Thrombectomy for secondary distal, medium vessel occlusions of the posterior circulation: seeking complete reperfusion

Abstract

BackgroundWhether to approach distal occlusions endovascularly or not in medium-sized vessels secondary to proximal large vessel occlusion stroke remains unanswered.ObjectiveTo investigates the technical feasibility and safety of thrombectomy for secondary posterior circulation distal, medium vessel occlusions (DMVO).MethodsTOPMOST (Treatment fOr Primary Medium vessel Occlusion STroke) is an international, retrospective, multicenter, observational registry of patients treated for distal cerebral artery occlusions. This study subanalysis endovascularly treated occlusions of the posterior cerebral artery in the P2 and P3 segment secondary preprocedural or periprocedural thrombus migration between January 2014 and June 2020. Technical feasibility was evaluated with the modified Thrombolysis in Cerebral Infarction (mTICI) scale. Procedural safety was assessed by the occurrence of symptomatic intracranial hemorrhage (sICH) and intervention-related serious adverse events.ResultsAmong 71 patients with secondary posterior circulation DMVO who met the inclusion criteria, occlusions were present in 80.3% (57/71) located in the P2 segment and in 19.7% (14/71) in the P3 segment. Periprocedural migration occurred in 54.9% (39/71) and preprocedural migration in 45.1% (32/71) of cases. The first reperfusion attempt led in 38% (27/71) of all cases to mTICI 3. On multivariable logistic regression analysis, increased numbers of reperfusion attempts (adjusted odds ratio (aOR)=0.39, 95% CI 0.29 to 0.88, p=0.009) and preprocedural migration (aOR=4.70, 95% CI,1.35 to 16.35, p=0.015) were significantly associated with mTICI 3. sICH occurred in 2.8% (2/71).ConclusionThrombectomy for secondary posterior circulation DMVO seems to be safe and technically feasible. Even though thrombi that have migrated preprocedurally may be easier to retract, successful reperfusion can be achieved in the majority of patients with secondary DMVO of the P2 and P3 segment.

A Review of the Advancements in the in-vitro Modelling of Acute Ischemic Stroke and Its Treatment

“…There are many reports in the literature of vessel movement and straightening during thrombectomy ( 30 , 31 ). There have also been reports of vessel movement and rupture of perforators when treating more distal occlusions due to the higher fragility of these vessels and looser attachment to the parenchyma ( 32 , 33 ). Thus, a thrombectomy manoeuvre may displace an entire arterial segment, increasing the risk of perforators detaching from the main trunk.…”

Association of Intravenous Thrombolysis with Delayed Reperfusion After Incomplete Mechanical Thrombectomy

“…Accurate prediction of perfusion outcome may help in the selection of patients for e.g. intra-arterial thrombolysis [35,36] administration of antithrombotics [37,38] or secondary distal MT [39,40]. While potentially beneficial, all of these treatments also harbor a risk of harm, warranting a careful patient selection.…”

Vertebral to Basilar Thrombus Migration Post Intravenous Thrombolysis

“…In addition, a recent retrospective study on posterior circulation thrombectomy revealed frequent evidence of distal migration even pre-procedurally similar to what we report. 14 This study identified seven cases that presented as an isolated VA occlusion and received alteplase. Detrimental TM was seen in two out of seven patients.…”