Cost, Not Efficacy Differentiates Stroke Thrombectomy Strategies

An aspiration-first approach to thrombectomy not only matched stent retrievers for efficacy in endovascular stroke therapy, but may be cheaper, according to COMPASS trial investigators.

Used as the first pass of thrombectomy, the Penumbra aspiration catheter was non-inferior in functional outcomes at 90 days compared with the Solitaire stent retriever (patients with modified Rankin Scale scores 0-2 (52% vs 50%, P=0.0014 for non-inferiority), reported the group led by Aquilla Turk III, DO, of Greenville Health System in South Carolina.

The paper was published in the March 9 issue of The Lancet, with top-line results previously shared at the 2018 International Stroke Conference.

Now a prespecified cost analysis adds the finding that the Penumbra strategy is on average $4,541-5,074 cheaper in device cost (P<0.0001), depending on the source of the cost data, Turk and colleagues reported.

“This study supports the use of the aspiration first pass approach for stroke thrombectomy, and the findings might directly affect current stroke treatment guideline recommendations,” the authors said, noting that such guidelines endorse stent retrievers alone in endovascular stroke therapy.

Both the Solitaire and Penumbra are FDA-approved devices.

“Taken together with the ASTER trial results, the COMPASS trial provides evidence to support a direct aspiration first-pass technique as an alternative to use of stent retrievers as first-line technique for endovascular thrombectomy,” noted Bijoy Menon, MD, and Mayank Goyal, MD, both of the University of Calgary, Alberta.

Yet it’s “difficult” to say whether these data should change practice, the duo wrote in an accompanying comment.

“Neurointervention is dependent on the specialized skillset of the operator; different operators might learn, adopt, and feel comfortable with different techniques. Neurointerventionalists should, however, constantly measure their procedural outcomes (i.e., speed, efficacy, and safety of reperfusion) against current benchmarks,” Menon and Goyal wrote.

COMPASS is a non-inferiority trial that randomized 270 acute ischemic stroke patients with anterior circulation large vessel occlusions to aspiration- or stent retriever-first thrombectomy. Eligibility criteria included an ASPECTS score 6 and higher.

Participating sites were 15 centers in North America that were highly experienced in both techniques, the researchers said.

Safety was similar between groups as intracranial hemorrhage (36% for aspiration vs 34% for stent retriever, OR 1.08, 95% CI 0.65-1.78) and all-cause mortality rates (22% for both groups, OR 1.02, 95% CI 0.57-1.81) were statistically indistinguishable.

Turk and colleagues acknowledged that their cost analysis could not be performed with site-specific data and that they did not account for entire procedure costs.

Menon and Goyal suggested that hybrid approaches that use both stent retrievers and aspiration have the potential to achieve better-quality reperfusion — and it is that high-quality reperfusion (achieved safely) that is likely to lead to clinical benefit.

“Continuing innovations will probably make current techniques obsolete,” they said. “Therefore, when using non-inferiority of clinical outcome as a design strategy in future trials, comparison of newer techniques or devices with older, well established ones should also assess whether the new intervention results in similar, if not better-quality, faster, and safer reperfusion.”