Impact of thrombectomy techniques on outcome in medium or distal vessel occlusion: subanalysis of the DISTAL Trial

Victor Schulze-Zachau¹, Nikki Rommers², Tomas Dobrocky³, Steven D Hajdu⁴, Jens Fiehler⁵, Isabel Fragata⁶, Jan Gralla⁷, Paolo Machi⁸, Jan S Kirschke⁹, Adriaan C G M van Es¹⁰, Johannes Kaesmacher¹¹, Jan-Hendrik Buhk¹², Jeffrey L Saver^{13

14}, Mario Martínez-Galdámez^{15

16}, Eike Immo I Piechowiak¹⁷, Daniel P O Kaiser^{18

19}, Illario Tancredi²⁰, Frans Van Den Bergh²¹, Victoria Hellstern²², Ali Khanafer²³, David Volders²⁴, Daniel Strbian²⁵, Marc Ribo^{26

27}, Grzegorz Marek Karwacki²⁸, Vera Aebischer²⁹, Alex Brehm³⁰, Urs Fischer^#³¹, Marios-Nikos Psychogios^#³⁰, Distal Collaborators³²

Affiliations

¹ Department of Diagnostic & Interventional Neuroradiology, Radiology & Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland victor.schulze-zachau@usb.ch.
² Clinical Research Department, Universitätsspital Basel, Basel, Switzerland.
³ Department of Diagnostic and Interventional Neuroradiology, Inselspital Universitatsspital Bern, Bern, Switzerland.
⁴ Department of Interventional and Diagnostic Neuroradiology, Lausanne University Hospital, Lausanne, Vaud, Switzerland.
⁵ Department of Neuroradiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany.
⁶ Department of Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal.
⁷ Department for Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland.
⁸ Division of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals, Geneva, Switzerland.
⁹ Department of Neuroradiology, Klinikum rechts der Isar, Munich, Germany, Germany.
¹⁰ Department of Radiology, Leiden Universitair Medisch Centrum, Leiden, Zuid-Holland, Netherlands.
¹¹ Department of Neuroradiology, University Hospital Bern, Bern, Switzerland.
¹² Department of Neuroradiology, Asklepios Hospital St. Georg, Hamburg, Germany.
¹³ Department of Neurology, UCLA, Los Angeles, California, USA.
¹⁴ Comprehensive Stroke Center and Neurology, David Geffen School of Medicine, Los Angeles, California, USA.
¹⁵ Department of Interventional Neuroradiology/Endovascular Neurosurgery, Hospital Clínico Universitario de Valladolid, Valladolid, Spain.
¹⁶ Department of Interventional Neuroradiology.Radiology Department, Hospital La Luz, Quironsalud, Madrid, Spain.
¹⁷ Department of Diagnostic and Interventional Neuroradiology, Inselspital - Bern University Hospital, Switzerland, Bern, Switzerland.
¹⁸ University Hospital Carl Gustav Carus, Dresden, Germany.
¹⁹ Technical University Dresden, Dresden, Germany.
²⁰ Department of Interventional Radiology, Hôpital Civil Marie Curie, Brussel, Belgium.
²¹ Department of Radiology, Universitair Ziekenhuis Brussel (UZ Brussel), Brussel, Belgium.
²² Interventional Neuroradiology Section, HOCH Health Ostschweiz, St. Gallen, Switzerland.
²³ Klinikum Stuttgart, Stuttgart, Germany.
²⁴ Department of Radiology, Dalhousie University, Halifax, Nova Scotia, Canada.
²⁵ Univ Helsinki, Helsinki, Finland.
²⁶ Stroke Unit. Neurology, Hospital Vall d'Hebron, Barcelona, Spain.
²⁷ Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain.
²⁸ Department of Radiology and Nuclear Medicine, Luzerner Kantonsspital Zentrumsspital, Luzern, Switzerland.
²⁹ Department of Diagnostic & Interventional Neuroradiology, Radiology & Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland.
³⁰ Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland.
³¹ Department of Neurology, University of Bern, Bern, Switzerland.
³² University Hospital Basel, Basel, BS, Switzerland.

^# Contributed equally.

PMID: 41339078
DOI: 10.1136/jnis-2025-024374

Impact of thrombectomy techniques on outcome in medium or distal vessel occlusion: subanalysis of the DISTAL Trial

Victor Schulze-Zachau et al. J Neurointerv Surg. 2025.

. 2025 Dec 3:jnis-2025-024374.

doi: 10.1136/jnis-2025-024374. Online ahead of print.

Authors

Affiliations

¹ Department of Diagnostic & Interventional Neuroradiology, Radiology & Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland victor.schulze-zachau@usb.ch.
² Clinical Research Department, Universitätsspital Basel, Basel, Switzerland.
³ Department of Diagnostic and Interventional Neuroradiology, Inselspital Universitatsspital Bern, Bern, Switzerland.
⁴ Department of Interventional and Diagnostic Neuroradiology, Lausanne University Hospital, Lausanne, Vaud, Switzerland.
⁵ Department of Neuroradiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany.
⁶ Department of Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal.
⁷ Department for Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland.
⁸ Division of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals, Geneva, Switzerland.
⁹ Department of Neuroradiology, Klinikum rechts der Isar, Munich, Germany, Germany.
¹⁰ Department of Radiology, Leiden Universitair Medisch Centrum, Leiden, Zuid-Holland, Netherlands.
¹¹ Department of Neuroradiology, University Hospital Bern, Bern, Switzerland.
¹² Department of Neuroradiology, Asklepios Hospital St. Georg, Hamburg, Germany.
¹³ Department of Neurology, UCLA, Los Angeles, California, USA.
¹⁴ Comprehensive Stroke Center and Neurology, David Geffen School of Medicine, Los Angeles, California, USA.
¹⁵ Department of Interventional Neuroradiology/Endovascular Neurosurgery, Hospital Clínico Universitario de Valladolid, Valladolid, Spain.
¹⁶ Department of Interventional Neuroradiology.Radiology Department, Hospital La Luz, Quironsalud, Madrid, Spain.
¹⁷ Department of Diagnostic and Interventional Neuroradiology, Inselspital - Bern University Hospital, Switzerland, Bern, Switzerland.
¹⁸ University Hospital Carl Gustav Carus, Dresden, Germany.
¹⁹ Technical University Dresden, Dresden, Germany.
²⁰ Department of Interventional Radiology, Hôpital Civil Marie Curie, Brussel, Belgium.
²¹ Department of Radiology, Universitair Ziekenhuis Brussel (UZ Brussel), Brussel, Belgium.
²² Interventional Neuroradiology Section, HOCH Health Ostschweiz, St. Gallen, Switzerland.
²³ Klinikum Stuttgart, Stuttgart, Germany.
²⁴ Department of Radiology, Dalhousie University, Halifax, Nova Scotia, Canada.
²⁵ Univ Helsinki, Helsinki, Finland.
²⁶ Stroke Unit. Neurology, Hospital Vall d'Hebron, Barcelona, Spain.
²⁷ Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain.
²⁸ Department of Radiology and Nuclear Medicine, Luzerner Kantonsspital Zentrumsspital, Luzern, Switzerland.
²⁹ Department of Diagnostic & Interventional Neuroradiology, Radiology & Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland.
³⁰ Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland.
³¹ Department of Neurology, University of Bern, Bern, Switzerland.
³² University Hospital Basel, Basel, BS, Switzerland.

^# Contributed equally.

PMID: 41339078
DOI: 10.1136/jnis-2025-024374

Abstract

Introduction: The optimal thrombectomy technique for medium/distal vessel occlusions (MDVOs) remains uncertain.

Objective: To compare the safety and efficacy of aspiration thrombectomy (ADAPT) versus stent retriever thrombectomy (SR only) versus a primary combined approach (PCA).

Patients and methods: In this post hoc analysis of the DISTAL Trial, patients treated with first-line ADAPT, SR only, or PCA were included. The primary outcome was successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b-3). Secondary outcomes included functional outcome (modified Rankin Scale score at 90 days) and intracranial hemorrhage. Statistical analysis was performed using mixed-effects logistic regression models.

Results: Of 222 patients treated with thrombectomy, 36 underwent ADAPT, 37 SR only, and 149 a PCA as first-line strategy. The median number of thrombectomy passes was 1 (IQR 1-2). Final successful reperfusion was achieved in 76.5% with first-line ADAPT, in 61.1% with first-line SR only, and in 82.4% with first-line PCA. First pass successful reperfusion was achieved in 44.4% with ADAPT, 59.5% with SR only, and 66.4% with PCA. PCA was associated with higher first pass reperfusion rates compared with ADAPT (aOR=2.37, 95% CI 1.13 to 5.05, P=0.024). There were no significant differences in functional outcomes or safety endpoints among the techniques. ADAPT resulted in numerically more favorable functional outcome. PCA resulted in numerically higher numbers of symptomatic intracranial hemorrhage.

Discussion and conclusion: Final successful reperfusion rate after PCA was higher than after SR only. Functional and safety outcomes were not significantly different. Further research is warranted, including individual patient data meta-analyses and data on novel aspiration devices not used in this trial.

Keywords: Device; Reperfusion; Stroke; Technique; Thrombectomy.

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Conflict of interest statement

Competing interests: VS-Z discloses speaker fees from Medtronic Inc. (money paid to institution). VS-Z is the recipient of research grants from Basel University, Basel, Switzerland, Bangerter-Rhyner-Foundation Basel, Basel, Switzerland, and Freiwillige Akademische Gesellschaft Basel, Basel, Switzerland. TD is a Consultant for MicroVention and Advisory Board Member for OM Pharma. SH is an Advisory Board Member for Medtronic Inc. JF is a Consultant for Acandis, Cerenovus, Medtronic USA, Inc., MicroVention Inc., Penumbra, Phenox, Roche, Stryker Corporation, TG Medical, and Tonbridge; is the Managing Director of Eppdata; and Stockholder of Eppdata, Tegus Medical, and Vastrax. JG discloses a Research Grant from Medtronic USA, Inc. (SWIFT-Direct trial), and is a Consultant for Medtronic. PM is a Consultant for Medtronic, MicroVention, Inc., Penumbra, and Stryker Corporation. JSK is a shareholder of Bonescreen GmbH. JK discloses Research Grants from Boehringer Ingelheim (TECNO trial), Swiss National Science Foundation (TECNO trial), and Siemens Healthcare (evaluation of perioperative Flat Panel Detector Imaging). JHB is a Consultant for Medtronic, MicroVention, Inc., and Stryker Corporation. JLS is a Consultant for Abbott Laboratories, Aeromics, Bayer, Biogen, Boehringer Ingelheim, BrainQ, BrainsGate, CSL Behring, Johnson & Johnson Health Care Systems Inc., Medtronic USA, Inc., Roche, and Stream Medical; DSMB member for MIVI Neuroscience and Occlutech; and stockholder of MindRhythm, Neuronics Medical, and Rapid Medical. EIP discloses Research Grants from Swiss National Science Foundation (SNF) and Bayer AG. VH discloses proctoring and consulting for Wallaby-Phenox. DS discloses unrestricted Educational Grant from Boehringer Ingelheim and is Consultant for AstraZeneca AB. MR is Consultant for AptaTargets, Cerenovus, Medtronic MiniMed, Inc., Philips, Stryker Corporation, and Vesalio; DSMB member for Sensome and Stockholder of Anaconda Biomed, Methinks, and Nora. UF discloses Research Grants from Medtronic (BEYOND SWIFT, SWIFT DIRECT), Penumbra, Phenox (DISTAL), Rapid Medical, Stryker, Swiss National Science Foundation, Swiss Heart Foundation and is PI of the ELAN Trial and Co-PI of DISTAL, TECNO, SWIFT DIRECT, SWITCH, ELAPSE, and ICARUS; is Consultant for AbbVie, AstraZeneca (former Alexion/Portola), Bayer, Biogen, Boehringer Ingelheim, CSL, and Siemens. He holds mandates for the Baasch Medicus Stiftungsrat (2000), Ellermann Stiftung, Fondation Adrian + Simone Frutiger (Stiftungsbeirat) and Gottfried + Julia Bangerter-Rhyner-Stiftung (Medizinischer Beirat); is President Elect of the European Stroke Organisation and Swiss Federation of Clinical Neuro-Societies, and President of the Swiss Neurological Society. MP discloses unrestricted grants from Swiss National Science Foundation (SNF), Bangerter-Rhyner Stiftung, Stryker Neurovascular Inc., Phenox GmbH, Medtronic Inc., Rapid Medical Inc., and Penumbra Inc. for the DISTAL trial, grant for SPINNERS trial from Siemens Healthineers AG (money paid to institution) and the following speaker fees: Stryker Neurovascular Inc., Medtronic Inc., Penumbra Inc., Acandis GmbH, Phenox GmbH, Rapid Medical Inc., and Siemens Healthineers AG (money paid to institution). NR, IF, DV, ACGMVE, MMG, DPOK, FVDB, AK, GMK, VA, and AB declare that they do not have any interest to disclose at this time.

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Impact of thrombectomy techniques on outcome in medium or distal vessel occlusion: subanalysis of the DISTAL Trial

Affiliations

Impact of thrombectomy techniques on outcome in medium or distal vessel occlusion: subanalysis of the DISTAL Trial

Authors

Affiliations

Abstract

Conflict of interest statement

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