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Original research
Multicenter investigation of technical and clinical outcomes after thrombectomy for distal vessel occlusion by frontline technique
  1. Ali M Alawieh1,
  2. Reda M Chalhoub2,
  3. Sami Al Kasab3,
  4. Pascal Jabbour4,
  5. Marios-Nikos Psychogios5,
  6. Robert M Starke6,
  7. Adam S Arthur7,8,
  8. Kyle M Fargen9,
  9. Reade De Leacy10,
  10. Peter Kan11,
  11. Travis M Dumont12,
  12. Ansaar Rai13,
  13. Roberto Javier Crosa14,
  14. Ilko Maier15,
  15. Nitin Goyal16,
  16. Stacey Q Wolfe17,
  17. C Michael Cawley1,
  18. J Mocco10,
  19. Stavropoula I Tjoumakaris18,
  20. Brian M Howard1,19,
  21. Laurie Dimisko20,
  22. Hassan Saad1,
  23. Christopher S Ogilvy21,
  24. R Webster Crowley22,
  25. Justin R Mascitelli23,
  26. Isabel Fragata24,
  27. Michael R Levitt25,
  28. Joon-tae Kim26,
  29. Min S Park27,
  30. Benjamin Gory28,
  31. Adam J Polifka29,
  32. Charles Matouk30,
  33. Jonathan A Grossberg1,
  34. Alejandro M Spiotta2
  35. on behalf of the STAR Collaborators
  1. 1 Department of Neurosurgery, Emory University School of Medicine Atlanta, Atlanta, Georgia, USA
  2. 2 Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
  3. 3 Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
  4. 4 Neurological surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
  5. 5 Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
  6. 6 Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
  7. 7 Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
  8. 8 Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
  9. 9 Neurosurgery, Wake Forest University, Winston-Salem, North Carolina, USA
  10. 10 Neurosurgery, Icahn School of Medicine at Mount Sinai, NEW YORK, New York, USA
  11. 11 Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
  12. 12 Department of Surgery, Division of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA
  13. 13 Radiology, West Virginia University Hospitals, Morgantown, West Virginia, USA
  14. 14 Endovascular Neurosurgery, Médica Uruguaya, Montevideo, Montevideo, Uruguay
  15. 15 Neurology, University Medicine Goettingen, Goettingen, NS, Germany
  16. 16 Neurology, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
  17. 17 Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
  18. 18 Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
  19. 19 Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
  20. 20 Emory Healthcare, Atlanta, Georgia, USA
  21. 21 Neurosurgery, BIDMC, Boston, Massachusetts, USA
  22. 22 Neurosurgery, Rush University, Chicago, Illinois, USA
  23. 23 Department of Neurosurgery, University of Texas Health Science Center, San Antonio, Texas, USA
  24. 24 Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
  25. 25 Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
  26. 26 Neurology, Chonnam National University, Gwangju, Jeollanam-do, Korea (the Republic of)
  27. 27 Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
  28. 28 Department of Diagnostic and Interventional Neuroradiology, CHRU Nancy, Nancy, Lorraine, France
  29. 29 Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
  30. 30 Neurosurgery, Yale University, New Haven, Connecticut, USA
  1. Correspondence to Dr Jonathan A Grossberg, Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA 30322, USA; jonathan.a.grossberg{at}; Dr Alejandro M Spiotta; spiotta{at}


Background Endovascular thrombectomy (EVT) is the standard-of-care for proximal large vessel occlusion (LVO) stroke. Data on technical and clinical outcomes in distal vessel occlusions (DVOs) remain limited.

Methods This was a retrospective study of patients undergoing EVT for stroke at 32 international centers. Patients were divided into LVOs (internal carotid artery/M1/vertebrobasilar), medium vessel occlusions (M2/A1/P1) and isolated DVOs (M3/M4/A2/A3/P2/P3) and categorized by thrombectomy technique. Primary outcome was a good functional outcome (modified Rankin Scale ≤2) at 90 days. Secondary outcomes included recanalization, procedure-time, thrombectomy attempts, hemorrhage, and mortality. Multivariate logistic regressions were used to evaluate the impact of technical variables. Propensity score matching was used to compare outcome in patients with DVO treated with aspiration versus stent retriever

Results We included 7477 patients including 213 DVOs. Distal location did not independently predict good functional outcome at 90 days compared with proximal (p=0.467). In distal occlusions, successful recanalization was an independent predictor of good outcome (adjusted odds ratio (aOR) 5.11, p<0.05) irrespective of technique. Younger age, bridging therapy, and lower admission National Institutes of Health Stroke Scale (NIHSS) were also predictors of good outcome. Procedure time ≤1 hour or ≤3 thrombectomy attempts were independent predictors of good outcomes in DVOs irrespective of technique (aOR 4.5 and 2.3, respectively, p<0.05). There were no differences in outcomes in a DVO matched cohort of aspiration versus stent retriever. Rates of hemorrhage and good outcome showed an exponential relationship to procedural metrics, and were more dependent on time in the aspiration group and attempts in the stent retriever group.

Conclusions Outcomes following EVT for DVO are comparable to LVO with similar results between techniques. Techniques may exhibit different futility metrics; stent retriever thrombectomy was influenced by attempts whereas aspiration was more dependent on procedure time.

  • Thrombectomy
  • Device
  • Stroke

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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  • Twitter @ChalhoubReda, @PascalJabbourMD, @Starkeneurosurg, @AdamArthurMD, @rdeleacymd, @PeterKa80460001, @BrianHoward_MD, @jmascite, @DrMichaelLevitt

  • Collaborators Christian Mustroph, MD; Emory University School of Medicine, Atlanta, GA, USA

    Kareem E Naamani, MD; Thomas Jefferson University, Philadelphia, PA, USA

    Italo Linfante, MD; Florida International University; Miami, FL, USA

    Clemens Schirmer, MD; Geisinger Medical Group, Danville, PA, USA

    Toshiya Osanai, MD. PhD; Hokkaido University Hospita; Sapporo, Japan

    Shinichi Yoshimura, MD PhD; Hyogo College of Medicine; Nishinomiya, Japan

    Waleed Brinjikji, MD; Mayo Clinic, Rochester, MN, USA

    Richard Crowley, MD; Rush Univeristy; Chicago, IL, USA

    Adam Polifka, MD; University of Floride, Gainesville, FL, USA

  • Contributors All authors have: provided a substantial contribution to the conception and design of the studies and/or the acquisition and/or the analysis of the data and/or the interpretation of the data; drafted the work or revised it for significant intellectual content; approved the final version of the manuscript; and agree to be accountable for all aspects of the work, including its accuracy and integrity. JAG/AMS are guarantors of the work and the conduct of the study.

  • 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 AMA: None, RMC: None, SAK: Grant Funding-Stryker; PJ: Consultant-Balt, Cerus, Microvention, Medtronic. M-NP Honoraria - Stryker, Medtronic, Penumbra, Acandis, Phenox, Siemens Healthineers, Research Support-Swiss National Science Foundation, Bangerter-Rhyner Stiftung, Stryker, Phenox, Medtronic, Rapid, Penumbra, Siemens Healthineers; RMS: None; ASA: Consultant for Arsenal, Balt, Johnson and Johnson, Medtronic, Microvention, Penumbra, Scientia, Siemens, Stryker, Research support from Balt, Medtronic, Microvention, Penumbra and Siemens, Shareholder-Azimuth, Bendit, Cerebrotech, Endostream, Magneto, Mentice, Neurogami, Neuros, Scientia, Serenity, Synchron, Tulavi, Vastrax, VizAI; KMF: Editorial Board-JNIS; RDL: Consultant-Stryker, Imperative Care, Cerenovus, Asahi Intec, Research Funding-Hypervention, Kaneka, Siemens Healthineers, SNIS Foundation, Equity-Synchron, Endostream, Q’Apel, Spartan Micro, Editorial Board-JNIS; PK: Consultant- Stryker, Imperative Care, Microvention, Grant Support-NIH, Editorial-Board JNIS; TD: None; AR: None; RJC: None; IM: None; NG: None; SQW: Board of Directors-AANS, Associate Editor- S:VIN Journal; CMC: None; JM: PI on trials funded by- Stryker Neurovascular, Microvention, and Penumbra, Consultant-Cerebrotech, Viseon, Endostream, Vastrax, RIST, Synchron,, Perflow, CVAid, Stockholder-Cerebrotech, Imperative Care, Endostream, Viseon, BlinkTBI, Myra Medical, Serenity, Vastrax, NTI, RIST,, Synchron, Radical, and Truvic; Editorial Board-JNIS; SIT: Consultant- Microvention, Medtronic; BMH: None; LD: None; HS: None; CSO: Grant Support- Bee Foundation, Brain Aneurysm Foundation, DSMB- Medtronic; RWC: Consultant/Proctor: Medtronic, Microvention; JMa: consultant-Stryker; IF: None; MRL: Educational Grant-Stryker, Medtronic, Consultant-Medtronic, Aeaean Advisers, Travel Support-Penumbra, Editorial Board, JNIS, Stock- Hyperion Surgical, Proprio, Synchron, Cerebrotech, Fluid Biomed, Stereotaxis, Advisor-Metis Innovative; J-tK: None; MSP: DSMB-Medtronic; BG: None; AJP: Consultant-Depuy Synthes, Stryker, CM: Consultant-Silk Road, Penumbra, Microvention, Cerevasc, Stryker, Speaker-Silk Road, Penumbra; JAG: Grant Support- Georgia Research Alliance, Department of Defense, Emory Medical Care Foundation, Neurosurgery Catalyst, Stock- NTI, Cognition; AMS: Consultant- Stryker, Penumbra, Terumo, RapidAI; STAR: funded by Penumbra, Medtronic, Stryker.

  • 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.