Risk of mechanical thrombectomy recanalization failure: intraoperative nuances and the role of intracranial atherosclerotic disease

Abstract Objective To present intraoperative observations that when recognized may facilitate the identification of patients at high risk of MT recanalization failure. We illustrate 4 cases of successful recanalization via rescue treatment with balloon angioplasty and/or stenting when such observations were noted. We also discuss the role of intracranial atherosclerotic disease in recanalization failure. Patients and Methods We conducted a retrospective review of a prospectively maintained database for 450 stroke patients and identified 122 patients who underwent MT that failed to achieve recanalization. Operative notes were reviewed, and intraoperative nuances were discussed amongst neurointerventionalists. Results Intraoperative observations that may suggest a high risk of MT recanalization failure include resistance to microwire advancement, significant resistance to microcatheter advancement, temporary antegrade flow upon stent retriever (SR) deployment, temporary retrograde flow upon SR deployment with simultaneous aspiration, restricted SR expansion (“pinched device”), moderate resistance to total impedance of SR removal causing vessel/SR stretch on angiographic roadmap, and minimal recanalization after ≥ 3 device passes. Conclusion Intraoperative observations may facilitate early recognition of patients at high risk of MT recanalization failure. We suggest considering rescue treatment when such observations are noted to avoid prolonged procedure times, futile reperfusion, and reocclusion post-MT. Intracranial balloon angioplasty and/or stenting may be a safe and effective treatment in this patient subgroup. Stent placement may be considered depending on the patient’s antiplatelet status, angioplasty success, and concern for intracranial hemorrhage. Further studies amongst larger patient cohorts are needed.