Masterclass #3: Distal and more distal thrombectomies: is the game worth the candle?

René CHAPOT, Mayank GOYAL, Jacques MORET, Laurent SPELLE

The success of mechanical thrombectomy tempts us to move distally, pushing the limits of our evidence-based decision making, but can we?

• Are the indications for thrombectomy the same when the clot is more distal?
• In distal clots, is intravenous thrombolysis more effective and thrombectomy potentially more dangerous because vessels are smaller?
• Do we have evidenced-based rules we can apply in these situations, a clear understanding that allows us to balance the risk, safety and benefits of more distal thrombectomies?

Join Professors Jacques Moret, Laurent Spelle and their expert panel as they explore the limits of our clinical knowledge, experience and skills concerning the question of distal thrombectomies:

• Are the clinical signs for medium and large vessel occlusions the same?
• Would a distal occlusion in the dominant hemisphere affect your decision making?
• What are the limitations of the NIHSS scale?

Discover the LAST Scale – the LAnguage Screening Test – a simple tool that can assist in decision making for revascularization, thrombolysis and thrombectomy? See how this might be useful in increasing our knowledge and treatment of more distal thrombectomies.

In distal vessel thrombectomies:

• Does it make a difference if the clot is in the superior or inferior division of the MCA?
• How do we distinguish clinically between a so-called lacuna infarct of a perforating artery and an ischemic stroke due to a distal arterial occlusion?

• Would you use conscious sedation, general anesthesia…or nothing at all? What issues exist concerning the standardization of general anesthesia?
• Would you use a stentriever, distal aspiration or both? Do you need a balloon guiding catheter?
• Is the size of the stentriever a real concern? Are we using devices in the M2 and M3 that were originally created for the M1?
• What is the role of cerebral protection and lysis and how will trials like ESCAPE-NA-1 impact our ability and willingness to perform distal thrombectomies?

What is involved in the design of clinical trials to study the efficacy and safety of distal MT?

• Can we randomize our patients before choosing a strategy or after the first pass, when the clot is seen to be more distal? 

Our panel asks, “Should we hesitate?, “Should we remain humble?” when considering distal thrombectomies – join us as we explore possible answers in these specially selected cases…