Abstract
BACKGROUND: Emerging evidence suggests that clinical and economic benefits of treatment with mechanical thrombectomy vary by level of reperfusion achieved, and the number of passes required to achieve revascularization. This study aimed to investigate the INFluence of revascularization Attempts on Clinical outcomes of mechanical Thrombectomy and the economic BURDEN (INFACT BURDEN) in Ireland using single center real-world data from the Irish National Thrombectomy Service database. METHODS: Primary clinical outcomes were reperfusion (modified thrombolysis in cerebral infarction 2b-3 or <2b) and functional outcome (90-day modified Rankin Scale ≤2 or modified Rankin Scale >2) among patients treated with 1-3 passes compared with ≥4 passes. Multivariable generalized linear models examined the association between number of passes with outcomes, with adjustment for covariates that may affect outcomes (eg, age, pre-procedure modified Rankin Scale, National Institutes of Health Stroke Scale, Alberta Stroke Program Early CT Score, occlusion site, time from symptom onset to groin puncture). A 90-day decision-tree and Markov model with a 5-year time horizon evaluated the cost-effectiveness of mechanical thrombectomy from the Irish public healthcare payer perspective. RESULTS: Eight hundred twenty three patients met the inclusion criteria. Compared with patients in the ≥4 passes group, patients in the 1-3 passes group achieved a significantly higher rate of successful reperfusion (94% versus 78%, odds ratio [OR], 4.7; P<0.001) and a higher rate of functional independence (49% versus 33%, OR, 2.0; P<0.001). Patients in the 1-3 passes group had a shorter time from onset to reperfusion, lower incidence of procedural complications, including distal emboli into non-involved territory and intra-procedure rupture, as well as lower 90-day mortality. The cost-effectiveness analysis demonstrated that patients successfully revascularized in 1-3 passes had 0.19 additional QALYs and lower costs (€3328; $3800) such that 1-3 passes was dominant compared with ≥4 passes over a 5-year time horizon. CONCLUSION: This study illustrates that the number of passes has a significant effect on both clinical outcomes and health care costs.