Superiority of thrombectomy within 8 hours of anterior circulation large vessel occlusion over medical therapy

The New England Journal of Medicine

REVASCAT was a multicenter randomized controlled trial enrolling patients within 8 hours of symptom onset and confirmed anterior circulation, large vessel occlusion.  Patients were randomized to medical therapy versus medical therapy plus thrombectomy with the Solitaire FR Stent Retriever device. The trial was halted after enrollment of 206 patients due to a loss of equipoise in light of other recently positive thrombectomy trials.  At 90 days, functional independence defined as mRS 0-2 was achieved in 43.7% of thrombectomy patients versus 28.2% of medical therapy patients (OR 2.1 with 95% CI 1.1-4.0).  Symptomatic hemorrhage rates were equal in both groups at 1.9%.Given the increased time horizon in this trial, not all patients received IV alteplase.  Unlike other recent trials, patients with tandem occlusions were permitted in the trial and a more stringent ASPECTS criteria score of 7 was required (quantifying volume of completed pre-procedural infarct).REVASCAT adds to the recent positive evidence regarding thrombectomy for confirmed large vessel occlusion, and suggests clinical benefit in patients with a longer time to presentation and independent of IV tPA administration

Alexander A. Khalessi, MD