Abstract WMP6: Delayed Device Access to the Occluded Target Vessel Predicts Worse Recanalization Rates and Poor Outcomes in Endovascular Therapy for Acute Stroke
During embolectomy for acute stroke, transfemoral access to occluded vessel may be technically difficult. We aim to study the impact of difficult catheter access to target artery.
Methods: Single center review of anterior circulation stroke patients enrolled in prospective trials/registries (MR Rescue, MERCI, DEFUSE) requiring recording of time from groin puncture to first device deployment(Tdep). Patients were divided according to Tdep quartiles (Q): patients in Q4 were considered as difficult access. We recorded recanalization (TICI≥2a), complete recanalization (TICI≥2b), infarct volume(24h DWI), day 5 NIHSS, and favorable outcome (3 months mRS≤2).
Results: We included 196 patients, mean age 66±14, median NIHSS 16(IQR:12-21). Overall outcomes were: median Tdep 52 min (36-77), recanalization 89.1%, complete recanalization 59.4%, favorable outcome 43.8%. We observed a positive correlation between Tdep and day 5 NIHSS (r=0.27; p=0.01) or 3 months mRS (r=0.26; p<0.01). Patients with difficult access (Q4: Tdep>77 min) had similar baseline NIHSS (16 Vs 17 p=0.58), time from symptom to procedure start (433 Vs 371min; p=0.28) and occlusion location (ICA/M1/M2: 46.7/42.2/11.1% Vs 39.1/54.3/6.5%; p=0.31). However, patients in Q4 had: longer IA procedures (153 vs 112 min;p<0.01), lower complete recanalization (41% Vs 66%;p<0.01), larger infarcts (87 Vs 53cc; p<0.01), higher day 5 NIHSS (15 Vs 9;p<0.01), and less favorable outcome (29.2% Vs 49%; p=0.02). After adjusting by age and time to reperfusion, a regression model identified admission NIHSS (OR% 1.12: 95%CI 1.02-1.21; p<0.01), age (OR% 1.03: 95%CI 1.01-1.06; p=0.01) and Tdep (OR% 1.02 95%CI 1.01-1.03; p=0.01) as independent predictors of poor outcome. In univariate analysis age>69, male gender and left hemisphere stroke were associated with difficult access. The combined presence of the 3 factors increased by 3.5 fold the likelihood of difficult access (OR:3.55 95%CI 1.5-8.6: p<0.01)
Conclusion: Delayed device access to target occluded artery independently predicts poor outcome. Identification of difficult access using clinical scores or imaging may lead to alternative strategies; brachial, radial or cervical approaches that could result in shortened procedural times and improved outcomes
- © 2012 by American Heart Association, Inc.