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First-line thrombectomy strategy for distal and medium vessel occlusions: a systematic review
  1. Cem Bilgin1,
  2. Nicole Hardy2,
  3. Kristen Hutchison2,
  4. John Michael Pederson2,3,
  5. Alexander Mebane3,
  6. Peace Olaniran2,
  7. Hassan Kobeissi4,
  8. Kevin M Kallmes2,
  9. David Fiorella5,
  10. David F Kallmes1,
  11. Waleed Brinjikji1
  1. 1 Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
  2. 2 Nested Knowledge, Inc, Saint Paul, Minnesota, USA
  3. 3 Superior Medical Experts, Inc, St. Paul, Minnesota, USA
  4. 4 Central Michigan University College of Medicine, Mount Pleasant, Michigan, USA
  5. 5 Department of Neurosurgery, Stony Brook University, Stony Brook, New York, USA
  1. Correspondence to Dr Cem Bilgin, Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA; bilgin.cem{at}


Background The benefit of mechanical thrombectomy (MT) and efficacy of different first-line MT techniques remain unclear for distal and medium vessel occlusions (DMVOs). In this systematic review, we aimed to compare the performance of three first-line MT techniques in DMVOs.

Methods The PubMed database was searched for studies examining the utility of MT in DMVOs (middle cerebral artery M2-3-4, anterior cerebral artery, and posterior cerebral artery). Studies providing data for aspiration thrombectomy (ASP), stent retriever thrombectomy (SR), and combined SR+ASP technique were included. Non-comparative studies were excluded. Safety and efficacy data were collected for each technique. The Nested Knowledge AutoLit platform was utilized for literature search, screening, and data extraction. Pooled data were presented as descriptive statistics.

Results 13 studies comprising 2422 MT procedures were identified. The overall successful recanalization rate was 77.0% (1513/1964) for DMVOs. SR+ASP had a successful recanalization rate of 83.7% (297/355), SR had a 75.6% rate (638/844), while ASP alone had a 74.2% rate (386/520). The overall functional independence rate was 51.3% (851/1659) among DMVOs. The ASP alone group had a functional independence rate of 46.9% (219/467), while functional independence rates of the SR and SR+ASP groups were 51.5% (372/723) and 61.7% (174/282), respectively. Finally, the subarachnoid hemorrhage rates were 1.8% (4/217) for the ASP group, 9.3% (26/281) for the SR group, and 11.9% (41/344) for the SR+ASP group.

Conclusions Our systematic review supports the proposition that MT is a safe and effective treatment option for DMVOs. Additionally, while the SR+ASP group had consistently high rates of clot clearance and good neurological outcomes, the SR and SR+ASP groups also had higher rates of subarachnoid hemorrhage, highlighting the need for improved DMVO treatment devices.

  • thrombectomy
  • stroke

Data availability statement

Data are available upon reasonable request. The data supporting the findings of this study are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request. The data supporting the findings of this study are available upon reasonable request.

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  • CB and NH contributed equally.

  • Contributors All authors contributed to the manuscript. CB, NH, JMP, KMK, DFK and WB were responsible for the conception and design of the work. KH, NH, CB, JMP, AM, PO and HK were responsible for data extraction, literature search, and risk of bias assessment. All authors were involved in the drafting of the article, critical revision of the article, and final approval of the version to be published. CB and NH were equally contributing authors. CB is responsible for the overall content as guarantor.

  • Funding This study was funded by MIVI Neuroscience.

  • Competing interests NH works for and holds equity in Nested Knowledge; KH works for Nested Knowledge and Superior Medical Experts; JMP is employed by and has ownership interest in Superior Medical Experts and Nested Knowledge; AM works for Superior Medical Experts; KMK works for and holds equity in Nested Knowledge and holds equity in Superior Medical Experts; DF consults for Medtronic, Cerenovus, Microvention, Stryker, Balt, RAPID.AI, RAPID Medical, Qapel Medical, Arsenal Medical, Phenox Medical, Perfuze, hold equity in MENTICE, Neurogami, Marblehead, Scientia Medical, NVMed, received research support from Microvention, Penumbra, Stryker, Balt, and Siemens; DFK consults for Medtronic, has ownership interest in Superior Medical Experts, Nested Knowledge Marblehead Medical, Conway Medical, Monarch Biosciences, Piraeus Medical, received research support from Cerenovus, Insera Therapeutics, Medtronic, Microvention, Balt, Monarch Biosciences, Brainomix, and MIVI Neuroscience; WB consults for Medtronic, has ownership interest in Superior Medical Experts, and received research support from MIVI Neuroscience.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.