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NCT Number: NCT05320263

Contact Aspiration Versus Stent Retriever for Recanalisation of Acute Stroke Patients With Basilar Artery Occlusion: The Posterior Circulation ASTER Randomized Trial Protocol

Acute ischemic stroke (AIS) patients with basilar artery occlusion (BAO) present a devastating, life-threatening prognosis.

Urgent recanalization with endovascular mechanical thrombectomy is routinely performed in patients with BAO although the level of evidence is lower than that in anterior circulation occlusions (randomization in this population versus medical treatment alone having been impossible in recent studies). Recently, a large retrospective study supports the interest of thrombectomy in this population .

Speed and grade of the recanalisation have a major impact on clinical outcome. Favorable outcome at 90 days is strongly associated with the successful recanalization status at the end of the endovascular procedure (OR=4.57, 95%CI=1.24-16.87, P=0.023).

First pass effect has been shown to be a strong marker of efficacy of endovascular procedure with significant correlation with clinical outcome.

Thrombectomy with Stent retrievers dramatically changed the prognosis of anterior circulation large vessel occlusion strokes and currently used in BAO patients (posterior circulation). Contact aspiration (CA) is currently used in anterior large vessel occlusions (COMPASS trial, Lancet 2019), with similar rates of recanalization and favorable outcomes (Boulanger M, 2019), as well as in BAO patients .

However, the benefit of CA compared to SR for the treatment of BAO remains under debate with the superiority of first line CA compared to SR or no difference. Available data are based on retrospective studies with no data from RCT.

In this context, a randomized controlled trial is needed to assess the benefit of CA versus SR.

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Key information

Conditions

Basilar Artery Occlusion Brain Diseases Cardiovascular Diseases Central Nervous System Diseases Cerebrovascular Disorders Nervous System Diseases Stroke Vascular Diseases

Age range

18 year and older

Sex eligibility

All sexes

Study type

Interventional

Phase

Not applicable

Primary location

Chu Bordeaux, Bordeaux, France

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Who can participate

Healthy volunteers accepted: No

Only the study team can determine whether someone qualifies for participation.

Inclusion criteria

Age ≥ 18 years

  • AIS with BAO on non-invasive imaging (CT or MRI)
  • Eligible for thrombectomy : groin puncture undergone within 24 hours of first symptoms or of last time the patient was seen normal
  • Being covered by a national health insurance
  • Informed consent obtained from the patients/his proxy or following an emergency procedure

Exclusion criteria

  • Known or suspected pre-existing (chronic) large vessel stenosis / occlusion in the symptomatic territory (basilar artery)
  • Severe contrast medium allergy or absolute contraindication to use of iodinated products
  • Clinical history, past imaging or clinical judgment suggesting intracranial stenosis of the basilar artery
  • Pregnancy (urine or serum beta HCG test for women of child-bearing potential)
  • Person deprived of liberty
  • Patient benefiting from a legal protection (guardianship or curatorship)

Treatment and study plan

Contact aspiration Thrombectomy

Procedure

The contact aspiration approach is performed, as in standard care, using a long sheath positioned in the distal cervical vasculature using an exchange technique.

A large bore balloon guide catheter as to be placed into the cervical ICA. The microcatheter is then advanced close to the thrombus and the large-bore aspiration catheter is advanced as close to the proximal aspect of the thrombus as possible. A control superselective angiogram may be used to document the extent of occlusion and thrombus. After a 3 min waiting period, the large-bore aspiration catheter is connected to a continuous aspiration from the dedicated aspiration pump while simultaneously advancing the aspiration catheter up to the face of the thrombus. through the long sheath positioned in the cervical vasculature.

Stent retriever thrombectomy

Procedure

The technique used should be in accordance with the device IFU. A large bore access guide catheter possible is recommended. A suitable delivery microcatheter is navigated over a microwire across the occlusion. A control superselective angiogram may be used to document the extent of occlusion and thrombus. The stent is left in place according to the internal practice of each participating center before the withdrawal. Any CE-marked stent retriever device is then deployed across the occlusion. A minimum of 3 attempts with SR should be performed. A revascularization score will be recorded after each device attempt.

Primary outcomes

  1. Rate of first pass effect (FPE) defined by complete reperfusion after first device pass

    Time frame: 24 hours

    The definition of FPE: single pass/use of the device, (2) complete revascularization of the large vessel occlusion and its downstream territory (mTICI 3), and (3) no use of rescue therapy

Secondary outcomes

  1. Rate of complete reperfusion after first-line thrombectomy strategy and at the end of endovascular procedure

    Time frame: 24 hours

    mTICI (modified Thrombolysis In Cerebral Infarction ) score equals to 3 after the first line thrombectomy and at the end of endovascular.

    mTICI score is evaluated between 0-3 : 0 a complete obstruction of the artery and 3 indicates a complete reperfusion

  2. Rate of successful reperfusion (mTICI 2b/2c/3) after first-line thrombectomy strategy and at the end of endovascular procedure

    Time frame: 24 hours

    mTICI score is evaluated between 0 to 3. Rate of patients with mTICI score equals to 2b/2c/3 after first-line thrombectomy strategy and at the end of endovascular procedure will be evaluated.

  3. Rate of near to complete reperfusion (mTICI 2c/3) after first-line thrombectomy strategy and at the end of endovascular procedure

    Time frame: 24 hours

  4. Rate of Arterial Occlusive Lesion (AOL) recanalization score III after first-line thrombectomy strategy and at the end of endovascular procedure

    Time frame: 24 hours

    AOL recanalization score is evaluated between 0 to 3 :

    • 0 indicates no recanalization of the primary occlusive lesion
    • 3 indicates complete recanalization of the primary occlusive lesion with any distal flow

  5. Groin puncture time to successful reperfusion time (evaluated in minutes)

    Time frame: 360 minutes

  6. Modified Rankin Score (mRS) at 3 and 12 months

    Time frame: 12 months

    mRS is evaluated between 0 to 6. A score of 0 indicates that there is no disability and a score of 6 indicates death.

  7. Rate of good functional outcome at 90-day and at one year defined by a mRS 0-3 or equal to pre-stroke mRS (Modified Rankin Score)

    Time frame: 12 months

  8. Quality of life at 90 days and 12 months assessed by EuroQol 5D-5L scale

    Time frame: 12 months

    EuroQol 5D-5L comprises five dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. Each dimension has 5 levels: no problems, slight problems, moderate problems, severe problems and extreme problems. The patient is asked to indicate his/her health state by ticking the box next to the most appropriate statement in each of the five dimensions. This decision results in a 1-digit number that expresses the level selected for that dimension. The digits for the five dimensions can be combined into a 5-digit number that describes the patient's health state.

  9. All cause of mortality at 90-day and 12 months

    Time frame: 12 months

  10. 24-hours change in NIHSS (National Institutes of Health Stroke Scale) from baseline defined as the difference between NIHSS score at 24 hours and NIHSS score at admission.

    Time frame: 24 hours

    NIHSS (National Institutes of Health Stroke Scale) score is evaluated between 0-42 0 is normal and 42 maximal gravity

  11. Subgroups analysis : Age (≤70 vs. >70 years)

    Time frame: 24 hours

  12. Subgroups analysis :Baseline NIHSS≥10 vs NIHSS<10 (18)

    Time frame: 24 hours

  13. Subgroups analysis : Volume of infarct area assessed by pc-ASPECTS (≤7 vs. >7)

    Time frame: 24 hours

    A pc-ASPECTS score of 10 indicates absence of visible ischemic changes in the posterior circulation, and pc-ASPECTS score of 0 indicates ischemic changes in the midbrain, pons, and bilateral thalami, posterior circulation territories, and cerebellar hemispheres

  14. Subgroups analysis : Time from admission of patient in hospital to randomization (≤ 300 vs. > 300 minutes)

    Time frame: 360 minutes

  15. Subgroups analysis: Baseline site of thrombi on vascular imaging (Top of the basilar artery vs other adjudicated by the core lab)

    Time frame: 24 hours

  16. Subgroups analysis: Prior use of IV alteplase (yes vs. no)

    Time frame: 24 hours

  17. Subgroups analysis : Collateral status (good versus poor, as adjudicated by the core lab on initial angiogram) with a 0-3 scale

    Time frame: 24 hours

    Collateral circulation is estimated by angiography with a 0-3 scale. The collateral status will be categorized as poor collaterals (scores 0-1) and good collaterals (scores 2-3)

  18. Incidence of any intracerebral hemorrhage (ICH), parenchymal hematoma (PH), symptomatic ICH on brain imaging (Magnetic resonance imaging MRI or CT (computed tomography) scan) at 24±12h after thrombectomy (according to ECASS3 classification)

    Time frame: 24 hours

    ECASS III (European Cooperative Acute Stroke Study) classification :

    • Hemorrhage infarction type 1 (HI1)
    • Hemorrhage infarction type 2 (HI2)
    • Parenchymal hematoma type 1 (PH1)
    • Parenchymal hematoma type 2 (PH2)

  19. Incidence of procedure-related complications defined as arterial perforation, arterial dissection, embolization in a new territory (ENT) and subarachnoid haemorrhage

    Time frame: hours

  20. Cost-effectiveness analysis at 12 months

    Time frame: 12 months

    Incremental cost-effectiveness ratio (ICER, cost per quality-adjusted life year [QALY]), of Contact Aspiration (CA) first-line thrombectomy compared to standard first-line SR thrombectomy in treatment of AIS due to BAO, from a collective perspective and with a 12-months' time horizon.

Study contacts

Contact information is provided by the study sponsor or research team.

Arturo CONSOLI

CONTACT

[email protected]

0033146251955

Bertrand LAPERGUE

CONTACT

[email protected]

0033146255973

Sponsors and collaborators

Lead sponsor

Hopital Foch

Other

Registry information

Official study title

Contact Aspiration Versus Stent Retriever for Recanalisation of Acute Stroke Patients With Basilar Artery Occlusion: The Posterior Circulation ASTER Randomized Trial

Acronym: pc-ASTER

Important dates

Study start
2022
Primary completion
2026
Study completion
2027
First posted
Apr 11, 2022
Registry last updated
Mar 1, 2023

OpenTrials presents study information sourced from ClinicalTrials.gov. The official registry record should be consulted for the latest information.

View the official ClinicalTrials.gov record (opens in a new tab)

This listing is for discovery and informational purposes only. It is not medical advice, does not guarantee that a study is recruiting, and does not determine eligibility. Contact the study team and a qualified healthcare professional when considering participation.

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