Aspiration Thrombectomy: Systematic Review with ☸️SAIMSARA.

• Generated: 2026-02-03 09:09:35 CET
• Plan: Pro (expanded craft tokens; source: Semantic Scholar)
• Source: Semantic Scholar
• Scope: All fields
• Keyword Gate: Fuzzy (≥60% of required terms, minimum 2 terms matched in title/abstract)
• Total Abstracts/Papers: 331592
• Downloaded Abstracts/Papers: 1000
• Included original Abstracts/Papers: 355
• Total study participants (naïve ΣN): 122918

• Bias: Qualitatively inferred from study design fields. Retrospective cohort studies and mixed designs are prevalent, introducing potential selection and confounding biases. The inclusion of experimental and in vitro studies indicates a focus on technical feasibility and device development, which may not directly translate to clinical outcomes. Randomized controlled trials (RCTs) are present but represent a smaller proportion of the evidence, suggesting a need for higher-level evidence in certain areas.

• Aspiration Thrombectomy Efficacy in Stroke: High successful recanalization rates (median 89.3%, range 50-100%) and first-pass effect (median 53%, range 11.8-100%) are consistently reported across various vessel occlusions, including LVOs, DMVOs, and MeVOs [1, 9, 12, 18, 20, 42, 49, 50, 55, 74, 79, 80, 99, 102, 103, 111, 114, 121, 129, 145, 149, 156, 185, 188, 194, 213, 214, 219, 227, 237, 241, 257, 259, 287, 301, 302, 304, 315, 318, 351].
• Catheter Design and Technique Optimization: Larger aspiration catheter inner diameters (e.g., 0.088-inch, Catalyst 7, ACE 68/71) are associated with higher first-pass effect rates and faster procedural times [19, 26, 107, 120, 145, 153, 193, 194, 203, 210, 216, 241, 243, 264, 298, 313, 318]. Techniques like the "plunger technique" [5, 17], manual cyclic aspiration [5], adaptive pulsatile aspiration [22], and longer dwell times [117] are explored for improved clot ingestion.
• Comparison with Stent Retriever Thrombectomy: Aspiration thrombectomy (AT) often shows comparable functional outcomes to stent retriever (SR) thrombectomy in AIS [2, 15, 36, 45, 67, 99, 113, 118, 123, 125, 183, 197, 205, 214, 268, 274, 285, 293], with some studies indicating shorter procedure times and fewer passes for AT [20, 38, 41, 45, 79, 99, 102, 104, 111, 114, 119, 208, 213, 214, 216, 219, 241, 243, 256, 257]. However, SR-first may have higher first-device recanalization in some contexts [36, 58, 285].
• Adjunctive Therapies and Combined Approaches: Combining AT with stent retrievers (SR+CA or similar) can improve first-pass effect (FPE) and successful reperfusion rates, especially in DMVOs [56, 116, 158, 163, 188, 191, 200, 202, 210, 217, 230, 238, 239, 247, 256, 269, 321, 342, 345, 348] and for specific clot characteristics [81, 169, 192, 223, 228, 238, 349]. Balloon guide catheters (BGC) further enhance outcomes by reducing passes and shortening times [44, 47, 75, 198, 239, 240, 256, 269, 341].
• Factors Influencing Outcomes: Clot characteristics (perviousness, composition, length, phenotype) and vessel anatomy (tortuosity, diameter, catheter-to-vessel ratio) significantly impact AT success [37, 70, 86, 94, 109, 154, 155, 187, 190, 195, 207, 212, 223, 224, 244, 249, 252, 284, 293, 295, 298, 300, 306, 314, 325, 339, 340, 349, 352]. Intracranial atherosclerotic disease (ICAS) can lead to less successful immediate reperfusion and more vessel injury with contact aspiration [108, 222, 293].
• Safety Profile and Complications: While generally safe, AT carries risks including symptomatic intracranial hemorrhage (sICH) (median 2.8% [67], range 0-19.64% [18, 97]) [2, 13, 15, 19, 20, 46, 48, 49, 53, 56, 62, 66, 74, 75, 79, 90, 97, 116, 129, 148, 158, 163, 188, 189, 192, 196, 197, 199, 200, 201, 225, 233, 242, 251, 254, 281, 294, 297, 299, 310, 336, 337, 340], distal embolization [38, 56, 58, 66, 195, 200, 242, 282, 284, 298, 339, 352], and vessel perforation [199, 297, 337]. In non-stroke settings, amputation-free survival can be worse [25].
• Applications Beyond Stroke: AT is effectively used in pulmonary embolism (PE) for hemodynamic improvement and clot removal [4, 13, 29, 30, 48, 235, 265, 266], acute myocardial infarction (AMI) for thrombus removal and microvascular function [11, 28, 51, 130, 354], deep vein thrombosis (DVT) for clot clearance and symptom relief [34, 52, 61, 166, 250, 291], and acute limb ischemia (ALI) for rapid revascularization [91, 164, 248].

• Device Selection Guidance: Larger bore aspiration catheters (e.g., 0.088-inch, ACE 68/71, Catalyst 7) are associated with higher first-pass effect rates and faster procedures, suggesting a preference for these devices when anatomically feasible [19, 107, 153, 210, 216, 241, 243, 313].
• First-Line Strategy Considerations: While AT often achieves comparable functional outcomes to stent retriever (SR) thrombectomy, it may offer advantages in terms of shorter procedure times and fewer passes [20, 38, 41, 45, 79, 99, 102, 104, 111, 114, 119, 208, 213, 214, 216, 219, 241, 243, 256, 257]. This could influence initial treatment choices in acute stroke.
• Combined Techniques for Complex Cases: For challenging occlusions, particularly in distal or medium vessels, or those with specific clot characteristics, combining AT with stent retrievers and/or balloon guide catheters (BGCs) can enhance recanalization rates and first-pass success [56, 116, 158, 163, 188, 191, 200, 210, 217, 230, 238, 239, 247, 256, 269, 342, 345, 348].
• Risk Mitigation for Hemorrhage: The direct aspiration first pass technique (ADAPT) has been identified as a negative predictor of symptomatic intracranial hemorrhage (sICH) in some contexts [336], suggesting a potentially safer profile compared to other techniques in specific patient groups.
• Expanding Indications: AT is a viable and effective treatment for various non-stroke thrombotic conditions, including pulmonary embolism, deep vein thrombosis, and acute limb ischemia, offering hemodynamic improvements and clot removal, especially when thrombolysis is contraindicated [4, 13, 29, 30, 48, 91, 164, 235, 250, 265, 266, 291].

• Optimal Catheter-to-Vessel Ratio: Further prospective studies are needed to define precise optimal catheter-to-vessel ratio cutoffs for various anatomical locations and clot types to maximize first-pass success and minimize complications [252, 249, 212].
• Comparative Effectiveness in DMVOs/MeVOs: Large-scale RCTs are needed to definitively compare aspiration-first versus stent retriever-first or combined techniques for distal and medium vessel occlusions, particularly concerning long-term functional outcomes and safety [1, 9, 16, 21, 23, 49, 53, 67, 110, 115, 123, 149, 156, 161, 183, 189, 192, 200, 301].
• Impact of Clot Characteristics on Strategy: Prospective studies should investigate how detailed pre-procedural imaging of clot composition (e.g., fibrin/platelet content, perviousness) and thrombus phenotype can guide the selection of aspiration-only, stent retriever-only, or combined thrombectomy strategies to optimize outcomes [37, 86, 109, 154, 207, 223, 224, 300, 314, 339, 349, 352].
• Long-Term Outcomes in Non-Stroke Indications: More long-term follow-up data (beyond 90 days) are required for non-stroke applications like PE, DVT, and ALI to assess sustained benefits, recurrence rates, and quality of life, especially for newer devices and techniques [4, 11, 13, 25, 28, 46, 52, 61, 62, 66, 91, 131, 152, 164, 231, 248, 250, 258, 266, 291, 296, 331, 332, 334, 354].
• Role of IV Alteplase with Aspiration: Further investigation is warranted into the potential adverse effects of prior intravenous alteplase administration on the efficacy of aspiration thrombectomy, particularly in specific stroke patient subgroups, to refine treatment protocols [90, 201, 233, 261, 310].

• Heterogeneity of Study Designs: The prevalence of retrospective cohort and mixed studies limits the certainty and generalizability of findings compared to prospective randomized controlled trials.
• Variability in Outcome Definitions: Different definitions for "successful recanalization" (e.g., TICI 2b, 2c, 3) and "good functional outcome" (e.g., mRS ≤2, ≤3) across studies make direct comparisons challenging.
• Device-Specific Reporting: Many studies focus on specific devices or techniques, making it difficult to draw broad conclusions about aspiration thrombectomy as a whole, as performance can vary significantly between catheters.
• Lack of Standardized Protocols: Procedural nuances like aspiration pressure, dwell time, and adjunctive techniques (e.g., BGC use) are not uniformly reported or standardized, potentially influencing outcomes.
• Limited Long-Term Follow-up: While 90-day outcomes are common for stroke, longer-term data, especially for non-stroke indications, are often sparse, limiting understanding of sustained efficacy and safety.

• Standardized Outcome Reporting: Develop and implement universal definitions for technical and clinical success endpoints in thrombectomy studies.
• Comparative Device Trials: Conduct head-to-head randomized controlled trials comparing newer generation aspiration catheters against established devices across various vessel sizes and clot types.
• Advanced Imaging Integration: Integrate advanced pre-procedural imaging (e.g., clot composition, vessel tortuosity) into prospective trials to guide individualized thrombectomy strategies.
• Longitudinal Registry Development: Establish comprehensive, international registries with long-term follow-up for all thrombectomy indications to track real-world effectiveness and safety.
• AI-Driven Procedural Optimization: Utilize computational models and AI to predict optimal catheter selection, aspiration parameters, and adjunctive techniques based on patient-specific anatomy and clot characteristics [167, 181].