Comparative efficacy and safety of various mechanical thrombectomy strategies for patients with acute ischemic stroke: a Bayesian network meta-analysis

BACKGROUND: Stent retriever, contact aspiration, and combined treatment are crucial mechanical thrombectomy strategies for patients with acute ischemic stroke (AIS). OBJECTIVES: The aim of this study was to compare and rank three different mechanical thrombectomy strategies for AIS due to large vessel occlusion by means of a Bayesian network meta-analysis. DESIGN: A systematic review and Bayesian network meta-analysis based on PRISMA guidelines. DATA SOURCES AND METHODS: Relevant randomized controlled trials (RCTs) were identified in Embase, MEDLINE, the Cochrane Library database, and Clinicaltrials.gov from inception to 15 March 2022. We used random effect models to estimate corresponding odds ratios (ORs) and rank probabilities using pairwise and Bayesian network meta-analysis. We applied the grading of recommendations assessment, development, and evaluation (GRADE) methodology to rate the certainty of evidence. RESULTS: We identified 10 RCTs enrolling 2098 participants. As for modified Rankin Scale (mRS) 0–2, moderate certainty evidence established all mechanical thrombectomy strategies that were more effective than standard medical treatment [combined: log OR 0.9288, 95% credibility intervals (CrI) 0.1268–1.7246; contact aspiration: log OR 0.9507, 95% CrI 0.3361–1.5688; stent retriever: log OR 1.0919, 95% CrI 0.6127–1.5702]. The same applied to mRS 0–3 (combined: log OR 0.9603, 95% CrI 0.2122–1.7157; contact aspiration: log OR 0.7554, 95% CrI 0.1769–1.3279; stent retriever: log OR 1.0046, 95% CrI 0.6001–1.4789). Combined treatment was superior to stent retriever in substantial reperfusion (log OR 0.8921, 95% CrI 0.2105–1.5907, high certainty). Stent retriever had the highest probability of being optimal for mRS 0–2 and mRS 0–3. Standard medical treatment had the lowest risk of subarachnoid hemorrhage. For all other outcomes, combined treatment was most likely the best treatment. CONCLUSION: Our results indicated that, with the exception of functional outcome, combined treatment might be the outstanding strategy. Apart from subarachnoid hemorrhage, all three mechanical thrombectomy strategies proved better strategies than standard medical treatment. REGISTRATION: PROSPERO (CRD42022351878).