Session report — SS8: Pushing the frontiers in endovascular treatment (ESO-ESMINT joint session)

The joint ESO–ESMINT scientific session on the opening evening of ESOC 2026 in Maastricht turned to the unresolved frontiers of endovascular stroke care. Chaired by Natalia Perez De La Ossa (Badalona, Spain) and Christian Taschner (Freiburg, Germany), the 90-minute programme worked outwards from the established core of large vessel occlusion thrombectomy to five areas where the evidence is still being built: extracranial carotid disease, medium and distal vessel occlusions, adjunctive intra-arterial thrombolysis, rescue stenting after failed reperfusion, and intravascular imaging.

EVT in isolated extracranial carotid artery occlusion

Christian Nolte (Berlin, Germany) opened the session with the case for endovascular treatment in patients with isolated cervical ICA occlusion — a scenario that affects a meaningful share of ischaemic stroke patients but has been largely excluded from the major thrombectomy trials. He emphasised that procedural complexity, and patient outcome, varies with the location of the occluded internal carotid artery segment. Drawing on observational data from several studies, including ETIICA and a post hoc analysis of the SELECT2 trial, his central message was that “one size does not fit all”: the benefit of EVT is more likely in occlusions of the C2–C6 segments rather than C1 (patients with a more likely embolic aetiology than atherosclerotic), in patients with a higher baseline NIHSS (a value of 15 has been proposed as a potential cutoff, a value above 15 being associated in the observational data with a favourable mRS shift). A persistent challenge remains in pinpointing the exact location of the occlusion on vascular imaging. Ongoing randomised trials such as ETICA, EVT-i ICAO and INTERNAL will give us more depth in understanding and finding the best solutions for this group of patients.

Who (if anyone) to treat in medium and distal vessel occlusion?

Marios Psychogios (Basel, Switzerland) addressed the post-DISTAL, post-ESCAPE-MeVO landscape, in which routine thrombectomy for medium vessel occlusions has not shown overall benefit. Even though recent guidelines limit the recommendations for treating patients with MeVO, Prof. Psychogios was certain that this debate is far from closed, and pointed to two new randomised trials: Oriental-MeVO, recently presented at ISC 2026, which showed improved outcomes in patients with medium vessel occlusion and moderate or high clinical severity treated with endovascular therapy; and DISTALS trial, evaluating Tigertriever 13, a stent retriever specifically designed  for distal vessel occlusion.

He then revisited the DISTAL data and identified subgroups of patients who might still benefit from thrombectomy — those with NIHSS >9 or with a larger perfusion deficit. He further pointed to limitations of the study, such as substantial heterogeneity in centre experience translating into heterogeneity in procedural outcomes, older-generation devices that weer used during the recruitment period. He also suggested that the trials might have been overly restrictive in their selection — a “reverse cherry-picking” phenomenon that may have biased the results. Other concerns he raised included overly complex inclusion criteria based on vessel occlusion definitions, potentially under-reported ICAD cases and slow time to randomisation.

His message to the audience was that the road towards routine thrombectomy in patients with medium and distal vessel occlusion is a difficult one, but that the field should keep faith that we will reach this point in the future. Until there are new data from ongoing RCT, we should still take into consideration treating patients with MDVO, if they are better selected and if the community is adapting its technique and uses newer devices.

Intra-arterial thrombolysis post successful reperfusion

Georgios Tsivgoulis (Athens, Greece) offered a comprehensive and up-to-date review of the data on adjunctive intra-arterial thrombolysis after successful endovascular reperfusion, weighing the positive signals from RCTs such as CHOICE, ANGEL-TNK and PEARL against the neutral primary results of POST-TNK and POST-UK. The rationale across these studies is that thrombolysis might address the “no-reflow” phenomenon observed in roughly a quarter of patients despite successful recanalization. He presented the key results of all RCTs published to date, including CHOICE-2 (2026), summarising the positive findings across the field.

He then turned to meta-analyses of the available RCTs, which show that intra-arterial thrombolysis is overall associated with reduced disability, a higher chance of an excellent functional outcome and a favourable mRS shift. The findings were most consistent in the meta-analysis that excluded Urokinase studies and demonstrated a clear benefit for anterior circulation stroke when intra-arterial Alteplase was used at the consistent dose of 0.225 mg/kg — one quarter of the standard intravenous dose. The benefit from intra-arterial Tenecteplase was less consistent, owing to dose heterogeneity across trials (one quarter or one half of the i.v. dose), but still, pooled analysis show improved functional outcomes. No clear benefit has been demonstrated in posterior circulation stroke, where the data remain limited and underpowered. These findings support the concept that targeting microcirculatory reperfusion — the “no-reflow” phenomenon — is a key determinant of clinical recovery beyond large-vessel recanalization.

When thrombectomy fails: acute intracranial stenting as a bail-out strategy

Marc Ribo (Barcelona, Spain) addressed a current hot topic: the role of acute intracranial stenting as a bail-out strategy when recanalization is not achieved after multiple thrombectomy passes. The impact of the first-pass effect on outcome is well established, and any level of recanalization is better than none, so the goal should always be to push for the highest possible reperfusion. Data from the RESISTANT International Registry show a steady increase in the number of patients treated with acute intracranial stenting over recent years.

Based on observational data, a higher number of passes before stenting is associated with worse outcomes. He argued that we should identify as early as possible which patients ought to be stented from the first passes, with a proposed cut-off of 3 retrieval attempts. He also encouraged the development and use of prediction models to identify patients unlikely to recanalize with routine techniques.

In closing, Ribo proposed a staged approach to achieving complete or near-complete recanalization (mTICI 2C/3): up to three passes of conventional thrombectomy, followed, if needed, by staged rescue treatment, consisting in intravenous or intra-arterial agents (a potential impactful proposed technique is SAIL – stent retriever assisted lysis with Tirofiban), then angioplasty, and finally stenting. RCT data to define the optimal approach are still awaited; until then, individual clinical judgement should guide decision-making.

Optical coherence tomography in acute ischaemic stroke

The session closed with a forward-looking talk from Vania Anagnostakou (Worcester, United States) on intravascular optical coherence tomography in the neurointerventional field. Originally developed for interventional cardiology, the technique is now being translated to the neurovascular field. This imaging modality uses near-infrared light to generate high-resolution images by measuring depth-resolved reflections and can visualise tissue microstructure and composition. A dedicated neurovascular OCT probe has been designed and can be delivered intravascularly through a microcatheter, making it very easy to use.

The technique offers micron-resolution imaging (down to 10 microns) of thrombus composition, underlying intracranial atherosclerosis, vasospasm, dissection flaps, post-thrombectomy vessel injury and stent placement. In large vessel occlusion strokes, it can help identify the length and type of clot (red or white) and thus helping in planning the thrombectomy procedure. She closed with a clear message that OCT can play an increasingly important role in the future management of patients with neurovascular disease.