Abstract
Background and PurposeTo determine reasons for failed recanalization in mechanical thrombectomy (MT) of the posterior circulation.MethodsRetrospective single center analysis of reasons for MT failure in the posterior circulation. Failed MTs were categorized according to the reason for procedure failure in failed vascular access, failed passage of the target vessel occlusion and MT failure after passing the occluded target vessel. Patient characteristics were compared between failed and successful MT.ResultsPatients with failed MT (30/218 patients, 13.8%) were categorized into futile vascular access (13/30, 43.3%), abortive passage of the target vessel occlusion (6/30, 20.0%) and MT failure after passing the vessel occlusion (11/30, 36.7%). In 188/218 (86.2%) successful MTs alternative vascular access, local intra-arterial (i.a.) thrombolysis and emergency stent-assisted PTA prevented 65 MT failures. Patients with failed MT showed a higher NIHSS at discharge, a higher pc-ASPECTS in follow-up imaging, a higher mRS 90 days after stroke onset and a high mortality rate of 77.0% (mRS at 90 days, median (IQR): 6 (6–6) vs. 4 (2–6) for successful MT, p-value < 0.001). Co-morbidities and stroke etiology were not different compared to sufficient recanalization with atherosclerotic disease as the leading stroke etiology in both groups.ConclusionFailure of MT in posterior circulation ischemic stroke patients is associated with a high mortality rate. Reasons for MT failure are diverse with futile vascular access and MT failure after passing the vessel occlusion as the leading causes. Alternative vascular access, local i.a. thrombolysis and stent-assisted PTA can prevent MT failure.
Highlights
Mechanical thrombectomy (MT) has become the state of the art for treating patients with ischemic stroke and large vessel occlusion (LVO) in the anterior circulation since several randomized, multicenter studies emerged in 2015 proved its superiority to intravenous rt-PA alone [1,2,3,4]
Intraprocedural complications or the patient’s deteriorating clinical status during the MT let to a termination of the intervention. In this single center analysis we showed that futile vascular access due to atherosclerotic disease or anatomic difficulties (n = 12/30 patients, 40.0%) and MT failure after passing the target vessel occlusion (n = 11/30 patients, 37.0%) are the leading causes for failed recanalization in posterior circulation MT, followed by abortive passage of the thrombus (n = 7/30 patients, 23.0%)
Patients with MT failure showed a higher mRS 90 days after stroke onset with a high mortality rate of 77.0% and a very high NIHSS at discharge as well as a lower pcASPECTS in follow-up imaging
Summary
Mechanical thrombectomy (MT) has become the state of the art for treating patients with ischemic stroke and large vessel occlusion (LVO) in the anterior circulation since several randomized, multicenter studies emerged in 2015 proved its superiority to intravenous rt-PA alone [1,2,3,4]. The second group is further classified as failure to pass the target vessel occlusion and as stent-retriever failure, where the thrombus cannot be removed despite all MT maneuvers. Studies following this approach investigated causes for recanalization failure in MT of the anterior circulation [8] and for stent-retrieverbased thrombectomy focusing on the anterior circulation [9]. Rescue strategies, such as intracranial stenting and alternative vascular access, are discussed for failed MT of the anterior circulation. To determine reasons for failed recanalization in mechanical thrombectomy (MT) of the posterior circulation
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