Contact Aspiration vs. Stent Retriever in Stroke

Study Questions:

In stroke patients with large vessel occlusion of the anterior circulation, does contact aspiration thrombectomy provide a better angiographic outcome than stent retriever thrombectomy?

Methods:

ASTER was a multicenter, open-label, blinded endpoint randomized clinical trial. The study sites were eight high-volume comprehensive stroke centers with frequent use of both contact aspiration thrombectomy and stent retriever thrombectomy. Patients with occlusion of the intracranial internal carotid artery or first or second branch of the middle cerebral artery (M1 or M2) were enrolled within 6 hours of symptom onset and randomized 1:1 to contact aspiration versus stent retrieval. The primary outcome was the percentage of patients with a good angiographic outcome, as defined by a modified Thrombolysis in Cerebral Infarction (mTICI) score of 2b or 3 at the close of the procedure.

Results:

Over 13 months, 381 patients (192 contact aspiration and 189 stent retrieval) were randomized. The median time from symptom onset to groin puncture across all subjects was 3 hours and 47 minutes. There was no difference in the primary outcome between the contact aspiration group (85.4% with mTICI 2b/3) and the stent retriever group (83.1%) in the intention-to-treat analysis. Similarly, there was no difference in the primary outcome between the two groups in the per-protocol analysis. There was no difference between the two groups in mean change in National Institutes of Health Stroke Scale score at 24 hours or in functional independence (modified Rankin scale score ≤2) at 3 months. There was no difference between the two groups in intracranial hemorrhage at 24 hours or in 3-month all-cause mortality. There was a nonsignificant trend toward more frequent use of rescue treatment in the contact aspiration group than in the stent retriever group (odds ratio, 1.57; 95% confidence interval, 0.99-2.47).

Conclusions:

In stroke patients with large vessel occlusion of the anterior circulation, contact aspiration thrombectomy does not provide a superior angiographic outcome when compared with stent retriever thrombectomy.

Perspective:

This study suggests that contact aspiration is not superior to standard stent retriever thrombectomy in the treatment of large vessel ischemic strokes. The study design does not permit for commentary on the equivalence or inferiority of contact aspiration when compared with stent retrieval. Some may interpret the trend toward more frequent use of rescue treatment in the contact aspiration arm to argue toward the superiority of the stent retriever technique. Overall, this study is unlikely to change providers’ existing practice habits.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Vascular Medicine, Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Nuclear Imaging

Keywords: Angiography, Cerebral Infarction, Endovascular Procedures, Intracranial Hemorrhages, Ischemia, Myocardial Revascularization, Primary Prevention, Stents, Stroke, Thrombectomy, Vascular Diseases


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