Rescue Stenting versus Medical Management for Failed Mechanical Thrombectomy in Acute Posterior Circulation Ischemic Stroke: A Systematic Review and Meta-analysis

Background: Recent evidence supports the efficacy of mechanical thrombectomy (MT) in recanalizing posterior circulation ischemic strokes. Nonetheless, a significant proportion of cases still requires adjunctive therapies, such as rescue stenting (RS), to achieve optimal recanalization. This study evaluates the efficacy and safety of RS for failed MT in such cases. Methods: A systematic literature review was conducted across PubMed, Cochrane, Scopus, Web of Science and OVID databases from inception to July 2025. A random effects meta-analysis was employed to calculate odds ratios and compare outcomes between patients receiving RS and those managed medically (MM) following unsuccessful MT. Included outcomes were: 0-day modified Rankin Scale scores (mRS 0-2 and mRS 0-3), 90-day mortality, and symptomatic intracranial hemorrhage within 48 hours. Additionally, a meta-analysis of proportions assessed successful reperfusion rates (modified Thrombolysis in Cerebral Infarction 2b–3) within the RS arm. The certainty of evidence was evaluated utilizing the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Results: Six studies including 1.206 patients (747 RS, 459 MM) were analyzed. RS resulted in lower levels of functional disability at 90 days, demonstrated by higher rates of functional independence (mRS 0-2: 46% versus 23%; OR: 2.57; CI: 1.37-4.82; very-low-certainty evidence) and favorable clinical outcomes (mRS 0-3: 46% versus 23%; OR: 2.78; CI: 1.75, 4.40; very-low-certainty evidence). Additionally, there was a high rate of successful reperfusion (95%; CI: 85%–99%; very-low-certainty evidence). RS also resulted in lower mortality rates (35.1% vs. 60.7%; OR: 0.47; CI: 0.32–0.69; very-low-certainty evidence) and did not increase the incidence of sICH (5.14% vs. 8.13%; OR: 0.62; CI: 0.26–1.48; very-low-certainty evidence), compared to the MM group. Conclusion: RS appears to be an effective and safe manoeuvre following unsuccessful MT. However, these findings should be interpreted with caution given the limited quality of available evidence. Further randomized trials are necessary.