Frequent flyers: recurrent large vessel occlusion requiring thrombectomy

BACKGROUND: Repeat thrombectomy for recurrent large vessel occlusion (LVO) is uncommon but clinically consequential. Although previous studies have described general causes of recurrent LVO, the association between recurrence timing and underlying aetiology-particularly atrial fibrillation-remains poorly characterised. METHODS: We performed a retrospective study of consecutive patients who underwent repeat thrombectomy for recurrent LVO at a tertiary comprehensive stroke centre between January 2020 and December 2024. Recurrence timing was stratified into early (≤1 day) versus delayed (≥2 days). Clinical characteristics, aetiology and procedural variables were compared between early versus delayed group. RESULTS: Among 1116 thrombectomy procedures, 16 patients (1.4%) had recurrent LVO requiring thrombectomy. Eight patients (50.0%) had early recurrence, and eight (50.0%) had delayed recurrence. Early events demonstrated a consistent same-vessel pattern (8/8, 100%) and were exclusively associated with non-atrial fibrillation mechanisms, including intracranial atherosclerotic disease and arterial dissection. In contrast, delayed recurrence was strongly associated with atrial fibrillation (7/8, 87.5%; p<0.001). Notably, four of seven atrial fibrillation-related cases (57.1%) were not on appropriate anticoagulation at the time of recurrence. Functional outcomes at 90 days did not differ significantly between groups (median modified Rankin Scale 5 vs 5; p=0.704). CONCLUSIONS: Recurrent LVO after thrombectomy appeared to display distinct time-dependent patterns in this cohort. These findings suggest that recurrence timing may serve as a practical clinical marker to guide targeted evaluation-vascular imaging and plaque assessment for early recurrence cases, and intensified rhythm monitoring for delayed cases. Larger studies are needed to validate these time-specific patterns.