Should the direct aspiration first pass technique be advocated over the stent-retriever technique for acute ischemic stroke? A systematic review and meta-analysis of 7692 patients

Background: The present meta-analysis aimed to synthesize evidence from all published studies with head-to-head data on the outcomes of a direct aspiration first pass technique (ADAPT) and the stent-retriever (SR) in acute ischemic stroke (AIS) patients. Methods: We searched PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials from inception to March 2021 for relevant clinical trials and observational studies. Eligible studies were identified, and all relevant outcomes were pooled in the meta-analysis random-effects model of DerSimonian-Laird. Results: Thirty studies were included in the meta-analysis with a total of 7868 patients. Compared with the SR, the ADAPT provides slightly higher rates of successful recanalization (RR 1.06, 95% CI [1.02 to 1.10]) and complete recanalization (RR 1.20, 95% CI [1.01 to 1.43]) but with more need for rescue therapy (RR 1.81, 95% CI [1.29 to 2.54]). There were no significant differences between the two techniques in terms of mortality at discharge, mortality at 90 days, change in the National Institutes of Health Stroke Scale score, the favorable outcome (modified Rankin scale (mRS) of 0-2), time to the groin puncture, or frequency of complications as intracerebral hemorrhage (ICH), symptomatic intracranial hemorrhage (sICH), embolus in a new territory (ENT), hemorrhagic infarction, parenchymal hematoma, subarachnoid hemorrhage, or procedural complications (all P > 0.05). Conclusion: Current evidence supports the use of the ADAPT technique to achieve successful and complete recanalization while considering the higher need for rescue therapy in some patients.