Response Letter to Senta Frol et al. regarding our paper,“Rescue therapy after failed thrombectomy in medium/distal vessel occlusions: A retrospective analysis of an international,multi-center registry”

We thank Senta Frol et al. for their thoughtful letter regarding our paper, “Rescue therapy after failed thrombectomy in medium/distal vessel occlusions: A retrospective analysis of an international, multi-center registry.” ¹ The letter is well-written and raises several important points. However, we would like to address some of the concerns raised and clarify certain aspects to improve the overall discussion.

Our first main point of concern relates to the statement that “rescue stenting offers higher recanalization rates than MT.” The cited recanalization rates of 84% in our study should not be directly compared with those from the DISTAL ² or ESCAPE-MeVO ³ trials. It is important to note that retrospective studies, such as ours, often report higher rates of recanalization compared to randomized controlled trials (RCTs). These differences should be considered when interpreting the results and making comparisons.

We also wish to address that, the letter states that RCTs on distal thrombectomy reported functional independence rates of 35%–43%. This is incorrect. The cited rates actually represent excellent functional outcomes, while functional independence rates in both the DISTAL and ESCAPE-MeVO trials were well above 50% for all groups. We believe this clarification is crucial for a more accurate comparison.

Another important point refers to the statement in the letter, “there is no evidence supporting MT’s benefit for MDVO, raising questions about the potential of rescue stenting as an alternative.” This statement is somewhat misleading. Rescue stenting should not be framed as an “alternative” to thrombectomy, but rather as an escalation strategy when initial thrombectomy attempts fail. The distinction between an escalation strategy and an alternative approach is crucial for accurate interpretation of the role of rescue stenting. We would like to clarify this point to avoid any misinterpretation and ensure that rescue stenting is viewed as a supplementary intervention, rather than a replacement for thrombectomy in the management of MDVO.

Additionally, the letter asserts that no RCT has been performed on rescue stenting in large vessel occlusions (LVOs). This is not completely accurate. The ANGEL-REBOOT ⁴ trial has reported results involving rescue stenting. While most patients in this trial were treated with balloon angioplasty, the study also included 62 cases of rescue stenting. The trial found no significant impact of rescue stenting on functional outcomes or recanalization rates, with the results being neutral. This is an important point to consider when discussing the evidence surrounding rescue stenting.

Finally, while the authors suggest that anti-GPIIb/IIIa Inhibitor medication may have contributed to the high (10%) sICH rate observed in their study, it is important to acknowledge that distal thrombectomies may carry a higher risk of sICH. Also important to state is that, the ANGEL-REBOOT study, where all patients received anti-GPIIb/IIIa Inhibitor, did not report a higher rate of sICH.