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. 2025 Apr 10;7(1):e000345.
doi: 10.1136/bmjsit-2024-000345. eCollection 2025.

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

Amir Molaie  1 , Salvador Miralbes  2 , Bharath Naravetla  3 , Alejandro M Spiotta  4 , Christian Loehr  5 , Mario Martínez-Galdámez  6 , Ryan A McTaggart  7 , Luc Defreyne  8 , Pedro Vega  9 , Osama O Zaidat  10 , Paul Jenkins  11 , Markus Möhlenbruch  12 , Rishi Gupta  13 , David S Liebeskind  1 ; ASSIST Investigators
Collaborators, Affiliations

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

Amir Molaie et al. BMJ Surg Interv Health Technol. .

Abstract

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.

Keywords: Neurointerventional Devices; Neurological Devices; Real World Evidence.

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Conflict of interest statement

DL is an editorial board member for BMJ SIT. RG serves as Principal Investigator (PI) for the ASSIST Registry (Stryker), PI for the RECCLAIM II Study (Zoll), Clinical Events Committee (CEC) for the MIND Trial (Penumbra), Data Safety Monitoring Board (DSMB) Membrane Study (Cerenovus), ELEVATE Study (Medtronic) consultant and stock options for Vesalio, Rapid Medical. AM serves as a consultant for Stryker. AMS received research grants from Penumbra, Stryker, Medtronic, Avail, Rapid AI, Brain Aneurysm Foundation, consultant for Penumbra, Stryker, Terumo, RAPID AI, DSMB Brain Aneurysm Foundation, Stock options for Avail. CL is a consultant for Penumbra, Phenox, Stryker. DV received a research grant from Microvention, is a consultant for Medtronic and receives payment or honoraria for lectures from Cerenovus, travel support from Microvention and Medtronic. LD is a consultant for Stryker. PJ is a consultant for Stryker. LD is a consultant for Cerenovus, Genentech, Medtronic, Rapid Medical, Stryker and Vesalio. MM receives research grants from Acandis, Balt, Medtronic, Microvention, Phenox, Stryker* (*industry payments are made to the research fund of the institution), receives payment or honoraria for lectures from Balt, Medtronic, Stryker* (*industry payments are made to the research fund of the institution).

Figures

Figure 1
Figure 1. Study flowchart.
Figure 2
Figure 2. (A) Clinical outcome based on reperfusion grade alone. (B) Clinical outcome based on reperfusion grade and distal emboli status. (A) Grotta bars illustrating the distribution of 90-day mRS scores based only on eTICI score, demonstrating a shift in improved 90-day mRS with increasing eTICI score and a significant difference across eTICI levels in predicting mRS 0–2. (B) Grotta bars illustrating the relationship between reperfusion grade, distal emboli status and clinical outcome. A similar shift in 90-day mRS is seen. Note that as reperfusion grade increases, there are proportionally less distal emboli observed at each eTICI level. In the intermediate eTICI grades, there was a shift 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. eTICI, expanded treatment in cerebral infarction; mRS, modified Rankin scale.
See this image and copyright information in PMC

References

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