Thrombectomy Passes and Acute Ischemic Stroke Outcomes in Network Meta‐analysis

Background Endovascular mechanical thrombectomy has become the standard of care for large vessel occlusion strokes. Multiple passes with stent retrievers or aspiration catheters are frequently required to retrieve the clot and re‐establish cerebral perfusion, but each additional attempt carries a risk of intimal injury or distal embolization. A comprehensive analysis of outcomes can inform our intraoperative decision making regarding the number of passes beyond which the procedural risks may outweigh the potential benefit. Methods A systematic review and meta‐analysis were conducted using articles found in PubMed, Scopus, and Web of Science up to February 2025. Articles assessing the safety and efficacy of the number of passes required to achieve recanalization in patients with acute ischemic stroke were included. The primary outcomes were 90‐day functional independence (defined as modified Rankin Scale [mRS 0‐2]), successful recanalization (TICI 2b‐3), symptomatic intracranial hemorrhage (sICH), and 90‐day mortality. Outcomes were evaluated based on the number of sequential passes and Patients were further stratified into two groups according to number of passes ≤3 versus >3. Results This meta‐analysis, which included 18 studies involving 8,571 stroke patients, showed that with each subsequent pass, there was a decline in 90‐day functional independence and successful recanalization rates. Conversely, 90‐day mortality and symptomatic intracerebral hemorrhage (sICH) increased (Figure 1A). Furthermore, a subgroup analysis dichotomizing patients who received ≤ 3 thrombectomy attempts compared to those who received > 3 attempts revealed increased odds of achieving functional independence (OR: 2.47; 95% CI: 2.11 ‐ 2.91; p < 0.01) and successful recanalization (OR: 3.86; 95% CI: 3.19 ‐ 4.68; p < 0.01). Moreover, receiving ≤ 3 passes also decreased the odds of sICH (OR: 0.49; 95% CI: 0.33 ‐ 0.72; p < 0.01) and 90‐day mortality (OR: 0.58; 95% CI: 0.47 ‐ 0.72; p < 0.01) (Figures 1B & 1C). Conclusions Achieving successful reperfusion within three or fewer passes appears to be a pragmatic benchmark and is associated with improved functional outcomes. Further research is needed to refine patient selection and device strategies for cases requiring multiple attempts beyond this threshold.