A direct aspiration first-pass technique (ADAPT) for acute ischemic stroke thrombectomy: Indications, technique, and emerging devices

Abstract

To date, the use of the most suitable first-pass technique for Mechanical Thrombectomy is still debated. In last years, several observational studies have suggested noninferiority or superiority of A Direct Aspiration first-Pass Technique (ADAPT) technique to achieve better reperfusion in comparison to stent retriever. While ASA/AHA 2018 guidelines recommend that patients with AIS should receive Mechanical Thrombectomy with a stent retriever, last European Stroke Organization guidelines report no evidence that stent retriever compared with contact aspiration could improve reperfusion rate. ADAPT is based on aspiration alone as the primary mechanism of thrombectomy and, if initially unsuccessful, then incorporating adjunctive alternatives. ADAPT improvement is also related to last generation of aspiration catheters. The purpose of this review is to report ADAPT principles, technique, efficacy, and safety as first-line treatment for acute ischemic stroke with the latest generation of reperfusion devices.

Keywords: Stroke; interventional; technique; thrombectomy; thromboaspiration.

Figure 1.

(A) Acute ischemic stroke with right M1 cerebral artery occlusion (arrowhead). (B, C) Under road map guidance, microwire and a microcatheter (white arrows) are advanced in front of the thrombus, without crossing the clot as the aspiration catheter (black arrows) could be pushed over the co-axial system to reach the thrombus, with no obstacles. (D) Complete reperfusion (mTICI 3) is obtained after a single aspiration pass.

Figure 2.

(A) Same right M1 occlusion as the Figure 1 (arrowhead). (B, C, D) In this case, because of a right carotid siphon coiling (asterix), microcatheter and microwire (white arrows) overcome the clot to stabilize the co-axial system, to allow the aspiration catheter (black arrows) to be navigated over the coiling in front of the thrombus. (E) Complete recanalization is obtained at the first aspiration attempt (mTICI 3).