Sex-Based Efficacy of Endovascular Thrombectomy Techniques in LVO Stroke: A Multicenter Registry Analysis

BACKGROUND: Sex differences in stroke cause, vessel anatomy, and thrombus composition are well established, yet whether these factors influence the efficacy of specific endovascular thrombectomy (EVT) techniques remains unknown. Here, we investigate sex-based differences in reperfusion outcomes across EVT techniques. METHODS: Consecutive patients with anterior circulation large vessel occlusion including intracranial internal carotid artery and the M1 and M2 segments of the middle cerebral artery treated with EVT across 4 comprehensive stroke centers in the Greater Houston area (January 2021 to June 2024) were included from a prospectively maintained registry. EVT techniques were categorized as stent retriever, contact aspiration, or combined technique. The primary outcome was the first-pass effect (modified Thrombolysis in Cerebral Infarction 2c/3 after 1 pass). Secondary outcomes included achieving modified Thrombolysis in Cerebral Infarction 2c/3 within 2 passes, 90-day modified Rankin Scale score (0-2), intracerebral hemorrhage, symptomatic intracerebral hemorrhage, and mortality. Multivariable logistic regressions were used for binary outcomes adjusted for age, National Institutes of Health Stroke Scale score, atrial fibrillation, smoking, and prior thrombolysis. Linear regression was used for the number of thrombectomy passes. RESULTS: <0.05). No difference in reperfusion outcomes was seen between EVT techniques in the male subgroup. Among patients receiving stent retriever as their first pass, female sex was associated with lower odds of achieving reperfusion within 2 passes (adjusted odds ratio, 0.43 [0.19-0.99]). CONCLUSIONS: This multicenter analysis provides the first evidence that EVT technique performance differs by sex. In females, contact aspiration achieved superior reperfusion with fewer passes compared with stent retrievers. These findings highlight the importance of sex-stratified EVT trials and support individualized, precision-based device selection in acute ischemic stroke.