Endovascular Thrombectomy in Medium and Distal Vessel Occlusions: A Focused Guideline From the Society of Vascular and Interventional Neurology Guidelines and Practice Standards Committee

BACKGROUND: The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke from distal- and medium-vessel occlusion (DMVO) for endovascular thrombectomy (EVT). The intended audiences are prehospital care providers, physicians, and allied health professionals. METHODS: The Society of Vascular and Interventional Neurology Guidelines and Practice Standards committee formed a writing group to conduct a structured literature review on EVT for DMVO-related acute ischemic stroke and to draft practice recommendations in accordance with the Society of Vascular and Interventional Neurology Guidelines and Practice Algorithm. A structured literature search was conducted across PubMed, MEDLINE, and the Cochrane Library from January 2015 through February 2026, supplemented by manual review of reference lists from key studies and conferences. Recommendations were developed with consensus from an expert panel and the Guidelines and Practice Standards committee, with final approval by the Society of Vascular and Interventional Neurology Board of Directors. RESULTS: Data from all randomized controlled trials, prior meta-analyses, and subgroup analyses were extracted to evaluate the latest evidence on the safety and efficacy of EVT in patients presenting with DMVO acute ischemic stroke. The guideline outlines practical considerations for patient selection, procedural technique, and systems of care. CONCLUSIONS: These guidelines provide focused practical recommendations based on recent evidence regarding patient selection and decision-making for EVT in patients presenting with acute DMVO. Routine EVT for DMVO is not supported by current evidence; however, performing EVT in patients with disabling acute dominant M2 occlusion remains reasonable.