First-pass aspiration versus stent retriever thrombectomy: machine learning study of treatment effect heterogeneity.
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Chen Huanwen, Isidor Julio, Schirmer Clemens, Ernst Marielle, Kim Joon-Tae, Rai Ansaar, Jabbour Pascal, Abecassis Isaac Josh, Grossberg Jonathan A, Alawieh Ali, Khanna Omaditya, Navia Pedro, Starke Robert M, Psychogios Marios-Nikos, Siddiqui Fazeel, Samaniego Edgar A, Goyal Nitin, Ezzeldin Mohamad, Dye Justin, Alaraj Ali, Yoshimura Shinichi, Alcedo Rodolfo, Cerejo Russell, Luther Evan, Almallouhi Eyad, Fiorella David, Romano Daniele G, Tanweer Omar, Fragata Isabel, Mascitelli Justin, Cuellar Hugo H, Chalouhi Nohra, Limaye Kaustubh, Mokin Maxim, Matouk Charles, Kellogg Ryan, Brinjikji Waleed, Chowdhry Shakeel A, Altschul David, Ogilvy Christopher S, Levitt Michael, Grandhi Ramesh, Spiotta Alejandro M, Kan Peter
Аннотация
METHODS: In this retrospective multicenter cohort study, patients with large vessel occlusion were included, and those who underwent ADAPT versus SR first-pass thrombectomy (either as standalone or combined with aspiration) were compared. The primary outcome was a composite of first-pass effect (FPE, modified Thrombolysis In Cerebral Infarction (mTICI) 2c or better with one attempt) with no symptomatic intracranial hemorrhage (sICH). A causal forest model was used to estimate the conditional average treatment effect (CATE) for each patient, with larger CATEs indicating that ADAPT is expected to be more advantageous. Patients were stratified by CATEs, and outcomes were compared between treatment groups.
RESULTS: Among 6700 included patients, ADAPT (n=3695, 55%) was associated with a higher rate of FPE with no sICH (39.9% vs 26.9%; adjusted OR (aOR) 2.07, 95% CI 1.77 to 2.41, P<0.001). The causal forest identified significant treatment effect heterogeneity (interaction P<0.001), where ADAPT was more advantageous in more recent years and among patients with M1 occlusions presenting in earlier time windows. Low-CATE patients showed no statistically significant difference between techniques (aOR 0.91, 95% CI 0.57 to 1.45, P=0.70), while medium- and high-CATE patients demonstrated progressively larger ADAPT advantages (aOR 2.06, 95% CI 1.67 to 2.55, and aOR 2.99, 95% CI 2.24 to 3.98, respectively, both P<0.001).
CONCLUSIONS: ADAPT may be superior to SR for a majority of patients, particularly in recent years, and among patients with M1 occlusions presenting in earlier time windows.