The Aspirations of Direct Aspiration for Thrombectomy in Ischemic Stroke: A Critical Analysis

Abstract

The treatment of acute ischemic stroke by mechanical thrombectomy has been revolutionary, however most of the clinical trials were done with the use a stent retriever. At the same time, an alternative technique of thrombectomy through direct aspiration with a large bore distal access catheter at the face of the clot is rapidly gaining popularity. Nonetheless, the data supporting this new technique is not yet as mature as that available on stent retrievers. This review is a critical analysis of the evidence supporting the principle of direct aspiration thrombectomy and a discussion of its potential strengths and weaknesses in comparison to the available studies on stent retrievers. While this is by no means a conclusive review, it should serve as a yardstick of where the science is currently, and what are the next trials that are necessary.

Keywords: Catheters; Stents; Stroke; Thrombectomy.

Figure 1.

Relationship between successful reperfusion and good functional outcomes in the various thrombectomy trials. mRS, modified Rankin Scale; TICI, treatment in cerebral infarction; MR CLEAN, Multicenter Randomized Clinical trial of Endovascular treatment for Acute ischemic stroke in the Netherlands; REVASCAT, Endovascular Revascularization With Solitaire Device Versus Best Medical Therapy in Anterior Circulation Stroke Within 8 Hours; TREVO 2, Thrombectomy Revascularization of Large Vessel Occlusions in Acute Ischemic Stroke 2; THRACE, Trial and Cost Effectiveness Evaluation of Intra-arterial Thrombectomy in Acute Ischemic Stroke; ESCAPE, Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke; NASA, North American Solitaire Stent-Retriever Acute Stroke; THERAPY, The Randomized, Concurrent Controlled Trial to Assess the Penumbra System’s Safety and Effectiveness in the Treatment of Acute Stroke; EXTEND-IA, Extending the Time for Thrombolysis in Emergency Neurological Deficits-Intra-Arterial; STAR, Solitaire Thrombectomy for Acute Revascularization; SWIFT PRIME, Solitaire FR With the Intention For Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke; STRATIS, Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke; ASTER, Direct Aspiration First Pass Technique for Thrombectomy Revascularization of Large Vessel Occlusion in Acute Ischemic Stroke; ARTS, Aspiration-Retriever Technique for Stroke; ADAPT FAST, A Direct Aspiration, First Pass Technique for the Endovascular Treatment of Stroke.