Optimizing Thrombectomy Strategies for Acute Ischemic Stroke Outcomes

In large‐vessel acute ischemic stroke, rapid and complete reperfusion with the fewest thrombectomy passes is strongly associated with improved outcomes. However, the optimal response to an unsuccessful first pass and the role of structured workflow optimization remain areas of investigation. Recent multicenter studies have evaluated whether adapting endovascular strategies after initial failure or refining in‐hospital processes can enhance recanalization success and clinical recovery. We summarize three such reports: two assessing technique switching and one examining workflow training. A narrative review of three multicenter studies was performed, including two retrospective registry cohorts and one pre‐post interventional trial. The “technique‐switch” analyses (Samaha et al., SVIN registry; Matsukawa et al., JNIS) compared outcomes when operators adopted an alternative retrieval method versus repeating the same approach after a failed initial thrombectomy pass. The “workflow training” study (Fugelli et al., Interv Neuroradiol) evaluated the impact of a multidisciplinary in‐hospital simulation program on procedural time metrics and outcomes in patients undergoing thrombectomy. Key angiographic, procedural, and clinical endpoints were extracted and compared. Technique switching ‐ Samaha et al. In a registry of 2,893 thrombectomies, 1,420 required ≥2 passes. For middle cerebral artery occlusions, switching from a combined stent retriever plus aspiration technique to an alternative method on the second attempt significantly improved reperfusion (adjusted OR for TICI 2c/3: 2.08, 95% CI 1.18‐3.67). Among patients with ≥2 failed attempts, aspiration alone ultimately achieved higher complete reperfusion than persistent stent‐retriever use (aOR 1.65, 95% CI 1.09‐2.51). Early adaptation of retrieval strategy improved second‐pass success without additional safety concerns. Technique switching ‐ Matsukawa et al. In an international cohort of 2,167 thrombectomies, changing technique after a failed first pass improved odds of successful reperfusion (TICI ≥2B) (aOR ∼1.5) and good 90‐day outcome (mRS 0‐2; aOR ∼1.6) compared with repeating the same modality. In a matched subset (n=490), technique conversion again increased second‐pass reperfusion (aOR 1.32) and good outcome (aOR 1.38). No increase in symptomatic intracranial hemorrhage was observed. Workflow optimization ‐ Fugelli et al. Among 244 thrombectomy patients (55 pre‐ and 189 post‐intervention), implementation of a multidisciplinary simulation program reduced groin puncture‐to‐reperfusion time from 76 to 53 minutes (p=0.003) and door‐to‐angio‐suite arrival from 54 to 35 minutes (p<0.001). Other workflow intervals similarly improved. However, clinical outcomes including revascularization rates, symptomatic hemorrhage, and 90‐day function did not differ significantly. The authors highlighted anesthesia management variability as a persistent barrier to outcome translation. These studies indicate that technical adaptation following an unsuccessful first thrombectomy attempt can substantially increase reperfusion success and likelihood of functional recovery, particularly when operators shift from combined to alternative strategies. In contrast, workflow simulation training reliably shortens critical treatment intervals but has yet to demonstrate clear clinical benefit, potentially due to peri‐procedural factors such as anesthesia. These findings support a two pronged optimization strategy: adopt early technique conversion when initial passes fail, and continue refining team based workflows to minimize delays. Further research should explore integrated protocols combining adaptive thrombectomy techniques with structured workflow and anesthesia optimization to maximize the therapeutic benefit of mechanical thrombectomy.