Background Whether to approach distal occlusions endovascularly or not in medium-sized vessels secondary to proximal large vessel occlusion stroke remains unanswered.
Objective To investigates the technical feasibility and safety of thrombectomy for secondary posterior circulation distal, medium vessel occlusions (DMVO).
Methods TOPMOST (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.
Results Among 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).
Conclusion Thrombectomy 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.
Data availability statement
The data that support the findings of this study are available from the corresponding author after consultation with the participating centers and upon reasonable request.
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Collaborators Jan Gralla, MD; Pasquale Mordasini, MD: Department of Diagnostic and Interventional Neuroradiology, Inselspital - Bern University Hospital, Switzerland, Bern, Switzerland. Christian Roth, MD; Maria Alexandrou, MD: Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte gGmbH, Bremen, Germany. Jorge Galván, MD; Miguel Schüller Arteaga MD:
Department of Interventional Neuroradiology/Endovascular Neurosurgery, Hospital Clínico Universitario de Valladolid, Valladolid, Spain. Maria Politi MD, Department for Interventional Neuroradiology, Henry Dunant Hospital, Athens, Greece.
Contributors LM, UH, and JF made substantial contributions to the conception and design of the work. Data acquisition was performed by all authors. LM and UH performed the data analysis. Interpretation of the data was done by LM, JF, CPS, UH, GB, and PP. LM drafted the manuscript and all other authors revised it critically for important intellectual content. All authors approved the final version to be published. They agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the manuscript are appropriately investigated and resolved.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests JF: research support from the German Ministry of Science and Education (BMBF), German Ministry of Economy and Innovation (BMWi), German Research Foundation (DFG), European Union (EU), Hamburgische Investitions-/Förderbank (IFB), Medtronic, Microvention, Philips, Stryker; consultancy appointments; Acandis, Bayer, Boehringer Ingelheim, Cerenovus, Covidien, Evasc Neurovascular, MD Clinicals, Medtronic, Medina, Microvention, Penumbra, Route92, Stryker, Transverse Medical; stock holdings for Tegus. PP: consultant for Penumbra and Ab Medica. AG: has served as proctor/consultant/speaker for Medtronic, Stryker, and Penumbra M. MM-G: consultant of Medtronic, Stryker, and Balt. FD: research support from Cerenovus; consultant for Cerus Endovascular, AB Medica, and Phenox; speaker honorary from Acandis, Cerenovus. JK reports grants from SAMW/Bangerter, grants from Swiss Stroke Society, and grants from Clinical Trial Unit Bern outside the submitted work. LLLY: consultant for Stryker and SeeMode; research support from National Medical Research Council (NMRC) Singapore and Ministry of Health (MOH); stock holdings for Cereflo. PBS: consultant/proctor for Balt, Acandis, Microvention. RC: consultant and/or proctor for BALT, Stryker, Microvention, Rapid Medical, Siemens Medical Systems. PN: consultant/proctor for Balt, Stryker, and Penumbra. KZ: support under the Operational Programme Integrated Infrastructure for the project: TENSION – complementary project, IMTS: 313011W875, co-financed by the European Regional Development Fund.
Provenance and peer review Not commissioned; internally peer reviewed.
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