Balloon Angioplasty as the First-Choice Treatment for Intracranial Atherosclerosis-Related Emergent Large Vessel Occlusion Involving the Microcatheter "First-Pass Effect"

BackgroundIt is unknown whether balloon angioplasty can be a first-choice treatment for intracranial atherosclerosis-related emergent large vessel occlusion (ICAS-ELVO) with small clot burden. The microcatheter "first-pass effect" is a valid predictor of ICAS-ELVO with small clot. ObjectiveTo determine balloon angioplastys efficacy as first-choice treatment for ICAS-ELVO involving the microcatheter "first-pass effect" during endovascular treatment (EVT). MethodsThis continuous retrospective analysis assessed ICAS-ELVO patients presenting with the microcatheter "first-pass effect" during EVT. Patients were divided into two first-choice treatment-based groups: preferred balloon angioplasty (PBA) and preferred mechanical thrombectomy (PMT). Efficacy and safety outcomes were compared between groups. ResultsSeventy-six patients with ICAS-ELVO involving the microcatheter "first-pass effect" during EVT were enrolled. Compared with patients in PMT group, patients in PBA group were associated with (i) a higher rate of first-pass recanalization (54.0% vs. 28.9%, p=.010) and complete reperfusion (expanded thrombolysis in cerebral ischemia[&ge;]2c; 76.0% vs. 53.8%, p=.049), (ii) a shorter puncture-to-recanalization time (49.5 min vs. 56.0 min, p<.001), (iii) less operation costs (48,499.5{yen} vs. 99,086.0{yen}, p<.001),and (iv) more excellent functional outcomes (modified Rankin scale:0-1; 44.0% vs. 19.2%, p=.032) at 90 days. No significant differences in symptomatic intracranial hemorrhage (12.0% vs. 15.4%, p>.999) and mortality (10.0% vs. 7.7%, p>.999) were noted. Logistic regression analysis revealed that first-choice treatment was an independent predictor of 90-day excellent functional outcomes (adjusted odds ratio [aOR] =0.10, 95% CI: 0.02-0.66, p=.017). ConclusionBalloon angioplasty, as the first-choice treatment, potentially improves 90-day functional outcomes for ICAS-ELVO patients with microcatheter "first-pass effect" during EVT. What is already known on this topicCompared with large vessel occlusion caused by embolization, mechanical thrombectomy has lower recanalization rate, longer procedure time, and poorer prognosis for patients with intracranial atherosclerosis-related emergent large vessel occlusion(ICAS-ELVO). What this study addsThis study revealed that balloon angioplasty, as the first-choice treatment, potentially improves 90-day outcomes, shortens procedure time, and reduces operation costs for patients with ICAS-ELVO involving the microcatheter "first-pass effect" during endovascular treatment. How this study might affect research, practice or policyWe believe that our study makes a significant contribution to the literature because its findings suggest that rapid and accurate methods of diagnosing the etiology and clot burden of ELVO as well as the development of an individualized EVT strategy based on etiology and clot burden need to be established.