Comparative Effectiveness of Mechanical Thrombectomy Techniques for Large Vessel Occlusion Stroke: A Network Meta-analysis of Randomized Controlled Trials.
Abstract
Background
Mechanical thrombectomy (MT) is a key intervention for acute ischemic stroke due to large vessel occlusion (LVO). Various MT strategies - stent retriever (SR), aspiration (Asp), and their combination (SR + Asp) - are widely used, but the optimal approach remains unclear.
Objectives
This network meta-analysis (NMA) aimed to compare the efficacy and safety of these techniques using evidence from randomized controlled trials (RCTs).
Materials And Methods
A Bayesian NMA was conducted, including RCTs evaluating different MT techniques in LVO-related stroke. The primary outcome was successful recanalization (thrombolysis in cerebral infarction ≥2b) and good functional outcome (modified Rankin Scale ≤2 at 90 days). Secondary outcomes included all-cause mortality at 90 days and symptomatic intracranial hemorrhage (sICH) within 24 h. Odds ratios (ORs) with 95% credible intervals (CrIs) were calculated using a Bayesian random-effects model.
Results
Twenty-seven RCTs were analyzed. Within the current evidence network, SR demonstrated the highest probability of good functional recovery (OR = 2.27; 95% CrI: 1.72-3.02) and successful recanalization (OR = 13.6; 95% CrI: 3.12-75.0). SR + Asp demonstrated the highest probability of reducing 90-day mortality (OR = 0.771; 95% CrI: 0.638-0.929). Rates of sICH were broadly comparable across thrombectomy strategies, although SR and SR + Asp showed higher estimated odds than standard treatment (ST).
Conclusions
This NMA suggests that SR thrombectomy has the highest probability of achieving successful recanalization and favourable functional outcomes, whereas combined (SR + Asp) showed the highest probability of reducing mortality within the current evidence network. These probability-based rankings should be interpreted cautiously because they were derived from a heterogeneous network with limited direct head-to-head comparisons. Future adequately powered randomized trials directly comparing thrombectomy strategies are required before definitive recommendations can be made.