Where Endovascular Treatment Fails

Stick to LVO where you belong.

It’s International Stroke Conference 2025 – almost always accompanied by a spate of impactful research highlights.

The first two off the rack this year look at expanding the indications for endovascular treatment from its current evidence-based niche in large vessel occlusion. Let’s see how they did!

ESCAPE-MeVO:

DISTAL:

[sad trombone] for endovascular treatment, despite the eagerness of the sponsoring device manufacturers.

There are always quirks in the heterogeneous population enrolled in these trials, and these are no different – ESCAPE required favorable perfusion imaging, DISTAL included posterior cerebral artery occlusions, etc. but nothing grossly invalidating hewing to the superficial conclusion of futility. Unsurprising, after all, as the EVT use case is predicated on the failure of IVT in LVO – and these aren’t LVO.

The accompanying editorial is appropriately evenhanded, and concludes with a strongly worded statement regarding the lack of evidence for use of EVT in medium- and distal-vessel occlusion. This certainly goes against the grain of contemporary scope creep for these devices – encouraged in no small part by 1) manufacturers love to sell devices, 2) hospitals love the revenue they receive by performing these sorts of procedures. If only all the scope creep from thrombolysis were viewed similarly skeptically ….