Session Report: Improving thrombectomy beyond recanalization times: complications, hurdles and solutions – joint with ESMINT

The joint ESO-ESMINT session focused on addressing the current challenges in the field of stroke endovascular treatment and brought forward valuable insights.

Professor Jens Fiehler highlighted the hurdles and limitations in the process of approving new devices for neurointerventions. Since the first documented thrombectomy in 2008, advancements in skill have enabled expanded indications for treatment and improved patient outcomes. When selecting the optimal technical approach, multiple variables must be considered (e.g., anatomical factors, use of a balloon guide catheter, or aspiration pump). Additionally, procedural success is influenced by the treating physician’s experience and preferred technique. As a result, the integration of new devices or techniques into routine practice is inherently complex. Theoretically, demonstrating a 6% improvement in treatment outcomes with a new device would require enrolling approximately 1,500–1,700 participants, which is not feasible. In-silico modeling may offer a viable alternative to evaluate new devices and establish their safety and efficacy.

Dr. Helena I. De Sousa Guerreiro discussed various complications associated with rescue stenting. Mechanical thrombectomy fails in about 20% of cases, with underlying intracranial atherosclerotic disease (ICAD) observed in 5–10% of these. Among ICAD cases, re-occlusion rates are high—occurring in 36% of cases intraprocedurally and approximately 50% postprocedurally. Recent publications have demonstrated the benefits of rescue stenting, mainly due to improved recanalization rates. However, rescue stenting carries risks such as symptomatic intracranial hemorrhage (up to 17%, often due to vessel perforation), re-occlusion, in-stent restenosis, stent deployment failure, distal embolization, and vessel dissection. Recommended strategies to mitigate these complications include early implementation of rescue stenting, appropriate antiplatelet management, careful patient selection, technical optimization, and comprehensive post-treatment care—including blood pressure control and drug resistance testing.

Dr. Julien Allard focused his presentation on optimizing antiplatelet therapy. Through a comprehensive review of available antiplatelet agents and their mechanisms of action, he provided guidance on selecting the most appropriate medication tailored to individual patient needs. He also introduced their institution’s local protocol for antiplatelet management. Key considerations in choosing the right medication include the route of administration, pharmacodynamics, hemorrhagic risk assessment, and platelet function restoration.

Dr. Anne Christine Januel addressed the current challenges in improving access to stroke care across Europe. Ideally, patients would receive treatment directly at a comprehensive stroke center by an experienced team. In practice, however, no single model fits all contexts. Consequently, various approaches have been implemented to enhance timely access to care, including “drip and ship,” “drive/fly a doctor,” “direct to angio,” and the use of AI tools to accelerate in-hospital workflows. Dr. Januel presented examples of infrastructure improvements following the implementation of these models. Scientific societies play a critical role in supporting such efforts by providing regulatory guidance and education. In this regard, ongoing ESMINT initiatives include skills courses, internships at high-volume centers, e-fellowships, and remote proctorships.

Continuing the theme, Dr. Violoza Inoa concluded the session with an overview of the success and feedback from fellowship programs and educational courses for physicians from low- and middle-income countries. Participants reported a significant positive impact on their clinical practice, including increased confidence in thrombectomy techniques, improved patient selection and treatment indication, and a subsequent rise in the number of procedures performed independently. Dr. Inoa emphasized the importance of sustained efforts to enhance stroke care infrastructure through tailored educational programs and ongoing local support.