to endovascular treatment. Stroke. 2018;49(8):1924–32. https://doi.org/10.1161/strokeaha.118.021579.

    Article  PubMed  Google Scholar 

  17. Alves HC, Treurniet KM, Jansen IGH, Yoo AJ, Dutra BG, Zhang G, et al. Thrombus migration paradox in patients with acute ischemic stroke. Stroke. 2019;50(11):3156–63. https://doi.org/10.1161/STROKEAHA.119.026107.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Fischer U, Kaesmacher J, Plattner P, Bütikofer L, Mordasini P, Deppeler S, et al. SWIFT DIRECT: solitaire™ with the intention for thrombectomy plus intravenous t‑PA versus DIRECT solitaire™ stent-retriever thrombectomy in acute anterior circulation stroke: methodology of a randomized, controlled, multicentre study. Int J Stroke. 2022. https://doi.org/10.1177/17474930211048768.

    Article  PubMed  Google Scholar 

  19. Mokin M, Primiani CT, Castonguay AC, Nogueira RG, Haussen DC, English JD, et al. First pass effect in patients treated with the trevo stent-retriever: a TRACK registry study analysis. Front Neurol. 2020; https://doi.org/10.3389/fneur.2020.00083.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Pop R, Finitsis SN, Arquizan C, Elhorany M, Naggara O, Darcourt J, et al. Poor clinical outcome despite successful basilar occlusion recanalization in the early time window: incidence and predictors. J NeuroIntervent Surg. 2022; https://doi.org/10.1136/neurintsurg-2022-018769.

    Article  Google Scholar 

  21. Baek J‑H, Kim BM, Kang D‑H, Heo JH, Nam HS, Kim YD, et al. Balloon guide catheter is beneficial in endovascular treatment regardless of mechanical recanalization modality. Stroke. 2019;50(6):1490–6. https://doi.org/10.1161/STROKEAHA.118.024723.

    Article  PubMed  Google Scholar 

  22. Nguyen TN, Castonguay AC, Nogueira RG, Haussen DC, English JD, Satti SR, et al. Effect of balloon guide catheter on clinical outcomes and reperfusion in trevo thrombectomy. J NeuroIntervent Surg. 2019;11(9):861–5. https://doi.org/10.1136/neurintsurg-2018-014452.

    Article  Google Scholar 

  23. Podlasek A, Dhillon PS, Jewett G, Shahein A, Goyal M, Almekhlafi M. Clinical and procedural outcomes with or without balloon guide catheters during endovascular thrombectomy in acute ischemic stroke: a systematic review and meta-analysis with first-line technique subgroup analysis. AJNR Am J Neuroradiol. 2021;42(8):1464–71. https://doi.org/10.3174/ajnr.A7164.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Blasco J, Puig J, López-Rueda A, Daunis-i-Estadella P, Llull L, Zarco F, et al. Addition of intracranial aspiration to balloon guide catheter does not improve outcomes in large vessel occlusion anterior circulation stent retriever based thrombectomy for acute stroke. J NeuroIntervent Surg. 2021; https://doi.org/10.1136/neurintsurg-2021-017760.

    Article  Google Scholar 

  25. Maïer B, Finitsis S, Bourcier R, Papanagiotou P, Richard S, Marnat G, et al. First-line thrombectomy strategy for anterior large vessel occlusions: results of the prospective ETIS egistry. J NeuroIntervent Surg. 2022;14(5):450–6. https://doi.org/10.1136/neurintsurg-2021-017505.

    Article  Google Scholar 

  26. Teo YN, Sia C‑H, Tan BYQ, Mingxue J, Chan B, Sharma VK, et al. Combined balloon guide catheter, aspiration catheter, and stent retriever technique versus balloon guide catheter and stent retriever alone technique: a systematic review and meta-analysis. J NeuroIntervent Surg. 2022; https://doi.org/10.1136/neurintsurg-2021-018406.

    Article  Google Scholar 

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Acknowledgements

Academic investigators designed SWIFT-DIRECT. Susan Kaplan provided English language support.

Funding

Medtronic supported the study by an unrestricted grant to the University Hospital Bern without involvement in the final design, data analysis or interpretation. The University Hospital of Bern, Switzerland provided additional funding.

Author information

Authors and Affiliations

  1. Interventional Neuroradiology Department, Strasbourg University Hospitals, Strasbourg, France

    Raoul Pop

  2. INSERM U1255, University of Strasbourg, Strasbourg, France

    Raoul Pop

  3. Institut de Chirurgie Minime Invasive Guidée par l’Image, Strasbourg, France

    Raoul Pop

  4. Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland

    Silja Räty

  5. Department of Neuroradiology, Hospices Civils de Lyon, Lyon, France

    Roberto Riva

  6. Department of Interventional and Diagnostic Neuroradiology, CHU Bordeaux, University of Bordeaux, Bordeaux, France

    Gaultier Marnat

  7. University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland

    Tomas Dobrocky, Eike Immo Piechowiak, Jan Gralla & Johannes Kaesmacher

  8. Department of Diagnostic and Interventional Neuroradiology, Centre Hospitalier Universitaire de Nantes, Nantes Université, Nantes, France

    Pierre Louis Alexandre

  9. Department of Radiology, CHU Rouen, Rouen, France

    Margaux Lefebvre

  10. Department of Neurology, Centre Hospitalier Universitaire de Toulouse, Toulouse, France

    Jean Francois Albucher

  11. Service de Neurologie, Université Caen Normandie, CHU Caen Normandie, Caen, France

    Marion Boulanger

  12. Department of Stroke and Diagnostic and Interventional Neuroradiology, Foch Hospital, Suresnes, France

    Federico Di Maria

  13. Department of Neurology, Stroke Unit, CHRU-Nancy, INSERM U1116, Université de Lorraine, Nancy, France

    Sébastien Richard

  14. Department of Neuroradiology, CHU Reims, Reims, France

    Sébastien Soize

  15. Department of Neurology, University Medical Center Goettingen, Goettingen, Germany

    Jan Liman

  16. Department of Neurology, University Medical Center Nuremberg, Paracelsus Private University, Nuremberg, Germany

    Jan Liman

  17. Department of Neurology, University Hospital RWTH Aachen, Aachen, Germany

    Arno Reich

  18. Stroke Unit. Department of Neurology, Vall d’Hebron Hospital, Barcelona, Spain

    Marc Ribo

  19. Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland

    Thomas Meinel

  20. Department of Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany

    Anastasios Mpotsaris

  21. Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles, USA

    David S. Liebeskind

  22. Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland

    Urs Fischer

Authors
  1. Raoul Pop
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  2. Silja Räty
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  3. Roberto Riva
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  4. Gaultier Marnat
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  5. Tomas Dobrocky
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  6. Pierre Louis Alexandre
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  7. Margaux Lefebvre
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  8. Jean Francois Albucher
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  9. Marion Boulanger
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  10. Federico Di Maria
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  11. Sébastien Richard
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  12. Sébastien Soize
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  13. Eike Immo Piechowiak
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  14. Jan Liman
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  15. Arno Reich
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  16. Marc Ribo
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  17. Thomas Meinel
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  18. Anastasios Mpotsaris
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  19. David S. Liebeskind
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  20. Jan Gralla
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  21. Urs Fischer
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  22. Johannes Kaesmacher
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the SWIFT DIRECT Collaborators

Corresponding author

Correspondence to Raoul Pop.

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Conflict of interest

G. Marnat reports consulting fees from Stryker Neurovascular; paid lectures for Medtronic and Microvention Europe. M. Ribo reports consulting fees from Medtronic, Stryker, Cerenovus, Philips and Apta Targets; payment or honoraria from Ischemia View; Participation on a Data Safety Monitoring Board or Advisory Board of Sensome; stock or stock options in Anaconda Biomed, CVAid and Methinks. D.S. Liebeskind reports consulting fees from Cerenovus, Genentech, Medtronic, Stryker, Rapid Medical as imaging core laboratory. J. Gralla reports a Swiss National Funds (SNF) grant for MRI in stroke. U. Fischer reports financial support for the present study from Medtronic. SWIFT DIRECT is an investigator-initiated trial. The sponsor was not involved in the final study design, protocol, conduct, evaluation of results or preparation of the manuscript. U. Fischer also reports research grants from Medtronic BEYOND SWIFT registry, Swiss National Science Foundation, Swiss Heart Foundation; consulting fees from Medtronic, Stryker and CSL Behring (fees paid to institution); membership of a Data Safety Monitoring Board for the IN EXTREMIS trial and TITAN trial and Portola (Alexion) Advisory board (fees paid to institution); and Vice President of the Swiss Neurological Society. J. Kaesmacher reports financial support of Medtronic for the BEYOND SWIFT Registry (fees paid to institution); research grant from the Swiss National Science Foundation supporting the TECNO trial (fees paid to institution); Swiss Academy of Medical Sciences research grant supporting MRI research (fees paid to institution); Swiss Heart Foundation research grant supporting cardiac MRI in the etiological work-up of stroke patients (fees paid to institution). R. Pop, S. Räty, R. Riva, T. Dobrocky, P.L. Alexandre, M. Lefebvre, J.F. Albucher, M. Boulanger, F. Di Maria, S. Richard, S. Soize, E.I. Piechowiak, J. Liman, A. Reich, T. Meinel and A. Mpotsaris declare that they have no competing interests.

Additional information

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03192332

The authors U. Fischer and J. Kaesmacher contributed equally to the manuscript.

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Pop, R., Räty, S., Riva, R. et al. Effect of Bridging Thrombolysis on the Efficacy of Stent Retriever Thrombectomy Techniques. Clin Neuroradiol 34, 93–103 (2024). https://doi.org/10.1007/s00062-023-01340-9

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