Tenecteplase versus Alteplase and First-Pass Reperfusion in Endovascular Thrombectomy

It is unknown whether thrombolysis with IV tenecteplase before endovascular thrombectomy (EVT) influences the probability of first-pass reperfusion when compared with IV alteplase. Therefore, we evaluated the effect of IV thrombolytic choice on this outcome. We investigated the effects of thrombolytic agent (IV tenecteplase or IV alteplase) on first-pass reperfusion in EVT patients from the Alteplase Compared to Tenecteplase in Patients with Acute Ischemic Stroke (AcT) trial. The primary outcome was first-pass reperfusion, defined as expanded Thrombolysis in Cerebral Infarction (eTICI) score 2c-3 with a single thrombectomy pass. Secondary outcomes were modified first-pass reperfusion (eTICI 2b-3 after 1 pass), final eTICI score, total number of thrombectomy passes, and time from arterial access to successful reperfusion. Univariable models and generalized linear mixed-effects models with a logit link function were constructed. Among the 506 patients who underwent EVT in the AcT trial, 445 patients were included (230 [51.7%] women; median [interquartile range {IQR}] age, 73 [63-81]). Two hundred twenty-six (50.8%) received IV tenecteplase and 219 patients received IV alteplase (49.2%). First-pass reperfusion and modified first-pass reperfusion was achieved in 169 (38.0%) and 245 (55.1%) patients, respectively. First-pass reperfusion was achieved in 79 (35.0%) IV tenecteplase and 90 (41.1%) IV alteplase patients (P = .20). Modified first-pass reperfusion was achieved in 123 (54.4%) IV tenecteplase and 122 (55.7%) IV alteplase patients (P = .85). Median (IQR) number of passes was 2 (1-3) in the tenecteplase group and 1 (1-2) in the alteplase group (P = .07). Median (IQR) time from arterial access to successful reperfusion was 36 (25-59) minutes and 34 (21-49) minutes in the tenecteplase and alteplase groups, respectively (P = .07). There was no difference in final eTICI 2c-3 scores. There were no significant interactions between sex, occlusion site, thrombus length, residual flow, clot burden score, hyperattenuated artery sign, or first-line thrombectomy technique with thrombolysis type on first-pass reperfusion. IV thrombolytic agent did not influence the probability of first-pass reperfusion.