Trial Review

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Trial registered on ANZCTR


Registration number
ACTRN12625000590460
Ethics application status
Approved
Date submitted
2/05/2025
Date registered
6/06/2025
Date last updated
6/06/2025
Date data sharing statement initially provided
6/06/2025
Type of registration
Prospectively registered

Titles & IDs
Public title
FRONTIER-AP-X: Randomized controlled trial of endovascular versus standard medical therapy for stroke with medium sized vessel occlusion
Scientific title
FRONTIER-AP-X: Randomized controlled trial of endovascular versus standard medical therapy or patients presenting with acute ischaemic stroke with medium sized vessel occlusion
Secondary ID [1] 314348 0
Nil Known
Universal Trial Number (UTN)
Trial acronym
FRONTIER-APX
Linked study record
This record is a follow up study to previously registered ACTRN12621001746820. ACTRN12621001746820 has now been closed and this record will now recommence a similar trial with updated inclusion criteria to include only occlusion related to branches of the middle cerebral arteries due to results from recent trials.

Health condition
Health condition(s) or problem(s) studied:
ischemic stroke 337330 0
Stroke 337328 0
Condition category
Condition code
Stroke 333715 333715 0 0
Ischaemic

Intervention/exposure
Study type
Interventional
Description of intervention(s) / exposure
Patients randomised to the thrombectomy arm will have clot extraction by Stent retriever or aspiration catheter. This will be performed by certified interventional radiologist. In brief, it involves performing digital subtraction angiography, navigating the catheter to the site of the clot and performing the extraction. The procedure is anticipated to be around 1 hour but can take up to 2 hours on average.

The standard care arm is alteplase or tenecteplase within 4.5 hours and between 4.5 - 9 hours, it’s alteplase or tenecteplase or best medical therapy according to the local guidelines. Post-intervention: A non-contrast Computed Tomography (CT) and CT Angiography will be performed 24 to 48 hr post intervention. At the investigator’s discretion, a repeat CT Perfusion or Magnetic Resonance Imaging (MRI) may be performed at 24 to 48 hr. For MRI (if used for baseline selection and at 24 to 48hrs), an initial scout view will be followed by isotropic Difiusion-weighted Imaging/DWI (created from DWI images obtained with diffusion sensitizing gradients applied in 3 orthogonal planes) using b values between 0 sec/mm2, equivalent to a T2-weighted image, and 1000 sec/mm2. Whole brain imaging will use 25 contiguous axial slices each 5 mm in thickness. The imaging time for DWI is approximately 3 minutes. Time of Flight MR Angiography will be obtained to determine the presence or absence of medium vessel occlusion (MVO). A T2*-weighted gradient echo sequence will be performed to assess for presence of intracerebral haemorrhage (ICH). A FLAIR sequence is also acquired. This protocol is identical between the acute and sub-acute (24 h) imaging.
Intervention code [1] 330961 0
Treatment: Devices
Comparator / control treatment
Standard medical care per local guidelines e.g. Living Stroke Guidelines in Australia. This can be alteplase, tenecteplase or best medical therapy
Control group
Active

Outcomes
Primary outcome [1] 341309 0
Disability will be measured by modified Rankin Scale (mRS). mRS is defined as 0-1 or no change from baseline at 90 days or 3 months if the mRS is 2 at the time of recruitment
Timepoint [1] 341309 0
90 days from stroke onset
Primary outcome [2] 341310 0
vessel perforations or symptomatic intracranial haemorrhage will be assessed using CT brain 24 hour after procedure.
Timepoint [2] 341310 0
24 hours after procedure
Secondary outcome [1] 447091 0
recanalization of arterial occlusion.
Timepoint [1] 447091 0
24 hours after procedure

Eligibility
Key inclusion criteria
1. Patients presenting with acute ischaemic stroke within 24 hours of stroke onset.
2. National Institute of Health Stroke Scale (NIHSS) greater or equal 8 and penumbra mismatch volume greater or equal 10 mL and penumbra ratio greater or equal to 1.2
3. Patient’s age is greater or equal to 18 years (or as per local requirements)
4. Endovascular therapy (arterial puncture) within 90 minutes of initial CT brain.
5. Arterial occlusion on CT Angiography (CTA) or MR Angiography (MRA) of the MeVO affecting M2/M3
Minimum age
18 Years
Maximum age
No limit
Sex
Both males and females
Can healthy volunteers participate?
No
Key exclusion criteria
1. Patients presenting with acute ischaemic stroke >24 hours of stroke onset16.
2. Intracranial haemorrhage identified by CT or MRI 16.
3. Anterior Cerebral Artery (ACA) or Posterior Cerebral Artery (PCA) occlusion
4. Rapidly improving symptoms at the discretion of the investigator
5. Pre-stroke modified Rankin Score (mRS) score of >2 (indicating previous disability)
6. Hypodensity in >1/3 MCA territory on non-contrast CT.
7. ICA (large vessel) occlusion ipsilateral to the distal MCA or ACA clot
8. Contraindication to imaging with contrast agents (requirement for performing thrombectomy)
9. Any terminal illness such that the patient has life expectance less than 1 year.
10. Patients with active cancer and undergoing treatment for cancer are excluded.
11. Any condition that, in the judgment of the investigator, could impose hazards to the patient if study therapy is initiated or affect the participation of the patient in the study.
12. Pregnancy

Study design
Purpose of the study
Treatment
Allocation to intervention
Randomised controlled trial
Procedure for enrolling a subject and allocating the treatment (allocation concealment procedures)
Yes. Allocation concealment is performed by central randomisation
Methods used to generate the sequence in which subjects will be randomised (sequence generation)
computerised sequence generation
Masking / blinding
Open (masking not used)
Who is / are masked / blinded?



Intervention assignment
Parallel
Other design features
Phase
Not Applicable
Type of endpoint/s
Efficacy
Statistical methods / analysis
Statistical analysis, Sample size and stopping rule: We monitor the efficacy endpoint using the 2-arm Bayesian optimal phase 2 (BOP2) design. Specifically, let n denote the interim sample size and N denote the maximum sample size. Let pcon denote the probability of response in control treatment, pexp denote the probability of response in experimental treatment.

We define the null hypothesis H0:pexppcon |data)p_con |data)>2 *Phi* Z_((1+ Lambda)/2) v(n/N))-1

where Lambda=0.96 and a=0.94 are design parameters optimised to maximize the power under H1:pcon = 0.4 and pexp = 0.6, while controlling the type I error rate at 0.05 under pcon = pexp = 0.4. This optimization is performed assuming a vague prior Beta (0.4,0.6) for pcon and a vague prior Beta (0.6,0.4) for pcon. The above decision rule corresponds to the following stopping boundaries and yields a statistical power of 0.91

We perform the interim analysis when the number of enrolled patients reaches 60, 120, 180. When the total number of patients reaches the maximum sample size of 240, we reject the null hypothesis and conclude that the experimental arm is acceptable, compared to the control, if the futility stopping boundary is not crossed.

Specific stopping boundaries for futility and superiority are generated for each interim analysis depending on the number of observed responses in control group. For example, for the interim analysis at 90 control participants and 90 intervention participants, if the observed number of control participants with positive outcome is 15-16, the trial can be stopped for futility if the corresponding number in treatment arm is 18 or below, while stopping for superiority can happen if this number is 29 or above.

This design exhibits the following operational characteristics on 10,000 simulations using the BOP2 web application: the probability of early stopping of 0.78 (for futility: 0.03; for superiority: 0.75) with average sample size of 171.

The proportions of participants with positive outcome will be used as inputs for the decision to declare futility, superiority, or acceptability of the intervention compared to control that will be based on the Bayesian decision rules specified above in the trial design section.

Recruitment
Recruitment status
Not yet recruiting
Date of first participant enrolment
Anticipated
1/07/2025
Actual
Date of last participant enrolment
Anticipated
28/06/2027
Actual
Date of last data collection
Anticipated
Actual
Sample size
Target
240
Accrual to date
Final
Recruitment in Australia
Recruitment state(s)
NSW,SA,VIC
Recruitment hospital [1] 27874 0
Austin Health - Austin Hospital - Heidelberg
Recruitment hospital [2] 27872 0
Barwon Health - Geelong Hospital campus - Geelong
Recruitment hospital [3] 27873 0
The Alfred - Melbourne
Recruitment hospital [4] 27869 0
Liverpool Hospital - Liverpool
Recruitment hospital [5] 27870 0
The Royal Adelaide Hospital - Adelaide
Recruitment hospital [6] 27868 0
Royal Melbourne Hospital - City campus - Parkville
Recruitment hospital [7] 27871 0
Prince of Wales Private Hospital - Randwick
Recruitment postcode(s) [1] 44063 0
3050 - Parkville
Recruitment postcode(s) [2] 44065 0
5000 - Adelaide
Recruitment postcode(s) [3] 44066 0
2031 - Randwick
Recruitment postcode(s) [4] 44064 0
2170 - Liverpool
Recruitment postcode(s) [5] 44068 0
3004 - Melbourne
Recruitment postcode(s) [6] 44067 0
3220 - Geelong
Recruitment postcode(s) [7] 44069 0
3084 - Heidelberg
Recruitment outside Australia
Country [1] 27029 0
China
State/province [1] 27029 0
Beijing
Country [2] 27030 0
Taiwan, Province Of China
State/province [2] 27030 0
Taipei

Funding & Sponsors
Funding source category [1] 318867 0
Government body
Name [1] 318867 0
NHMRC
Country [1] 318867 0
Australia
Primary sponsor type
Government body
Name
Melbourne Health
Address
Country
Australia
Secondary sponsor category [1] 321329 0
None
Name [1] 321329 0
Address [1] 321329 0
Country [1] 321329 0

Ethics approval
Ethics application status
Approved
Ethics committee name [1] 317481 0
Metro South Human Research Ethics Committee
Ethics committee address [1] 317481 0
Ethics committee country [1] 317481 0
Australia
Date submitted for ethics approval [1] 317481 0
01/02/2022
Approval date [1] 317481 0
06/05/2025
Ethics approval number [1] 317481 0
RES-22-0000-123A

Summary
Brief summary
Trial website
Trial related presentations / publications
Public notes

Contacts
Principal investigator
Name 141190 0
Prof Thanh Phan
Address 141190 0
Monash Health, 246 Clayton Rd Clayton 3168 VIC
Country 141190 0
Australia
Phone 141190 0
+613 85722612
Fax 141190 0
Email 141190 0
[email protected]
Contact person for public queries
Name 141191 0
Thanh Phan
Address 141191 0
Monash Health, 246 Clayton Rd Clayton 3168 VIC
Country 141191 0
Australia
Phone 141191 0
+613 85722612
Fax 141191 0
Email 141191 0
[email protected]
Contact person for scientific queries
Name 141192 0
Thanh Phan
Address 141192 0
Monash Health, 246 Clayton Rd Clayton 3168 VIC
Country 141192 0
Australia
Phone 141192 0
+613 85722612
Fax 141192 0
Email 141192 0
[email protected]

Data sharing statement
Will the study consider sharing individual participant data?
Yes
Will there be any conditions when requesting access to individual participant data?
Persons/groups eligible to request access:
• Researchers
Conditions for requesting access:
• Yes, conditions apply:
• Requires review on a case-by-case basis by the trial custodian, sponsor or data sharing committee
What individual participant data might be shared?
• De-identified individual participant data:
• All outcomes data
• Published results
• Primary outcome(s)
• Safety data
What types of analyses could be done with individual participant data?
• Systematic reviews and meta-analyses
• Health economic analyses
When can requests for individual participant data be made (start and end dates)?
From:
After publication of main results
To:
A finite period of: 5 years
Where can requests to access individual participant data be made, or data be obtained directly?
• Email of trial custodian, sponsor or committee: from principal investigators [email protected] (Thanh Phan) or [email protected] (Bernard Yan)




Are there extra considerations when requesting access to individual participant data?
No


What supporting documents are/will be available?

No Supporting Document Provided


Results publications and other study-related documents

Documents added manually
No documents have been uploaded by study researchers.

Documents added automatically
No additional documents have been identified.