Aspiration vs Stent Retriever for Thrombectomy

Three RCTs — ASTER, COMPASS, and ASTER2 — found no statistically significant difference in functional outcomes between aspiration-first and stent-retriever-first strategies. Reperfusion rates were similar. Device choice is largely operator-dependent.

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Clinical Question

Aspiration first or stent retriever first for thrombectomy?

Synthesises 3 trialsthree RCTs comparing direct aspiration with stent-retriever-first thrombectomy

What does the guideline say?

§4.7.4 Endovascular Techniques· 2026
In patients with AIS due to an LVO, EVT with stent retrievers, contact aspiration, or combination techniques is recommended to achieve rapid and adequate reperfusion (COR 1, LOE A). In the management of patients with AIS in the setting of LVO, preoperative administration of tirofiban before EVT is not useful to improve 90-day functional outcome (COR 3 No Benefit, LOE A based on RESCUE-BT). In patients with AIS who achieve complete or near-complete EVT (modified TICI 2b or greater), the administration of adjunctive intraarterial thrombolytics with urokinase, alteplase, or tenecteplase may be reasonable to improve cerebral reperfusion and 90-day functional outcomes (COR 2b, LOE B-R per CHOICE).
Source: 2026 AHA/ASA Guideline — §4.7.4 (Endovascular Techniques)

The trials cited in the guideline's supportive text appear below.

Trials in this question· 3

ASTER2017

NS85.4% vs 83.1% (P=0.53)

No significant difference between aspiration-first and stent-retriever-first reperfusion.

NS85.4% vs 83.1% (P=0.53)

COMPASS2019

Non-inferior52% vs 50% (Δ+2)

Aspiration-first was noninferior to stent-retriever-first for 90-day mRS 0–2.

Non-inferior52% vs 50% (Δ+2)

ASTER22021

NS+6.6% (P=0.17)

Routine combined aspiration + stent retriever did not improve near-total reperfusion.

NS+6.6% (P=0.17)