Journal Article

O-004 Beyond the first pass effect: the contribution of inter pass time to procedural efficacy and clinical outcome

DeLeacy, R, Goldman, D, Mehta, A, Reddi, P, Mocco, J, Majidi, S, Fifi, J

2025

Overview

BackgroundWhile first-pass effect (FPE) is an increasingly used benchmark in endovascular thrombectomy (EVT), overall procedural efficiency is influenced by multiple factors, including time between thrombectomy passes. It remains unclear whether the importance of FPE is maintained when a therapy can provide multiple passes in a short time with adequate safety. Prolonged inter-pass time may contribute to ongoing ischemic injury, procedural inefficiencies, and worse clinical outcomes and may be fundamental to the observed correlation of FPE with outcome. This study evaluates the impact of inter-pass time on procedural and functional outcomes in EVT, comparing aspiration-first versus stent retriever thrombectomy techniques.MethodsWe conducted a retrospective cohort study of consecutive EVT cases for large vessel occlusion (LVO) stroke at our institution from 2013 to 2025. Prospective adjudicated data from the COMPASS randomized trial was analyzed for external validation. Patients treated with aspiration-first (ADAPT) or stent retriever (SR) as the initial technique were included, and patients with tandem occlusion, ICAD or those who required more than 3 passes to achieve recanalization were excluded. Procedural time metrics, including first-pass effect (TICI 3 after one pass), inter-pass time, groin-to-recanalization time, and number of passes were assessed. The primary outcome was 90-day functional independence (modified Rankin Scale [mRS] 0–2). Secondary outcomes included successful reperfusion (TICI ≥2b), symptomatic intracerebral hemorrhage (sICH), and mortality. Multivariable logistic regression was performed to evaluate independent associations.ResultsA total of 1,280 EVT patients were analyzed (795 ADAPT, 280 SR). Patients treated with ADAPT had significantly shorter inter-pass times (mean: 13 vs. 23 min, p = 0.006) and groin-to-final recanalization times (31vs. 49 min, p = 0.01) compared to SR. FPE was higher with ADAPT (38.1% vs. 30.7%, p = 0.007). In multivariable analysis, longer inter-pass time was associated with lower odds of 90-day functional independence (OR: 0.33, 95% CI: 0.12–0.89, p = 0.026), independent of FPE or total procedural time. Similarly, in COMPASS trial, ADAPT arm had faster inter-pass time, shorter procedure time compared to SR time.ConclusionsMinimizing inter-pass time is a critical but underrecognized factor in optimizing EVT efficiency and outcomes. Shorter inter-pass times were independently associated with improved functional outcomes. ADAPT was associated with both shorter inter-pass times and superior procedural efficiency, potentially contributing to better patient outcomes. Future studies should report inter-pass time as a procedural metric as it is a major contributor to successful recanalization time and may impact the relevance of FPE.Abstract O-004 Figure 1Time between passes seen in sinai dataset[Figure omitted. See PDF]Abstract O-004 Figure 2Time between passes seen in COMPASS cohort[Figure omitted. See PDF]DisclosuresA. Mehta: None. D. Goldman: None. P. Reddi: None. R. DeLeacy: None. J. Fifi: None. J. Mocco: None. S. Majidi: None.

• Publisher: BMJ Publishing Group LTD
• Subject: Efficiency