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Original research
Endovascular therapy in the distal neurovascular territory: results of a large prospective registry
  1. Raul G Nogueira1,
  2. Mahmoud H Mohammaden1,
  3. Diogo C Haussen1,
  4. Ronald F Budzik2,
  5. Rishi Gupta3,
  6. Antonin Krajina4,
  7. Joey D English5,
  8. Ali R Malek6,
  9. Amrou Sarraj7,
  10. Ana Paula Narata8,
  11. Muhammad Asif Taqi9,
  12. Michael R Frankel1,
  13. Timothy Ryan Miller10,
  14. Thomas Grobelny11,
  15. Blaise W Baxter12,
  16. Bruno Mario Bartolini13,
  17. Paul Jenkins14,
  18. Laurent Estrade15,
  19. David Liebeskind16,
  20. Erol Veznedaroglu17
  21. on behalf of the Trevo Registry Investigators
  1. 1Department of Neurology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia, USA
  2. 2Department of Neuroradiology, Riverside Methodist Hospital, Columbus, Ohio, USA
  3. 3Department of Neurosciences, WellStar Health System, Atlanta, Georgia, USA
  4. 4Department of Neuroradiology, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
  5. 5Department of Neurology, California Pacific Medical Center, San Francisco, California, USA
  6. 6Neurointerventional & Comprehensive Stroke Program, Saint Mary Medical Center, Long Beach, California, USA
  7. 7Neurology, University of Texas McGovern Medical School, Houston, Texas, USA
  8. 8Department of Radiology, Diagnostic and Interventional Neuroradiology Section, Regional University Hospital Centre Tours, Tours, Centre, France
  9. 9Department of Neurology, Vascular Neurology of Southern California, Thousand Oaks, California, USA
  10. 10Department of Radiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
  11. 11Advocate Neurovascular Center, Advocate Health Care Library Network, Park Ridge, Illinois, USA
  12. 12Department of Radiology, University of Tennessee, Chattanooga, TN, USA
  13. 13Department of Neuroradiology, CHUV, Lausanne, VD, Switzerland
  14. 14Division of Biostatistics, Stryker Neurovascular, Fremont, California, USA
  15. 15Department of Interventional Neuroradiology, Centre Hospitalier Regional Universitaire de Lille, Lille, France
  16. 16Department of Neurology, UCLA, Los Angeles, California, USA
  17. 17Department of Neurosciences, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
  1. Correspondence to Dr Raul G Nogueira, Neurology, Emory University School of Medicine, Atlanta, GA 30322, USA; raul.g.nogueira{at}


Background There is a paucity of data regarding mechanical thrombectomy (MT) in distal arterial occlusions (DAO). We aim to evaluate the safety and efficacy of MT in patients with DAO and compare their outcomes with proximal arterial occlusion (PAO) strokes.

Methods The Trevo Registry was a prospective open-label MT registry including 2008 patients from 76 sites across 12 countries. Patients were categorized into: PAO: intracranial ICA, and MCA–M1; and DAO: MCA–M2, MCA–M3, ACA, and PCA. Baseline and outcome variables were compared across the PAO vs DAO patients with pre-morbid mRS 0–2.

Results Among 407 DAOs including 350 (86.0%) M2, 25 (6.1%) M3, 10 (2.5%) ACA, and 22 (5.4%) PCA occlusions, there were 376 DAO with pre-morbid mRS 0–2 which were compared with 1268 PAO patients. The median baseline NIHSS score was lower in DAO (13 [8–18] vs 16 [12–20], P<0.001). There were no differences in terms of age, sex, IV-tPA use, co-morbidities, or time to treatment across DAO vs PAO. The rates of post-procedure reperfusion, symptomatic intracranial hemorrhage (sICH), and 90-mortality were comparable between both groups. DAO showed significantly higher rates of 90-day mRS 0–2 (68.3% vs 56.5%, P<0.001). After adjustment for potential confounders, the level of arterial occlusion was not associated with the chances of excellent outcome (DAO for 90-day mRS 0–1: OR; 1.18, 95% CI [0.90 to 1.54], P=0.225), successful reperfusion or SICH. However, DAO patients were more likely to be functionally independent (mRS 0–2: OR; 1.45, 95% CI [1,09 to 1.92], P=0.01) or dead (OR; 1.54, 95% CI [1.06 to 2.27], P=0.02) at 90 days.

Conclusion Endovascular therapy in DAO appears to result in a comparable safety and technical success profile as in PAO. The potential benefits of DAO thrombectomy should be investigated in future randomized trials.

  • thrombectomy
  • stroke

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  • Contributors RGN: Study conception, design of the work, interpretation of data, drafting of the manuscript. PJ: Statistical analysis. Other co-authors: critical revision of manuscript. All authors gave final approval of the version to be published and 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 work are appropriately investigated and resolved.

  • Funding The Trevo Retriever Registry was funded by Stryker Neurovascular.

  • Competing interests RGN reports consulting fees for advisory roles with Stryker Neurovascular, Cerenovus, Medtronic, Phenox, Anaconda, Genentech, Biogen, Prolong Pharmaceuticals, and Imperative Care, and stock options for advisory roles with Brainomix, Viz-AI, Corindus Vascular Robotics, Vesalio, Ceretrieve, Astrocyte, and Cerebrotech. DCH is a consultant for Stryker and Vesalio, and holds stock options at Viz.AI. RG has ownership interest/royalties from UpToDate and is a consultant for Stryker, Medtronic, and Rapid Medical. AK is a consultant for Stryker. JDE is a consultant for Penumbra, Medtronic, and Stryker. ARM is a proctor for Stryker and consultant for InNeuroCo. AS reports research grants from, and is consultant for, Stryker. MAT is a consultant for Stryker, Rapid Medical, Balt USA, and Medtronic. MRF is a consultant for Nico Corporation. BWB is a consultant for Stryker, Penumbra, Medtronic, Cerenovus, Route 92 Medical, and Artio Medical, and has stock/stock options/equity in Penumbra,, Rapid Medical, Route 92 Medical, Artio Medical, 880 Medical, and Marblehead Medical. PJ is a consultant for Stryker. BMB, is a consultant for Stryker. DL is a consultant for Cerenovus, Genentech, Medtronic, Rapid Medical, Stryker, and Vesalio. EV is a consultant for Stryker, patent holder and scientific advisor for Penumbra, is a Trice consultant, and holds a Mizuho patent.

  • Patient consent for publication Not required.

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

  • Data availability statement Data are available upon reasonable request. Data-sharing anonymized data from the study are available upon reasonable request to the corresponding author.

  • 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.

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