Thrombectomy for secondary distal, medium vessel occlusions of the
posterior circulation: seeking complete reperfusion
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Abstract
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