Endovascular Thrombectomy Found Ineffective for Distal Vessel Ischemic Stroke

Recent findings from three randomized trials presented at the International Stroke Conference (ISC) 2025 in Los Angeles have shown that endovascular thrombectomy does not offer any significant benefit to patients with acute ischemic stroke caused by occlusions in distal vessels. This contrasts with its established effectiveness in treating large vessel occlusions.

Key Study Findings

The trials, titled DISTAL, ESCAPE-MeVO, and DISCOUNT, included a total of 1,573 patients. While endovascular thrombectomy has been a promising treatment for strokes involving larger arteries, these studies demonstrate no additional benefits when applied to smaller, more distal blood vessels.

DISTAL Trial

The DISTAL study included 543 participants, mainly older adults with isolated occlusions in medium to distal vessels. Patients were randomly assigned to receive either endovascular therapy or best medical treatment. After 90 days, there was no statistical difference in the level of disability between the two groups. The modified Rankin scale score, a common measure for neurological recovery, showed no significant improvement in the endovascular therapy group.

ESCAPE-MeVO Trial

The ESCAPE-MeVO study involved 530 patients presenting with medium-vessel occlusions. Results indicated that a favorable outcome at 90 days, defined as a modified Rankin scale score of 0 or 1, was similar between the endovascular therapy and control groups. Mortality rates were slightly higher in the endovascular group, although this difference did not reach statistical significance.

DISCOUNT Trial

The DISCOUNT trial, which was halted early, found a worse outcome for patients receiving endovascular therapy. Preliminary results suggested a harmful effect, with a lower rate of good clinical outcomes in the intervention group compared to those receiving standard care.

Expert Opinions

Senior investigators from the DISTAL trial, Dr. Urs Fischer, highlighted that while the endovascular treatment did not cause significant harm, there are still unmet needs in treating distal occlusions. Dr. Marios Psychogios echoed these sentiments, emphasizing the importance of identifying potential subgroups that might benefit from the treatment.

Dr. Mayank Goyal, lead of the ESCAPE trial, expressed caution regarding the application of endovascular therapy in patients with distal occlusions, especially due to the DISCOUNT trial’s indication of possible harm.

Dr. Michael Hill, co-investigator in the ESCAPE trial, suggested focusing future research on patient subgroups and improving reperfusion rates—which he believes could enhance treatment outcomes.

Future Directions

The trial investigators are planning to merge and analyze the data from the three studies to better understand subgroups that might benefit from endovascular therapy. A fourth trial, underway in China, will provide additional data on the subject.

Dr. J Mocco from Icahn School of Medicine emphasized that these trials represent the current state of evidence for endovascular thrombectomy in distal occlusions. He advised against assuming endovascular therapy as the default approach for such cases.

Funding and Disclosures

The DISTAL trial was funded by the Swiss National Science Foundation, Medtronic, Stryker Neurovascular, Phenox, Rapid Medical, and Penumbra. The ESCAPE-MeVO trial received support from the Canadian Institutes for Health Research and Medtronic. The DISCOUNT trial was funded by the French Ministry of Health with devices supplied by Stryker, Phenox, Penumbra, Balt, AB Medica, MiVi, and Cerenovus.

Several investigators reported receiving grants, speaker fees, and consulting fees from various device manufacturers, including Medtronic, Stryker, Phenox, Penumbra, Rapid Medical, and Acandis.

Conclusion

While endovascular thrombectomy remains a cornerstone in treating large vessel ischemic strokes, these new studies indicate that it does not offer additional benefits for patients with distal vessel occlusions. Researchers and clinicians must remain vigilant and explore new strategies for improving outcomes in this challenging patient population.

We invite our readers to share their thoughts on these findings and any experiences related to stroke treatment. Your comments can help us better understand the impact of these studies on patient care.

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