Outcomes Following First-Pass Direct Aspiration Versus Stent Retriever for Endovascular Thrombectomy in Primary Medium or Distal Vessel Occlusion: An Analysis of the SVIN Registry

BACKGROUND: Endovascular thrombectomy is increasingly performed for acute ischemic stroke due to medium vessel occlusion (MeVO); however, recent randomized trials—primarily using stent retriever (SR) techniques—have not demonstrated a clear benefit over medical management. This study aimed to compare the direct aspiration first-pass technique (ADAPT) and SR in MeVO using a multicenter endovascular thrombectomy consortium. METHODS: The Society of Vascular and Interventional Neurology registry was queried for all primary MeVO cases treated with ADAPT or SR as the first-pass technique. MeVO was defined as an occlusion of A1, P1, M2, or beyond. Outcomes included time to recanalization, recanalization rates, first-pass effect (defined as treatment in cerebral infarction-3 after first pass), intracranial hemorrhage, symptomatic intracranial hemorrhage, and clinical outcomes. RESULTS: A total of 1391 patients with MeVO were identified; 415 (29.8%) in the ADAPT group and 976 (70.2%) in the SR group. The most common location of occlusion was the middle cerebral artery-M2 (75.9%), followed by the middle cerebral artery-M3 (11.4%). The median age was 70, and 698 (50.4%) patients were men. Time from angio-suite arrival to expanded Treatment in Cerebral Infarction (eTICI) ≥2b (54 versus 60, P =0.002), time from endovascular access to final recanalization (42 versus 52, P <0.001), time from endovascular access to eTICI 2b (31 versus 39, P <0.001), and eTICI 3 (26 versus 34, P <0.001) were shorter for the ADAPT group. Conversely, the SR group had higher rates of eTICI ≥2b (91.6% versus 86.3%, P =0.002) and first-pass effect (31.7% versus 23.4%, P =0.002). Rates of good outcome, excellent outcome, intracranial hemorrhage, and sICH were not significantly different between groups. CONCLUSIONS: Although ADAPT yielded faster recanalization, SR achieved a higher first-pass effect and slightly higher recanalization rates. Intracranial hemorrhage, symptomatic intracranial hemorrhage, and clinical outcomes were comparable between groups. This study suggests that both techniques may offer distinct advantages. Prospective randomized controlled studies are warranted to further understand the safety and efficacy of ADAPT versus the SR technique in patients with MeVO.

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Journal
Stroke Vascular and Interventional Neurology
Published
2026-09-24
DOI
https://doi.org/10.1161/svin.125.001950
Primary Topic
Acute Ischemic Stroke Management
Type
article
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article

Outcomes Following First-Pass Direct Aspiration Versus Stent Retriever for Endovascular Thrombectomy in Primary Medium or Distal Vessel Occlusion: An Analysis of the SVIN Registry

Sunil A. Sheth, Samantha E. Miller, Stavros Matsoukas, Mahmoud H. Mohammaden et al.
Stroke Vascular and Interventional Neurology
Acute Ischemic Stroke Management
article

Outcomes Following First-Pass Direct Aspiration Versus Stent Retriever for Endovascular Thrombectomy in Primary Medium or Distal Vessel Occlusion: An Analysis of the SVIN Registry

Sunil A. Sheth, Samantha E. Miller, Stavros Matsoukas, Mahmoud H. Mohammaden, Amol M. Mehta, Santiago Ortega‐Gutiérrez, Jonathan Andrew Grossberg, Italo Linfante, David S. Liebeskind, Mohamad K. Abdalkader, Johanna T Fifi, J Mocco, Shahram Majidi, Jorge Cespedes, Alhamza R Al‐Bayati, Jane Khalife, Ananya S. Iyyangar, Guillermo Linares, Brijesh Mehta, Jaydevsinh N. Dolia, Guilherme C. Dabus, Wondwossen G. Tekle, Joy Sessa, Raul G. Nogueira, Diogo C Haussen, H Saei, Ameer E Hassan, Mouhammad A. Jumaa, Taha Nisar, Milagros Galecio‐Castillo, Piers Klein, Jacklyn Samaha, Michael J. Dubinski, Leonardo Cruz‐Criollo, Linda Zhang
article en

Abstract

BACKGROUND: Endovascular thrombectomy is increasingly performed for acute ischemic stroke due to medium vessel occlusion (MeVO); however, recent randomized trials—primarily using stent retriever (SR) techniques—have not demonstrated a clear benefit over medical management. This study aimed to compare the direct aspiration first-pass technique (ADAPT) and SR in MeVO using a multicenter endovascular thrombectomy consortium. METHODS: The Society of Vascular and Interventional Neurology registry was queried for all primary MeVO cases treated with ADAPT or SR as the first-pass technique. MeVO was defined as an occlusion of A1, P1, M2, or beyond. Outcomes included time to recanalization, recanalization rates, first-pass effect (defined as treatment in cerebral infarction-3 after first pass), intracranial hemorrhage, symptomatic intracranial hemorrhage, and clinical outcomes. RESULTS: A total of 1391 patients with MeVO were identified; 415 (29.8%) in the ADAPT group and 976 (70.2%) in the SR group. The most common location of occlusion was the middle cerebral artery-M2 (75.9%), followed by the middle cerebral artery-M3 (11.4%). The median age was 70, and 698 (50.4%) patients were men. Time from angio-suite arrival to expanded Treatment in Cerebral Infarction (eTICI) ≥2b (54 versus 60, P =0.002), time from endovascular access to final recanalization (42 versus 52, P <0.001), time from endovascular access to eTICI 2b (31 versus 39, P <0.001), and eTICI 3 (26 versus 34, P <0.001) were shorter for the ADAPT group. Conversely, the SR group had higher rates of eTICI ≥2b (91.6% versus 86.3%, P =0.002) and first-pass effect (31.7% versus 23.4%, P =0.002). Rates of good outcome, excellent outcome, intracranial hemorrhage, and sICH were not significantly different between groups. CONCLUSIONS: Although ADAPT yielded faster recanalization, SR achieved a higher first-pass effect and slightly higher recanalization rates. Intracranial hemorrhage, symptomatic intracranial hemorrhage, and clinical outcomes were comparable between groups. This study suggests that both techniques may offer distinct advantages. Prospective randomized controlled studies are warranted to further understand the safety and efficacy of ADAPT versus the SR technique in patients with MeVO.

Stroke Vascular and Interventional Neurology
Boston Medical Center (US), Mount Sinai Health System (US), University of California, Los Angeles (US), University of Pittsburgh (US), ProMedica Toledo Hospital (US), University of Iowa Hospitals and Clinics (US), Baptist Health South Florida (US), Valley Baptist Medical Center (US), University of Pittsburgh Medical Center (US), Cooper University Health Care (US), The University of Texas Health Science Center (US), University of South Alabama (US)
Good health and well-being
Openalex Percentile: Top 11%
Acute Ischemic Stroke Management
DOIOpen Access PDFOpenAlex
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