COMPASS Trial: Aspiration First Pass vs Stent Retriever First Line
In patients with anterior circulation LVO treated within 6 hours, is aspiration first-pass technique non-inferior to stent-retriever first-line for 90-day functional outcome (mRS 0-2)?
Turk et al. (Lancet 2019) · doi:10.1016/S0140-6736(19)30297-1 · 270 patients
Population
Included
- Age 18 years or older
- Acute ischemic stroke with anterior circulation large vessel occlusion (ICA terminus, M1, or M2)
- Groin puncture initiable within 6 hours of last known well
- NIHSS 6 or greater
- Pre-stroke mRS 0 or 1
- ASPECTS 6 or greater
- Age 18 and older
- NIHSS ≥8 at the time of neuroimaging
- Symptoms presenting or persisting within 6 hours of groin puncture access
- Neuroimaging shows large vessel proximal occlusion (distal ICA through MCA bifurcation)
- Operator determines stroke can be treated with traditional endovascular approaches (ADAPT or conventional first-line stent retriever)
- Pre-event Modified Rankin Scale score 0–1
- Non-contrast CT/CTA for eligibility performed or repeated at treating ADAPT stroke center
- Consenting requirements met per local IRB
Excluded
- Posterior circulation occlusion
- Pre-existing functional disability (mRS 2 or greater)
- Tandem cervical occlusion requiring stenting
- Contraindication to contrast or anesthesia
- Life expectancy under 6 months
- More than 6 hours from symptom onset
- Rapidly improving neurologic examination
- Absence of large vessel occlusion on non-invasive imaging
- Presence of existing or pre-existing large territory infarction
- Known or suspected pre-existing chronic large vessel occlusion in symptomatic territory
- Absent femoral pulses
- Excessive vascular access tortuosity preventing stable access platform
- Pregnancy (positive urine or serum beta-HCG in women of childbearing potential)
- Severe contrast allergy or absolute contraindication to iodinated contrast
- Clinical history or imaging suggests intracranial occlusion is chronic
- Severe or fatal comorbidities preventing improvement/follow-up or rendering procedure unlikely to benefit patient
- Blood on imaging (SAH, ICH, etc.)
- Core infarct volume >50 cc
- Large regions of hypodensity (>1/3 MCA territory) or ASPECTS <7
Source: ClinicalTrials.gov NCT02466893· Retrieved 2026-06-08
Primary Outcome — mRS 0-2 at 90 Days (Non-inferiority)
All randomized patients (anterior circulation LVO, within 6 hours)
Non-inferiority design: technique equivalence
This trial shows aspiration-first is no worse than stent-retriever-first for functional outcome, not that either technique is superior. Aspiration achieved lower first-pass reperfusion (68.9% vs 76.3%) but equivalent clinical outcomes.
Small absolute difference — interpret with caution
mRS 0-2 at 90 Days
Study Arms
- Agent
- Direct aspiration first-pass technique (ADAPT) with large-bore aspiration catheter
- Route
- Endovascular
- Frequency
- Up to 3 first-line passes with assigned approach; rescue therapy thereafter if persistent occlusion
- Co-interventions
- FDA-cleared aspiration catheter (Penumbra System) first line; if aspiration failed after up to 3 passes, operators could switch to stent retriever or any therapy per physician preference; adjunctive balloon-guide / concurrent distal aspiration permitted.
Penumbra aspiration first line; ≥3 passes then crossover; success = TICI 2b/2c/3 (Turk Lancet 2019 Procedures p.999-1000).
- Agent
- Stent retriever as first-line device
- Route
- Endovascular
- Frequency
- Up to 3 first-line passes with assigned approach; rescue therapy thereafter if persistent occlusion
- Co-interventions
- FDA-cleared stent retriever (Solitaire, Trevo, or Stryker) first line; if persistent occlusion after up to 3 passes, any therapy per physician preference including aspiration; adjunctive balloon-guide / concurrent distal aspiration permitted.
Solitaire/Trevo/Stryker first line; ≥3 passes then crossover (Turk Lancet 2019 Procedures p.999-1000).
Trial Design
Type
- Multicenter randomized open-label noninferiority trial
- Aspiration first pass vs stent retriever first line
- Anterior circulation LVO within 6 hours
- Blinded outcome assessment with core-lab adjudication
Timeline
Conducted at 15 North American sites
N
270
Enrollment
Multicenter randomized open-label non-inferiority trial enrolling 270 patients at 15 North American sites (Turk Lancet 2019). Blinded outcome assessment.
ClinicalTrials.gov
NCT02466893Bedside Pearl
COMPASS supports operator choice between aspiration-first and stent-retriever-first as initial EVT technique. Lower first-pass reperfusion with aspiration (68.9% vs 76.3%) did not translate to worse 90-day outcomes when rescue devices were available. Choose based on clot characteristics, operator experience, and access anatomy.
See also