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观点:机械取栓术中应优先考虑首次再通而不是手术速度

在机械血栓切除术中以尽可能少的通过次数实现凝块取出至关重要,甚至可能比手术完成的速度更重要——尽管“时间就是大脑”这一古老的口头禅。这是2022年根据欧洲微创神经治疗学会 (ESMINT) 大会最近发表的一份报告,该报告由ESMINT主席Jens Fiehler(德国汉堡大学医学中心)发表。

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我们简单地梳理了一下Jens Fiehler教授的观点:
1-机械取栓肯定是有时间相关性的,再灌注时间对计算机断层扫描 (CT) 灌注成像结果有直接影响。而完全再灌注是机械取栓的理想结果;

2-“首次再通”的价值:在血栓切除术中实现再通之间存在“巨大差异”。第一次通过与两次或多次通过,平均再通的TICI3比首次再通的TICI3差6%。

3-三次及以上的取栓尝试并不会带来更好的临床结果;
在0-1次尝试中的良好结果率为40%,而在两次或多次尝试中只有4%。实际上如果我们尝试不成功是会伤害患者的。

4-在任何给定时间,再灌注可能比没有再灌注要好;


5-取栓时间很重要,取栓次数相比于取栓时间更影响患者预后;

虽然TICI 3在第一次和第二次再灌注时比第一次TICI 2b再灌注产生更好的结果,但在TICI 3后三次或更多次再灌注后的结果并不比首次通过TICI 2b更好。因此你需要非常确定,通过第二次取栓尝试,你能完成TICI 3再通。

6-不同的术者可能会以不同的方式定义成功并做出不同的决定,例如是否遵循前两次或三次不成功的取栓尝试;


7-首次再通(TICI3级) 应该始终是术者的目标,我们应该把所有努力都放在第一次取栓尝试中——而不是简单地先做一个快速的选择,然后再做更多技术补救上的努力。

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报道原文:
Achieving clot retrieval with the fewest possible number of passes is critical in mechanical thrombectomy, and may even hold greater importance than how quickly the procedure is completed—despite the age-old mantra that ‘time is brain’. That is according to a recent presentation from the European Society of Minimally Invasive Neurological Therapy (ESMINT) congress (7–9 September, Nice, France), delivered by outgoing ESMINT president Jens Fiehler (University Medical Center Hamburg-Eppendorf, Hamburg, Germany), who also claimed that, “at any given time, reperfusion is still better than no reperfusion”.
Fiehler began with a nod to the undoubted relevance that time to recanalisation has, referencing previous studies that have demonstrated the direct influence reperfusion times have on computed tomography (CT) perfusion imaging outcomes. “We definitely have a time dependency and we all know that complete reperfusion is the desired outcome for thrombectomy,” he said. “And, Osama Zaidat’s group [Mercy Health, Toledo, USA] made it clear, really for the first time, that it is also about having complete reperfusion as early as possible.”

Moving on to discuss the lauded ‘first-pass effect’ in thrombectomy, defined as complete reperfusion (thrombolysis in cerebral infarction [TICI] 2c–3) with a single device pass, the speaker noted a “huge difference” between achieving recanalisation at the first pass versus with two or more passes. “Any TICI 3 is already 6% worse [on average] than first-pass TICI 3, and any TICI 2b is worse still,” Fiehler asserted.

Here, he also touched on the fact that several publications have shown higher reperfusion rates are achieved with each successive retrieval attempt—“obviously”, because they are essentially “adding up”—but that the rate of good clinical outcomes does not actually improve beyond the third attempt. And, despite the fact that successful reperfusion will naturally always lead to improved outcomes when compared directly to no reperfusion, Fiehler stated that average outcomes associated with four-plus attempts are “no better than if we did not try at all”.

“But the problem is that we cannot go back in time,” he continued. “We cannot say ‘what if we did not try it’—we did try it, because, at any given time, reperfusion is likely better than no reperfusion.” According to Fiehler, prior research has found that failed reperfusion attempts may be harmful as well, with one study involving TICI 0 patients demonstrating a 40% rate of good outcome in 0–1 attempts versus just 4% with two or more attempts. “So, we can actually harm patients [if we are not] successful,” he noted.

Outlining another illustration of this problem, Fiehler claimed that, while TICI 3 reperfusion at both the first and second pass results in better outcomes than first-pass TICI 2b reperfusion, outcomes following TICI 3 in three or more passes are “no better” than those seen with first-pass TICI 2b. “The conclusion is that you need to be pretty sure that, with the second retrieval attempt, you [will] achieve TICI 3,” he explained. “And, if you do not, then you made the wrong decision and you should have stopped right away.”

Referencing a study published by him and his colleagues, Fiehler noted a trend towards elapsing time being linked to poorer outcomes—even within a group of patients who underwent successful recanalisation at the first attempt. He also informed the ESMINT audience that the issue becomes “really complex” when attempting to analyse which of these two factors, time elapsed or number of passes, independently affects patient outcomes more profoundly. “But, the conclusion was that it is not so much the time that makes the difference—it is the number of passes,” he added.

Fiehler conceded that interpreting many of the ‘per-pass’ data these arguments are based on is “very difficult” as well, owing to the variability that can be found across multicentre, self-assessed studies. He cited the fact that different operators will likely define success differently and make contrasting decisions about, for example, whether or not to continue following the first two or three unsuccessful retrieval attempts, and their decision-making process will also be influenced by the individual patient in front of them.

“Theoretically, the only way to solve this is to have a randomised controlled trial […] and I think the most sensible approach would be to have a randomised trial after the third failed attempt,” Fiehler opined. “Similar things are already happening with ICAD [intracranial atherosclerotic disease] patients—for instance, the ANGEL-REBOOT study in China is randomising stenting versus doing nothing after two failed attempts—and I think this could help us better understand the problem.”

Fiehler concluded that first-pass TICI 3 should always be the operator’s goal and, responding to a query from the audience regarding aspiration versus other thrombectomy techniques, stated: “If you are successful at the first pass with aspiration, that is wonderful, but the problem is more to do with how often we get there. My own thinking regarding these data is that [we should] put everything into the first attempt—rather than simply doing a quick aspiration first and then making a more technical effort later.”



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