Effect of intravenous tirofiban on the efficacy and safety of stent retriever versus aspiration first-line thrombectomy secondary analysis of the RESCUE BT trial

Background: Tirofiban is increasingly used as an adjuvant medication during endovascular thrombectomy (EVT) in acute ischemic stroke. We investigated the influence of intravenous tirofiban versus placebo on the clinical outcomes of first-line thrombectomy strategies. Methods: This secondary analysis of the RESCUE BT (The Endovascular Treatment With versus Without Tirofiban for Patients with Large Vessel Occlusion Stroke) trial included patients who underwent EVT with a stent retriever (with or without aspiration) or aspiration thrombectomy technique as the first-line strategy. We compared clinical and safety outcomes between stent retrievers and aspiration thrombectomy as first-line EVT strategy, and evaluated the interactions with intravenous tirofiban. The primary outcome was the modified Rankin Scale (mRS) score at 90 days follow-up, analyzed using ordinal regression for a shift towards better outcome. Secondary outcomes included angiographic outcomes and symptomatic intracranial hemorrhage (sICH) within 48 hours and 90-day mortality. Multivariable regression analyses with interaction terms were performed. Results: Among the 830 included patients, 464 (55.9%) were treated with a stent retriever as first-line strategy, including 212 (45.7%) patients in tirofiban group. There was no difference in the distribution of mRS score between stent retriever versus aspiration groups (adjusted common odds ratio [acOR] 1.26 [95%CI, 0.99-1.61], P = 0.07), and tirofiban did not improved outcome compared to placebo (acOR, 1.07 [95%CI, 0.84-1.37], P = 0.56). Intravenous tirofiban may potentially enhance the efficacy of first-line stent retriever thrombectomy by increasing the rates of complete reperfusion (aOR, 1.43 [95%CI, 0.98-2.08], P = 0.06) and first pass effect (aOR, 1.45 [95%CI, 0.97-2.18], P = 0.07), whereas intravenous tirofiban may potentially enhance the risk of sICH (aOR, 2.10 [95%CI, 0.93-4.43], P = 0.08) in first-line aspiration thrombectomy. No significant interaction between intravenous tirofiban and first-line EVT strategy was found for the clinical and safety outcomes. Conclusions: In RESCUE BT trial, the treatment effect of perioperative intravenous tirofiban was not influenced by the first-line EVT strategy. In both first-line stent retriever thrombectomy and aspiration thrombectomy groups, we observed no significant differences in the clinical outcomes with the adjunctive use of intravenous tirofiban. Randomized controlled trials are needed to confirm these findings.