Evaluating the Efficacy of Thrombectomy in Distal Vessel Occlusions: J Mocco, MD, MS

WATCH TIME: 4 minutes

“There are key components to each of the trials and things for us to pay attention to. This is not meant to criticize, but rather to make sure we're aware of the nuances of the trials and how it might inform our decision making right now.”

Researchers recently published findings of 2 prospective, randomized trials (ESCAPE-MeVO, NCT05151172; DISTAL; NCT05029414) that assessed thrombectomy in patients with medium and distal vessel occlusion stroke in The New England Journal of Medicine (NEJM). The procedure, which uses a specialized clot-removal device inserted through a catheter to restore blood flow in patients who experienced ischemic stroke, showed no added clinical benefit when compared with standard medical management in the trials. Presented as a late-breaker at the 2025 International Stroke Conference (ISC), held February 5-7, in Los Angeles, California, these findings are anticipated to spark considerable discussion among stroke specialists in the clinical community.^1,2

To further address these findings and their clinical implications, J. Mocco, MD, recently wrote an editorial for NEJM on the 2 trials. He highlighted that thrombectomy for large vessel occlusions has long been proven to be beneficial, and smaller strokes have seen increasing acceptance for thrombectomy. However, he noted that these new trials raise key questions, especially regarding patient selection. Mocco pointed out that the inclusion criteria for both trials differed from prior studies, enrolling older patients with higher baseline disabilities and milder deficits. Additionally, technical factors may have contributed to the lack of observed benefit. Ultimately, Mocco noted that these trials suggest that thrombectomy for distal vessel occlusions should no longer be assumed as a default treatment approach.³

During ISC 2025, Mocco, vice chair of the department of neurosurgery and director of the Cerebrovascular Center at Mount Sinai, sat down with NeurologyLive^® to discuss the evolving considerations around thrombectomy for distal vessel occlusions. In the conversation, Mocco emphasized the importance of observational studies and subgroup analyses in informing clinical decisions. He highlighted the need to carefully weigh factors such as the location and nature of the occlusion, as well as the patient’s overall clinical status, when considering thrombectomy for distal occlusions. Despite the lack of conclusive evidence, he noted that in certain high-risk or selected cases, the potential benefits might still justify thrombectomy. However, he cautioned about the risk of higher mortality and hemorrhage rates, suggesting that careful patient selection and a clear understanding of the risks involved are crucial when deciding whether to pursue this treatment approach.

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REFERENCES
1. 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.
2. Goyal M, Ospel JM, Ganesh A, et al. Endovascular Treatment of Stroke Due to Medium-Vessel Occlusion. NEJM. Published February 5, 2025.
3. 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