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HOUSTON -- Direct aspiration of large-vessel ischemic strokes was as safe and successful for reperfusion as stent retriever use, the ASTER trial showed.

The rate of TICI 2b/3 reperfusion was 85.4% with the direct aspiration first pass technique (ADAPT) and 83.1% with stent retriever as the first-line strategy (P=0.53), , of Foch Hospital in Suresnes, France, and colleagues reported here at the International Stroke Conference.

All safety endpoints, including new territory embolization or infarct, arterial perforation, arterial dissection, vasospasm, and intracranial or subarachnoid hemorrhage, likewise were similar between treatment strategies.

While stent retriever use has been a real advance for these large vessel occlusions, "it's good, but we think we need to increase the rate of successful reperfusion and perfect reperfusion," Lapergue said at a press conference for the late-breaking clinical trial session.

The direct aspiration technique is reasonable as an alternative first-line strategy, concluded , of the University of Miami, past president of the American Heart Association and president-elect of the American Academy of Neurology, who served as a discussant at the briefing.

He cautioned, though, that the trial's French population may raise issues for generalizability. Stent retriever use could plausibly be better for the intracranial atherostenosis that is a more common source of ischemic stroke in certain U.S. populations than the embolic occlusions more common in French populations, he said.

Lapergue countered that there are some data suggesting that whereas stent retriever use can destabilize plaque in the vessel, aspiration is a "very atraumatic technique."

A similar U.S. trial, COMPASS, is more than two-thirds enrolled and should report results within the year to answer that issue, noted another member of the panel, , of the Baptist Neurological Institute in Jacksonville, Fla.

Meanwhile, though, this trial was important as the first to support the idea that as long as the vessel gets recanalized, it might not matter how you get there, Hanel said.

And if all else is equal in terms of efficacy and safety, cost may be a deciding factor in clinical use, both he and Lapergue agreed, noting that the aspiration technique is less expensive, although with more rescue therapy use.

"If the catheter is used as primary line, it might be that we have the second factor as saving a $6,000 device," Hanel said.

The ASTER trial was a prospective, multicenter, controlled open-label comparison of the two strategies with blinded outcome evaluation. Patients who met large-vessel, posterior circulation ischemic stroke criteria on imaging were randomized to either direct aspiration (n=192) or stent retriever use (n=189) first-line, with a switch to other therapy allowed after three failed attempts.

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