Nuances in Thrombectomy Techniques and Anesthesia Use for Stroke: J Mocco, MD, MS

WATCH TIME: 3 minutes

“Number one, physicians need to really understand this data and its nuances because it influences their decision-making. And number two, I think this is a bit of a call to arms for our community to ensure that we are committed to performing high-quality trials where we don’t allow our implicit bias to potentially skew the results.”

Thrombectomy has become a cornerstone in the treatment of acute ischemic stroke, particularly for large vessel occlusions, where it has demonstrated significant improvements in clinical outcomes. However, medium and distal vessel occlusions have traditionally been excluded from many thrombectomy protocols because of challenges such as more tortuous access routes, thinner arterial walls, and smaller volumes of at-risk tissue.¹ These factors have raised concerns about the risk of complications and the potential limited benefit of reperfusion in these regions. Nevertheless, there is growing interest in exploring whether thrombectomy could be extended to medium and distal vessels for carefully selected patients.

Presented at the 2025 International Stroke Conference (ISC), held February 5-7, in Los Angeles, California, 2 recent clinical trials (ESCAPE-MeVO, NCT05151172; DISTAL; NCT05029414) showed that treatment with thrombectomy for medium and distal vessel occlusion stroke had no additional clinical benefit compared with standard care.^2,3 A related editorial published in The New England Journal of Medicine, by J. Mocco, MD, MS, further examined the clinical implications of these trials. While Mocco acknowledged the benefits of thrombectomy for large vessel occlusions, he raised concerns about the trials, such as technical factors could have influenced the findings and concluded that thrombectomy for distal vessel occlusions should no longer be viewed as a default treatment.⁴

Following the publication of the editorial, Mocco, vice chair of the department of neurosurgery and director of the Cerebrovascular Center at Mount Sinai, sat down for an interview with NeurologyLive^® to discuss key aspects of the recent trials. He highlighted the potential impact of anesthesia choices on clinical outcomes, particularly in older patients. Mocco also talked about the implications of predominantly using stent retrievers in thrombectomy procedures, suggesting that although this technique is widely adopted, it may limit understanding of other approaches. He called for improvements in clinical trial design to minimize bias and enhance the generalizability of thrombectomy outcomes, emphasizing the importance of rigorous methodologies to ensure that results are applicable across diverse patient populations.

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REFERENCES
1. Saver JL, Chapot R, Agid R, et al. Thrombectomy for Distal, Medium Vessel Occlusions: A Consensus Statement on Present Knowledge and Promising Directions [published correction appears in Stroke. 2020 Oct;51(10):e296. doi: 10.1161/STR.0000000000000349.]. Stroke. 2020;51(9):2872-2884. doi:10.1161/STROKEAHA.120.028956
2. Goyal M, et al. Endovascular treatment to improve outcomes for medium vessel occlusions: The ESCAPE-MeVO trial. Presented at: ISC 2025; February 5-7; Los Angeles, CA. LB4.
3. Goyal M, Ospel JM, Ganesh A, et al. Endovascular Treatment of Stroke Due to Medium-Vessel Occlusion. N Engl J Med. Published online February 5, 2025. doi:10.1056/NEJMoa2411668
4. HEADS UP Re: NEJM Editorial About 2 New Randomized Trials Evaluating Mechanical Removal of Certain Clot-Related Strokes. Mount Sinai Health System. News Release. Published February 8, 2025. Accessed February 10, 2025. https://www.newswise.com/articles/heads-up-re-nejm-editorial-about-2-new-randomized-trials-evaluating-mechanical-removal-of-certain-clot-related-strokes