Stent retriever-assisted intra-arterial lysis for distal vessel occlusions: a feasible pharmacomechanical rescue strategy
Judith Cendrero, Manuel Requena, Marc Rodrigo-Gisbert, Francesco Diana, Magda Jabłońska, Marta de Dios Lascuevas, Alejandro Tomasello, David Hernandez, Mayank Goyal, Cristina Márquez González, Jiahui Li, Marc RiboIntroduction
The optimal endovascular treatment strategy for medium and distal vessel occlusions remains undefined given the anatomical challenges of distal vessels. Stent retriever-assisted intra-arterial lysis (SAIL) is a pharmacomechanical technique designed to facilitate clot dissolution while minimizing mechanical stress on fragile distal vessels.
Methods
We performed a retrospective single-center analysis of consecutive patients with acute ischemic stroke due to distal vessel occlusions treated with SAIL between November 2022 and January 2026. Distal occlusions included M2–M3, A2–A3, and P1–P2 segments, and were classified as primary or secondary. SAIL consisted of temporary stent retriever deployment across the thrombus to restore flow, followed by intra-arterial tirofiban infusion through a distal access catheter and subsequent device resheathing. Primary outcomes were feasibility and safety; secondary outcomes included angiographic reperfusion and clinical outcomes.
Results
24 patients were included (mean age 74±14.6 years; median baseline National Institutes of Health Stroke Scale (NIHSS) 16). Most occlusions involved the middle cerebral artery territory (79.2%). SAIL was predominantly used after unsuccessful mechanical thrombectomy (70.8%), with a median of two prior device passes. Successful reperfusion (modified Thrombolysis In Cerebral Infarction (mTICI) ≥2b) was achieved in 87.5% of patients, including near-complete or complete reperfusion (mTICI 2c–3) in 62.5%. Any intracranial hemorrhage occurred in 25.0% of patients and symptomatic intracranial hemorrhage in 4.2%. At 90 days, functional independence (modified Rankin Scale 0–2) was observed in 6 of 12 patients (50%) with available follow-up.
Conclusions
SAIL was feasible and achieved high reperfusion rates with a low rate of symptomatic intracranial hemorrhage despite frequent use as rescue therapy after failed thrombectomy. These findings support further evaluation of pharmacomechanical strategies for distal vessel occlusions.