Long Sheath Use in Stroke Thrombectomy Leads to Improved Outcomes in Octogenerians

INTRODUCTION: Comparative evaluation of efficacy of using a long sheath-first approach in stroke thrombectomy patients where no initial arch information is available does not exist. Lower door-to-reperfusion times are associated with better outcomes in stroke thrombectomy. Multiple factors affect reperfusion times including approach, arch navigability, and the amount of support provided by equipment. METHODS: Study Design and Setting: An institutional review-board-approved, prospectively maintained endovascular arterial thrombectomy database from 2016 to 2018 was reviewed. Inclusion criteria: manual aspiration thrombectomy or stent-assisted, femoral approach, >80 yo, and LVO in anterior circulation. Study Variables: Demographic information such as age, sex, medical comorbidities, NIHSS score on presentation, tPA administration, and thrombus location were extracted. Arch navigability was defined by time from puncture to first base catheter run. Procedural times, and angiographic results (TICI score) were recorded and used as metrics for efficacy. Ninety-day outcome was also evaluated based on modified Rankin scale. The analysis was performed based on an intention-to-treat analysis. Statistical Analysis: Univariate statistical analysis was performed using an unpaired t test with Bonferonni correction for continuous variables and Fisher’s exact test for categorical variables. Statistically significant differences between groups were defined as p < 0.05. Procedural Technique: All procedures were performed emergently under local anesthesia. Consent was obtained from the patient or their next of kin under our institution’s guidelines. RESULTS: A total of n = 287 patients were included in the final analysis. There were no significant differences in baseline demographics. Upfront “long-sheath first” approach resulted in improved outcomes: time to first run (15.6 vs 32 min, p = 0.0005), time to first pass (21.4 vs 40 min, p < 0.0001), time to final reperfusion (35.8 vs 50 min, p < 0.0001), delta NIHSS (2.2 vs 6.6, p < 0.0001). CONCLUSION: Upfront “long-sheath first” approach results in improved outcomes during stroke thrombectomy in octogenerian population.