Balloon Angioplasty as the First-Choice Treatment for Intracranial Atherosclerosis-Related Emergent Large Vessel Occlusion Involving the Microcatheter “First-Pass Effect”

Background It is unknown whether balloon angioplasty can be a first-choice treatment for intracranial atherosclerosis-related emergent large vessel occlusion (ICAS-ELVO) with small clot burden. The microcatheter “first-pass effect” is a valid predictor of ICAS-ELVO with small clot. Objective To determine balloon angioplasty’s efficacy as first-choice treatment for ICAS-ELVO involving the microcatheter “first-pass effect” during endovascular treatment (EVT). Methods This continuous retrospective analysis assessed ICAS-ELVO patients presenting with the microcatheter “first-pass effect” during EVT. Patients were divided into two first-choice treatment-based groups: preferred balloon angioplasty (PBA) and preferred mechanical thrombectomy (PMT). Efficacy and safety outcomes were compared between groups. Results Seventy-six patients with ICAS-ELVO involving the microcatheter “first-pass effect” during EVT were enrolled. Compared with patients in PMT group, patients in PBA group were associated with (i) a higher rate of first-pass recanalization (54.0% vs. 28.9%, p=.010) and complete reperfusion (expanded thrombolysis in cerebral ischemia≥2c; 76.0% vs. 53.8%, p=.049), (ii) a shorter puncture-to-recanalization time (49.5 min vs. 56.0 min, p<.001), (iii) less operation costs (48,499.5¥ vs. 99,086.0¥, p<.001),and (iv) more excellent functional outcomes (modified Rankin scale:0-1; 44.0% vs. 19.2%, p=.032) at 90 days. No significant differences in symptomatic intracranial hemorrhage (12.0% vs. 15.4%, p>.999) and mortality (10.0% vs. 7.7%, p>.999) were noted. Logistic regression analysis revealed that first-choice treatment was an independent predictor of 90-day excellent functional outcomes (adjusted odds ratio [aOR] =0.10, 95% CI: 0.02–0.66, p=.017). Conclusion Balloon angioplasty, as the first-choice treatment, potentially improves 90-day functional outcomes for ICAS-ELVO patients with microcatheter “first-pass effect” during EVT. What is already known on this topic Compared with large vessel occlusion caused by embolization, mechanical thrombectomy has lower recanalization rate, longer procedure time, and poorer prognosis for patients with intracranial atherosclerosis-related emergent large vessel occlusion(ICAS-ELVO). What this study adds This study revealed that balloon angioplasty, as the first-choice treatment, potentially improves 90-day outcomes, shortens procedure time, and reduces operation costs for patients with ICAS-ELVO involving the microcatheter “first-pass effect” during endovascular treatment. How this study might affect research, practice or policy We believe that our study makes a significant contribution to the literature because its findings suggest that rapid and accurate methods of diagnosing the etiology and clot burden of ELVO as well as the development of an individualized EVT strategy based on etiology and clot burden need to be established. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study did not receive any funding ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethics committee of Shenzhen Hospital of Southern Medical University gave ethical approval for this work(NYSZYYEC20180001) I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors * aOR : adjusted odds ratio CI : confidence interval CT : computed tomography ELVO : emergent large vessel occlusion eTICI : expanded thrombolysis in cerebral ischemia EVT : endovascular treatment FPR : first pass recanalization ICAS : intracranial atherosclerosis IQR : interquartile range mRS : modified Rankin Scale MT : mechanical thrombectomy NIHSS : National Institutes of Health Stroke Scale PBA : preferred balloon angioplasty PMT : preferred mechanical thrombectomy PRT : puncture to recanalization time SD : standard deviation t-PA : tissue-type plasminogen activator sICH : symptomatic intracranial hemorrhage.