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Thrombectomy for Distal, Medium Vessel Occlusions a Consensus Statement on Present Knowledge and Promising Directions

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Thrombectomy for Distal, Medium Vessel Occlusions a Consensus Statement on Present Knowledge and Promising Directions Stroke SPECIAL REPORT Thrombectomy for Distal, Medium Vessel Occlusions A Consensus Statement on Present Knowledge and Promising Directions Jeffrey L. Saver, MD; Rene Chapot, MD; Ronit Agid, MD; Ameer Hassan, DO; Ashutosh P. Jadhav, MD; David S. Liebeskind, MD; Kyriakos Lobotesis, MD; Dan Meila , MD; Lukas Meyer, MD; Guy Raphaeli, MD; Rishi Gupta, MD; for the Distal Thrombectomy Summit Group*† ndovascular thrombectomy (EVT) is well established and thromboaspiration devices suggest EVT for DMVOs as a highly effective treatment for acute ischemic is safe, technically efficacious, and potentially clinically Estroke (AIS) due to proximal, large vessel occlusions beneficial. Collaborative investigations are desirable to (PLVOs). With iterative further advances in catheter tech- enhance imaging recognition of DMVOs; advance device nology, distal, medium vessel occlusions (DMVOs) are now design and technical efficacy; conduct large registry stud- emerging as a promising next potential EVT frontier. This ies using harmonized, common data elements; and com- consensus statement integrates recent epidemiological, plete formal randomized trials, improving treatment of this anatomic, clinical, imaging, and therapeutic research on frequent mechanism of stroke. DMVO-AIS and provides a framework for further studies. Rapid EVT to restore cerebral perfusion is now the DMVOs cause 25% to 40% of AISs, arising as primary cornerstone of treatment for AIS due to PLVOs. Multiple Downloaded from http://ahajournals.org by on August 7, 2020 thromboemboli and as unintended consequences of EVT randomized trials demonstrated dramatically improved performed for PLVOs, including emboli to new territories patient outcomes with EVT among broadly selected (ENTs) and emboli to distal territories (EDTs) within the patients within the first 6 hours and imaging-selected initially compromised arterial field. The 6 distal medium patients 6 to 24 hours after last known well. With PLVOs arterial arbors (anterior cerebral artery [ACA], M2–M4 well established as a treatment target, DMVOs have middle cerebral artery [MCA], posterior cerebral artery emerged as a promising next potential frontier for EVT, [PCA], posterior inferior cerebellar artery [PICA], anterior for several reasons. First, the overwhelming benefit mag- inferior cerebellar artery [AICA], and superior cerebellar nitude of EVT for PLVOs suggests thrombectomy would artery [SCA]) typically have 25 anatomic segments and also be beneficial for DMVOs. Second, the advent of EVT give rise to 34 distinct branch arterial segments nourish- as a standard PLVO therapy has triggered rapid, iterative ing highly differentiated, largely superficial cerebral neu- advances in endovascular retriever and aspiration tech- roanatomical regions. DMVOs produce clinical syndromes nology, leading to more navigable and smaller devices that are highly heterogenous but frequently disabling. able to reach more distal, narrower vessels. Third, a recog- While intravenous fibrinolytics are more effective for dis- nized unintended event during EVT for PLVO is thrombus tal than proximal occlusions, they fail to recanalize one- fragmentation and escape from retrieval devices, lead- half to two-thirds of DMVOs. Early clinical series using ing to emboli in distal arteries. For EVT of PLVO-AIS to recently available, smaller, more navigable stent retriever achieve maximal benefits, effective rescue endovascular Key Words: animals ◼ brain ischemia ◼ dogs ◼ embolism ◼ Hong Kong Correspondence to: Jeffrey L. Saver, MD, Department of Neurology, Geffen School of Medicine at UCLA, 710 Westwood Plaza, Los Angeles, CA 90095. Email [email protected] This manuscript was sent to Kazunori Toyoda, Guest Editor, for review by expert referees, editorial decision, and final disposition. *A list of Distal Thrombectomy Summit Group collaborators is given in the Appendix. †Institutions of Distal Thrombectomy Summit Group collaborators are listed in Table I in the Data Supplement. The Data Supplement is available with this article at https://www.ahajournals.org/doi/suppl/10.1161/STROKEAHA.120.028956. For Sources of Funding and Disclosures, see page XXX. © 2020 American Heart Association, Inc. Stroke is available at www.ahajournals.org/journal/str Stroke. 2020;51:00–00. DOI: 10.1161/STROKEAHA.120.028956 September 2020 1 Saver et al Distal, Medium Vessel Occlusions therapy for DMVOs arising from initial thrombus manipu- surface pial arteries (typical pial artery diameter, 0.2–0.7 lation is desirable. mm).6,7 Squarely in the medium vessel category are the This consensus statement integrates recent research M3 MCA arteries (typical diameters at origin, 1.1–1.5 2,8 eport on DMVO stroke epidemiology, imaging, medical and mm), M4 MCA, A2 to A5 ACA, and P2 to P5 PCA. R endovascular therapy, and clinical trial design with clas- Since distance tortuosity and size are each important sic understanding of the distal cerebral vasculature and aspects, the Summit group recommended adopting a pecial S its ischemic syndromes, to provide a statement of cur- general label that captures both—DMVOs. Where appro- rent understanding of the opportunities and limitations priate, the use of labels using either of the distinctive of EVT for DMVOs. Promising research directions and anatomic features alone was also endorsed: distal vessel steps to promote collaborative, systematic investigation occlusions (DVOs) or medium vessel occlusions (MVOs) are delineated. (contrasted with proximal vessel occlusions [PVOs] or large vessel occlusions [LVOs], respectively). It is important to note these 2 anatomic features may KEY DISTINCTIVE FEATURES AND occur in a dissociated manner. For example, in a patient GENERAL TERMINOLOGY with a duplicate MCA stem, the M1 MCA segment may be proximal but medium in diameter (and an occlusion Two key distinctive anatomic features of distal, medium would be a proximal, medium vessel occlusion [PMVO]). cerebral arteries profoundly affect endovascular proce- Conversely, in a patient with an azygous ACA, the A2 seg- dure conduct and endovascular device design: (1) vessel ment may be distal but large in diameter (and an occlu- distance/tortuosity and (2) vessel size. sion would be a distal, large vessel occlusion [DLVO]). Similarly, in a patient with a dominant M2 MCA division, Vessel Distance/Tortuosity an occlusion in the initial segment of the artery, exceed- ing 2 mm diameter, would be a DLVO. The distal cerebral arteries are distinguished by longer dis- There is wide agreement in the literature that the proxi- tances and more tortuous cumulative travel pathways from mal, large artery category includes the intracranial ICA, M1 the arterial puncture site. Distal arteries have ≥1 additional MCA segment, intracranial vertebral arteries, and basilar branch steps than proximal arteries and also loop around artery. Similarly, a general consensus recognizes the distal, neuroanatomic structures such as the corpus callosum middle artery category as including the M3 and M4 MCA Downloaded from http://ahajournals.org by on August 7, 2020 (ACA), insula and temporal lobe (MCA), and temporal and segments, A2 to A5 ACA segments, P2 to P5 PCA seg- occipital lobe (PCA). This tortuosity increases the difficulty ments, and PICA, AICA, and SCAs. However, categorization of successful navigation to target occlusions and con- of M2 MCA, A1 ACA, and P1 PCA has varied.9 Positioning strains the physical forces deliverable by a retrieval device of the M2 MCA within any classification system is particu- separated from its manipulable end by multiple turns.1,2 larly challenging, as M2 MCA angioarchitecture is highly heterogenous across patients. M2 MCA branch patterns Vessel Size include bifurcation, trifurcation, tetrafurcation, and cande- labra8,10; M2 MCA vessel segments range in size from 1.1 The intermediate-size cerebral arterial tree is bounded to 2.1 mm in diameter11; M2 MCA occlusions may occur in by 2 vessel size ranges with well-established rubrics in dominant segments that are similar to M1 in size (though the neurovascular literature. Above are the wide proximal still more distal and branched/tortuous to reach) or in non- intracranial arteries that, when obstructed, carry the label dominant segments that are similar to M3 and other much of “large vessel occlusions.” Below are the narrow pene- small arteries in size.12 Accordingly, it seems ill advised to trating arteries that, when stenotic or occluded, carry the advance a fixed, inflexible naming system that places all label of “small vessel” disease in the classic neurovascu- segments of all M2 MCAs in all patients in one or another lar literature. Accordingly, small vessel occlusions [SVOs] category. It is preferable to use the particular size and dis- are those occurring within penetrating arteries, currently talness of the involved M2 MCA segment to drive clas- far too small for endovascular targeting. Consequently, sification in an evidence-based, case-specific manner, and the intermediate, “medium vessels” can be operation- that is the approach here proposed. ally defined as cerebral arteries with lumen diameters A proposal has been advanced to resolve the mild between 0.75 and 2.0 mm. The upper 2.0-mm thresh- approach differences between investigative groups when old places into the large vessel category the intracranial demarcating proximal large vessels versus distal medium internal carotid artery (ICA; typical diameter, 3.8 mm), vessels by conflating the two into a single category, the M1 segment of the MCA (2.7
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