Large vessel occlusion stroke (LVO) patients do better when treated with a direct aspiration first pass (ADAPT) approach than those treated with a stent retriever first-line (SRFL) approach, the current standard of care for mechanical thrombectomy in patients suffering acute ischemic strokes. The study was conducted by a research team at the Icahn School of Medicine at Mount Sinai. The findings of the study were presented at the main event plenary session at the International Stroke Conference (ISC) 2018.
"Our data strongly demonstrates that the two approaches are clinically equivalent, meaning that patients do just as well when you start with aspiration, or clot suction, as when you start with a stent retriever to trap and pull out the clot," says J Mocco, MD, MS, Vice Chair of Neurosurgery and Director of the Cerebrovascular Center for the Mount Sinai Health System, who designed the study and presented the data at ISC 2018. "COMPASS is the first trial designed to compare patient functional outcome between these treatment approaches and we found that patients do equally well with either treatment."
Both the aspiration and stent retriever techniques are initiated by inserting a guide catheter into the femoral artery in the groin and guiding it up into the brain under image guidance. The aspiration approach involves passing a specialized aspiration catheter through the guide catheter, moving it directly to the lesion and then attaching it to an aspiration pump. Once attached to the aspiration system, the catheter is advanced into the proximal end of the clot, suction is initiated and the clot is either aspirated through the catheter or it becomes stuck at the catheter tip and is withdrawn back into the guide catheter. The stent retriever approach involves introducing a stent retriever, which resembles a tiny wire cage, through the guide catheter and moving it to the clot. The stent then opens up, traps the clot and the stent that contains the clot is removed through the guide catheter.
Secondary safety endpoints presented, including embolization in new territory (ENT) and symptomatic intracranial hemorrhage (sICH), were not statistically different between the two arms.
A number of clinical trials published in 2015 demonstrated the superiority of endovascular thrombectomy (restoring blood flow to the brain by surgically removing the clot) over medical management (administration of clot busting drugs) for treatment of ischemic strokes. The majority of stoke thrombectomy data to date has focused on stent retrievers, leading many to believe that they represented the gold standard of thrombectomy devices, as reflected by recent American Heart Association/American Stroke Association guidelines. Results from this new study show that an aspiration-first strategy is at least as effective as using retrievable stents, and may even be faster, safer and cheaper.
"This study is very exciting because it shows that there are other ways to open the arteries that are just as effective and perhaps, less expensive. Whether you approach the brain clot with suction or whether you approach it with trapping and pulling it out, patients do equally well," says Dr. Mocco. "Stroke is a massive disease that is prevalent across the globe, so finding ways to provide these therapies to patients who need it in a cost-effective manner is going to be another great step forward in medicine."
Dr. Mocco designed the COMPASS trial in collaboration with leading stroke experts Aquilla Turk, DO, from The Medical University of South Carolina and Adnan Siddiqui, MD, from The University of Buffalo. The COMPASS trial was paid for by Penumbra but the trial was conducted independently by Dr. Mocco and his collaborators, who also handled all data analysis. The Mount Sinai Health System served as the international data coordinating center for the study.