Thrombolysis with the current dose of alteplase was initiated in 1996. In the 27 years since the NINDS trial was published, little has changed in this practice. The extended time window observed in the 2008 ECASSIII trial, and the use of multimodal imaging in the extended time window for the treatment of stroke indications of unknown etiology. However, the management of acute reperfusion in LVO stroke has changed considerably since the landmark mechanical thrombectomy trial in 2015 and will continue to change. This has been made possible by rapid improvements in mechanical thrombectomy technology and artificial intelligence-based software. Rapid advances in technology have led to rapid advances in the field of endovascular therapy, and previous findings on which technique is more effective: the distinction between stent retriever and aspiration mechanical thrombectomy have become less clear. The introduction of a 0.88 catheter in the M1 segment is expected to have a disruptive effect on aspiration technique, whereas the improvement in thrombectomy stents may not be great.
The Frist Line aspiration technique has previously been shown to be non-inferior to stent retrieval. Nonetheless, the issues of incomplete reperfusion, traceability of large inner diameter lumen devices, first-pass reperfusion rates, and the need to use assistive devices have been criticized by several experts who insist on using a thrombectomy stent first, or a combination technique. Most aspiration catheters in use today have an internal diameter of 0.070-0.074 inches, equivalent to 1.8 mm, which is smaller than the 3 mm lumen diameter of the standard M1 segment. This explains the lower first-pass rate and more frequent distal embolism. Furthermore, literature data support previous theoretical considerations that aspiration technique can be closely related to inner diameter (ID) size. Only aspiration recanalization was significantly more common at larger IDs, and there was less need for assistive devices at larger IDs.
As mentioned in the previous analysis, first-pass aspiration technology is developing rapidly and the first-pass effect rate is expected to reach 70-80%. These improvements are expected to lead to routine clinical use in the next few years. They do so primarily by increasing the size of the device, which provides subsequent improvements in direct aspiration force and allows for complete aspiration of the thrombus, thereby minimizing distal embolism. However, several other improvements may affect "aspiration technology" and make future aspiration techniques more effective. It has been shown in previous experiments that aspiration pumps do not provide any additional benefit when aspiration is performed using a 0.070 catheter compared to manual aspiration. Although this sounds counterintuitive, the vacuum created by the pump has to be maintained in the 1.5 L canister and the 2.7m tubing, so is not superior to that produced by manual aspiration with a 60ml syringe. Each aspiration pump used in clinical practice costs at least 200-300 Euros, we should keep this in mind and not use the aspiration pump lightly unless it is absolutely necessary.
However, some improvements in the design of suction pump engineering and artificial intelligence may create significant advantages for pump aspiration: especially periodic aspiration and intermittent aspiration. Several reports have shown promising initial results with periodic aspiration. In a pioneering study, Kalousek and team reported first-pass reperfusion rates as high as 68.4%, 76.3% of which with the novel circulatory aspiration system. This compares very favorably with the historical first-pass effect of 24%-30%. However, to obtain valid results, further validation of the efficacy of circulatory aspiration in randomized patient populations and outsourcing of adjudication of the results to individuals blinded to the type of initial aspiration must be achieved—the most objective results can be obtained.