BMJ Surgery, Interventions, & Health Technologies (Apr 2025)

Incomplete reperfusion and the presence of distal emboli in predicting clinical outcome after endovascular thrombectomy

  • ,
  • Lei Feng,
  • Eric Sauvageau,
  • David S Liebeskind,
  • Amin Aghaebrahim,
  • Gerard Deib,
  • Christian Ulfert,
  • Alejandro M Spiotta,
  • Jérome Berge,
  • Xavier Barreau,
  • Bruno Bartolini,
  • Francesco Puccinelli,
  • Guillaume Saliou,
  • Maxim Mokin,
  • Ryan A McTaggart,
  • Alejandro Spiotta,
  • Clemens Schirmer,
  • Adam Arthur,
  • Alan Reeves,
  • Jasmeet Singh,
  • Tobias Boeckh-Behrens,
  • Johanna Fifi,
  • Ricardo Hanel,
  • SoHyun Boo,
  • Tomoyoshi Shigematsu,
  • Christoph Griessenauer,
  • Demetrius Lopes,
  • Patrick Nicholson,
  • Timo Krings,
  • Antonin Krajina,
  • Robert James,
  • Nitin Goyal,
  • Daniel Hoit,
  • Lucas Elijovich,
  • Christopher Nickele,
  • Abhinav Singh,
  • Thomas Liebig,
  • Francesco Massari,
  • Ahmad Khaldi,
  • Osama O Zaidat,
  • Wondwossen Tekle,
  • Kyriakos Lobotesis,
  • Christian Herweh,
  • Abdulnasser Alhajeri,
  • Eugene Kim,
  • Katarina Dakay,
  • Ryan McTaggart,
  • Gernot Reimann,
  • Elad Levy,
  • Adnan Siddiqui,
  • Wendy Smith,
  • Ansaar Rai,
  • Pascal Jabbour,
  • Stavropoula Tjoumakaris,
  • Robert Rosenwasser,
  • Nirav Vora,
  • Ronald Budzik,
  • Peter Pema,
  • Kenneth Snyder,
  • Hazem Shoirah,
  • Ahmed Cheema,
  • Marios-Nikos Psychogios,
  • Woong Yoon,
  • Byung Hyun Baek,
  • Fawaz Al-Mufti,
  • Gaultier Marnat,
  • Mario Martínez-Galdámez,
  • Jean-Christophe Gentric,
  • Julien Ognard,
  • Chris Neal,
  • Steven Hajdu,
  • Manuel Requena,
  • Christian Maegerlein,
  • Claire Richardson,
  • Dong Hoon Lee,
  • Rishi Gupta,
  • Nils Mueller-Kronast,
  • Justin Santarelli,
  • Pamela Shaw,
  • Alejandro Tomasello,
  • Alex Brehm,
  • Ioannis Tsogkas,
  • Robert Forbrig,
  • Gustavo Rodriguez,
  • Ichiro Yuki,
  • Mahesh Jayaraman,
  • Kunal Vakharia,
  • Chrysanthi Papagiannaki,
  • Gianmarco Bernava,
  • Andrea Rosi,
  • Paolo Machi,
  • Jonathan Lena,
  • Nabeel Herial,
  • Seon-Kyu Lee,
  • Javier Rodriguez,
  • Paul Singh,
  • Thomas Oxley,
  • Kiffon Keigher,
  • Jacopo Scaggiante,
  • Markus Möhlenbruch,
  • Allan Brook,
  • Robert Dodd,
  • Michael Reid Gooch,
  • Matteo Fantoni,
  • Olivier Deryck,
  • Dennys Reyes,
  • Sudeepta Dandapat,
  • Gurmeen Kaur,
  • Kavit Shah,
  • Oded Goren,
  • Jeremy Peterson,
  • Silke Wunderlich,
  • Waldo Guerrero,
  • Osama Zaidat,
  • Pedro Vega,
  • Shahram Majidi,
  • Ronit Agid,
  • Paul Jenkins,
  • Kimberly Kicielinski,
  • Sami Al Kasab,
  • Violiza Inoa,
  • Shamsher Dalal,
  • Gregory Weiner,
  • Thomas Grobelny,
  • Florent Gariel,
  • Santiago Rosati,
  • Carlos Gómez-Escalonilla,
  • Manuel Moreu,
  • Jeremy Hofmeister,
  • Michel Muster,
  • David Dornbos,
  • Patrice Menegon,
  • Bradley Bohnstedt,
  • Richard Haas,
  • Eduardo Murias,
  • Jose Maria Jimenez,
  • Eugene Lin,
  • Mohamed Teleb,
  • Saif Bushnaq,
  • Charlotte Rüther,
  • Sandra Mitchell,
  • Rafael González,
  • Sandra Bracco,
  • Paola Gennari,
  • Shuichi Suzuki,
  • Alberto Maud,
  • Jason Davies,
  • Stephanie Corder,
  • Robert Flynn,
  • Megan Smith,
  • Nicolas Pangon,
  • Kornelia Kreiser,
  • Radmehr Torabi,
  • Neil Rane,
  • Stephanie Wilson,
  • José Luis Caniego,
  • Jeffery Wilseck,
  • Mahmoud Rayes,
  • Kiarash Golshani,
  • Christopher Kellner,
  • Johannes Pfaff,
  • Enrico Pampana,
  • Jennifer Domico,
  • William Humphries,
  • Eduardo Bárcena,
  • Peter Vanlangenhove,
  • Luc Defreyne,
  • Salvador Miralbes,
  • Lorena Nico,
  • Pedro Saura,
  • Kessarin Panichpisal,
  • Stefano Vallone,
  • Guido Bigliardi,
  • Andrew Bauer,
  • Michael Abraham,
  • Andrey Lima,
  • David Altschul,
  • Kuo Chao,
  • Koji Ebersole,
  • Christian Loehr,
  • Geert Vanhooren,
  • Brijesh Mehta,
  • Laura Allen,
  • Sebastiano Fabiano,
  • Kristine Blackham,
  • David Hernández,
  • Monika Probst,
  • Laura Vandelli,
  • Ludo Vanopdenbosch,
  • Sergio Lucio Vinci,
  • Agostino Tessitore,
  • Mariano Velo,
  • Carlos Piñana,
  • Peter Sporns,
  • Gregory Lock,
  • Margaux Lefebvre,
  • Stefan Rohde,
  • Molly Baker,
  • Ameer Hassan,
  • Krisztina Moldovan,
  • Eva Vítková,
  • Lucio Castellan,
  • Eila Rivera,
  • Jan Raupach,
  • Itay Melamed,
  • Reade DeLeacy,
  • Ludovico Ciolli,
  • Roberto Menozzi,
  • Laura Malfatto,
  • Andrea Calzoni,
  • Mercedes de Lera,
  • Shail Thanki,
  • Yigit Ozpeynirci,
  • Christoph Trumm,
  • Jessica Jesser,
  • Thomas Wolfe,
  • Tim Hilgenfeld,
  • Muhammad Taqi,
  • Jan Kirschke,
  • Dominik Vollherbst,
  • Susanne Bonekamp,
  • Antonio Pitrone,
  • Antonio Caragliano,
  • Axel Schaefer,
  • Bharath Naravetla,
  • Ho Jun Yi,
  • Enrico Cotroneo,
  • Jae Hoon Sung,
  • Nancy Ebreo,
  • Lanaya Lewis,
  • Mary Hartney,
  • Jonna Sakowski,
  • Meredith Robinson,
  • Anastasia Vechera,
  • Amanda Nolte,
  • Andreea Cioltan,
  • Elisabeth Dhondt,
  • Varun Chaubal,
  • Arne Hostens,
  • Bridget Nolan,
  • Ashima Sharma,
  • Jared Cooper,
  • Tristan Kerdraon,
  • Melissa Cambron,
  • Amir Molaie,
  • Lesley Honeyfield,
  • Abdul Tarabishy,
  • Lucian Maidan,
  • Marc Viles,
  • Rebeca Bermejo,
  • Angel Calleja,
  • Onishchuk Valentyna,
  • Tanya Mosley Gardner,
  • Emily Paschal,
  • Stephanie Bruma,
  • Emily Infinger,
  • Stephan Bossmann,
  • Jan Oliver Kuhnt,
  • Johanna Zabel,
  • Christian Dynak,
  • Alexander Hubert,
  • Alexander Mohr,
  • Leonie Jestaedt,
  • Faith Seker,
  • Sabine Johnson,
  • Jenny Frech,
  • Lukas Diebold,
  • Gabriele Neureither,
  • Jorge Galvan,
  • Carlos Castaneda,
  • Stephanie Rowe,
  • Lauryn Taylor,
  • Martha Kelly,
  • Gina Merola,
  • Susan Foley,
  • Laurens Hermie,
  • Lynn Huyck,
  • Lien Van Cauwenberghe,
  • Juan Chaviano,
  • Vendelin Chovanec,
  • Miroslav Lojik,
  • Bader Alenzi,
  • Nicholas Liaw,
  • Alyssa Bickley,
  • Ronda White,
  • India Bass,
  • Amy Krueger,
  • Cynthia Upham,
  • Rachel Gregis,
  • Abdul Alhalak,
  • Orazio Buonomo,
  • Nicola Milazzo,
  • Narae Kwon,
  • Nicola Mavilio,
  • Giancarlo Salsano,
  • Bruno Del Sette,
  • Maria Luisa Dell'Acqua,
  • Giuseppe Borzi,
  • Livio Picchetto,
  • Riccardo Ricceri,
  • Francesca Rosafio,
  • Stefania Maffei,
  • Karissa Graham,
  • Katherine Freedman,
  • Angela Whitmire,
  • Chelsie Derr,
  • Pouria Moshayedi,
  • Benjamin Rapoport,
  • Sukaina Davdani,
  • Emily Fiano,
  • Armand Harb,
  • Serina Deeba,
  • Bruno Bergmans,
  • Tybault Hollanders,
  • Heleen Parmentier,
  • Kristof Verhoeven,
  • Johan Ghekiere,
  • Isaline Demarcin,
  • Louise Adams,
  • Robin Bouttelgier,
  • Lisa Van Doeselaer,
  • Louise De Temmerman,
  • Valerie Schotte,
  • Heleen Couckuyt,
  • Julie Derous,
  • Maria Bauer,
  • James Jaffe,
  • Dharati (Dorothy) Trivedi,
  • Glen Pollock,
  • Genevieve Kuchinsky,
  • Samantha Goedde,
  • Payton Tepp,
  • Kristopher Rowe,
  • Gary Dennison,
  • Batul Dhariwala,
  • Kaite McPolin,
  • Tonya Hollrith,
  • Marissa Lowe,
  • Lauren Snyder,
  • Geraldine Viard,
  • Fernando Ostos,
  • Federico Ballenilla,
  • Jorge Campollo,
  • Miriam Fernandez Gomez,
  • Neil Haranhali,
  • Richard Zampolin,
  • Aureliana Toma,
  • Lavinia Williams,
  • Catherine Lui,
  • Vanessa Audea,
  • Nathalie Sanchez,
  • Marissa Barron,
  • Joshua Billingsley,
  • Khaled Asi,
  • Bridget Cantrell,
  • Gina Barbaglia,
  • Eric Leadley,
  • Linda Jiang,
  • Pavan Murty,
  • Arth Srivastava,
  • Nicholas Armijo,
  • Gina Littlejohn,
  • Sherri Velez,
  • Nicole Hannigan,
  • Kathleen Hesse,
  • Geroge Luh,
  • Danielle Hornbuckle,
  • Sharon Bluemel,
  • Juan Vega,
  • Mazen Noufal,
  • Valerie Wyman,
  • Ali Malek,
  • Juan Ramos,
  • Muneer Hassan,
  • Jennafer Hallquist,
  • Natasha Molina,
  • Sandra Ripper-Brown,
  • Charity Denson,
  • Marianne Torres-Malaga,
  • Chirag Ghandhi,
  • Christeena Kurian,
  • Haris Kamal,
  • Divya Viswanathan,
  • Monique Carrero-Tagle,
  • Kevin Clare,
  • Daniel Heiferman,
  • Kendrick Johnson,
  • Valorie Horner,
  • Kamal Lotay,
  • Olaf Adamczewski,
  • Stephan Schwarz,
  • Kristina Hauptmann,
  • Torsten Doring,
  • Bettina Zoeller,
  • Malvina Destro,
  • Hoang Duong,
  • Doris Alaby,
  • Joy Sessa,
  • Viviane Kleva,
  • Erum Usman,
  • Nicole Mercado,
  • Pualani Smith,
  • Enrico Epifani,
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  • Luca Bertaccini,
  • Jennifer Gay,
  • Staci Smith,
  • Shelby Halm,
  • Viola Dallas,
  • Nadirah Jones,
  • Chris Kazmierczak,
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  • Grace San Agustin,
  • Pamela Sloan,
  • Andrew Ku,
  • Jonathan Pace,
  • Laurie Dennis,
  • Pamela White,
  • Mary Fetter,
  • Emily Shank,
  • John Ernest Madarang,
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  • Sebastien Normant,
  • Anna Kuhn,
  • Nadeen Elayan,
  • Aniel Majjhoo,
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  • Jan Peter Püttmann,
  • Miguel Arturo Schüller,
  • Ondrej Renc,
  • Seung Yoon Song,
  • Luis López Ibor,
  • Mais Al Kawaz,
  • Sofie De Blauwe,
  • Annelies Van Dycke,
  • Charlotte Vanden Berghe,
  • Alex Kostynskyy,
  • Conrad Liang,
  • Rachid El Mouden,
  • Ines Gaedke,
  • Roberts Marci,
  • Erida Castro-Rivas,
  • Carla Zavala,
  • Doreen Zokvic AbigailWalters,
  • Alexia Resner,
  • Muthana Sweis,
  • Nickalus Khan,
  • Jessica Ward,
  • Kaylah Payne,
  • Jill Granado,
  • Lee Ann Dials,
  • Rosemary DeLeon,
  • Ignazio Vallone,
  • Marc Ribó Ribó,
  • Caitlin Sprole,
  • Sonia McCoy,
  • Kirstyn Andrade Hayes,
  • Doaa Abdelmoety,
  • Anmar Razak,
  • Alyssa Ruckel,
  • Frank Lückert,
  • Megan Heckathorne,
  • Morgan Davis,
  • Zainab Al Obaidi

DOI
https://doi.org/10.1136/bmjsit-2024-000345
Journal volume & issue
Vol. 7, no. 1

Abstract

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Objectives To explore the relationship between final expanded treatment in cerebral infarction (eTICI) score and the presence or absence of distal emboli on final angiography on clinical outcome after endovascular thrombectomy (EVT) for acute ischaemic stroke (AIS). Persistent distal emboli on angiography are commonly noted, yet not all patients with intermediate eTICI scores demonstrate clear angiographic emboli, raising the possibility that these angiographic differences may correlate with distinct mechanisms of ‘no-reflow’. Therefore, we sought to better understand the potential clinical impact of such angiographic markers in cases of incomplete reperfusion.Design We performed an exploratory retrospective analysis of a prospectively collected group of AIS patients who underwent EVT for M1 occlusions using the ASSIST Registry.Setting 71 sites in 11 countries participated in the registry.Participants A total of 650 patients with M1 occlusions were included.Main outcome measures We compared 90-day modified Rankin scale (mRS) scores based on eTICI score as well as the presence or absence of distal emboli on final angiography.Results Clinical outcome based only on eTICI score revealed a shift in 90-day mRS, with a significant difference across eTICI scores in predicting 90-day mRS 0–2. In the intermediate eTICI grades 2b67 and 2c, there was a trend towards better 90-day mRS when emboli were present on final angiography than when emboli were absent. However, pairwise comparisons between these levels were non-significant.Conclusion In patients with final eTICI 2b67 or 2c, those with persistent emboli trended towards better clinical outcomes. With intermediate eTICI reperfusion, identifying the presence or absence of distal emboli on final angiography may be useful in distinguishing patterns of incomplete reperfusion. These findings should be followed by investigations on correlation between angiography and other markers of microcirculatory ‘no-reflow’.Trial registration number NCT03845491.