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VIDEO: COMPASS shows stroke-clot aspiration noninferior to retrieval



– Clot removal in acute ischemic stroke patients using an aspiration catheter was noninferior to clot removal using the standard method, a stent retriever, in a multicenter, randomized trial with 270 patients.

“There is now level I evidence that stent retrievers and primary aspiration have equivalent outcomes in emergent large vessel occlusions,” J Mocco, MD, said at the International Stroke Conference, sponsored by the American Heart Association.

The results “will give physicians more choice,” Dr. Mocco said in a video interview. Until now, “many physicians felt that they had to use stent retrievers” because these devices had an much bigger evidence base of efficacy and safety. The new findings provide evidence that supports aspiration as an alternative strategy, said Dr. Mocco, professor of neurosurgery and director of the Cerebrovascular Center at Mount Sinai Medical Center in New York.

The results Dr. Mocco reported from the COMPASS trial (Comparison of Direct Aspiration vs. Stent Retriever as a First Approach) were the second time that clot aspiration was shown to produce outcomes similar to stent retrieval. Similar findings came from a French multicenter trial, ASTER, reported in 2017 (JAMA. 2017 Aug 1;318[5]:443-52).

The study ran at 15 U.S. centers during 2015-2017 and randomized patients with emergent large vessel occlusion strokes to receive initial treatment with either an aspiration catheter or a stent retriever. The specific type of catheter or stent used was left up to each operator. In 83% of the aspiration cases and 81% of the stent retriever cases, the initial device used produced a moderately high or better level of restored blood flow within the occluded artery, with thrombolysis in cerebral infarction (TICI) 2b flow or greater.

The study’s primary efficacy endpoint was the percentage of patients with a modified Rankin Scale score of 0-2 at 90 days after treatment, which occurred in 52% of patients treated with aspiration first and in 49% of those treated by retrieval first, which met the study’s prespecified criterion for noninferiority of the aspiration strategy, Dr. Mocco reported.

The results also showed suggestions of faster responses in the patients treated by aspiration first, although these did not reach statistical significance. The highest rate of restored blood flow within the occluded artery, TICI 3 flow, occurred in 34% of patients treated by aspiration first and in 23% of those treated with retrieval first. The average time to produce TICI 2b flow or greater was 22 minutes in the aspiration-first patients, compared with 33 minutes among retrieval-first patients.

“I prefer to start with aspiration first because it’s fast and efficient,” Dr. Mocco said. “I find encouragement in the nonsignificant faster rate of reperfusion” seen in the results.

Dr. Ralph L. Sacco, professor and chairman of neurology at the University of Miami Mitchel L. Zoler/Frontline Medical News

Dr. Ralph L. Sacco

Although Dr. Mocco highlighted operator preference when choosing aspiration or clot retrieval, “clot composition and underlying pathophysiology could potentially be important” considerations when selecting a strategy, commented Ralph L. Sacco, MD, professor and chairman of neurology at the University of Miami. “For cardioembolic, fresh clot, it makes sense that aspiration could be better. For atherosclerotic, fibrous clot, perhaps retrieval is better.”

The study’s safety endpoints, the rate of all-cause mortality after 90 days, all intracranial hemorrhages, and symptomatic intracranial hemorrhages, were all similar in the two study arms.

The COMPASS study was funded by Penumbra, but the company had no role in the trial’s design or analysis. Dr. Mocco has been a consultant to Cerebrotech Medical, EndoStream, Rebound Medical, Synchron, and Viseon and has investments in some of these companies. Dr. Sacco had no disclosures.

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SOURCE: Mocco J et al. ISC 2018, Abstract LB4.

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