Stent retriever-assisted intra-arterial lysis for distal vessel occlusions: a feasible pharmacomechanical rescue strategy

INTRODUCTION: The optimal endovascular treatment strategy for medium and distal vessel occlusions remains undefined given the anatomical challenges of distal vessels. Stent retriever-assisted intra-arterial lysis (SAIL) is a pharmacomechanical technique designed to facilitate clot dissolution while minimizing mechanical stress on fragile distal vessels. METHODS: We performed a retrospective single-center analysis of consecutive patients with acute ischemic stroke due to distal vessel occlusions treated with SAIL between November 2022 and January 2026. Distal occlusions included M2-M3, A2-A3, and P1-P2 segments, and were classified as primary or secondary. SAIL consisted of temporary stent retriever deployment across the thrombus to restore flow, followed by intra-arterial tirofiban infusion through a distal access catheter and subsequent device resheathing. Primary outcomes were feasibility and safety; secondary outcomes included angiographic reperfusion and clinical outcomes. RESULTS: 24 patients were included (mean age 74±14.6 years; median baseline National Institutes of Health Stroke Scale (NIHSS) 16). Most occlusions involved the middle cerebral artery territory (79.2%). SAIL was predominantly used after unsuccessful mechanical thrombectomy (70.8%), with a median of two prior device passes. Successful reperfusion (modified Thrombolysis In Cerebral Infarction (mTICI) ≥2b) was achieved in 87.5% of patients, including near-complete or complete reperfusion (mTICI 2c-3) in 62.5%. Any intracranial hemorrhage occurred in 25.0% of patients and symptomatic intracranial hemorrhage in 4.2%. At 90 days, functional independence (modified Rankin Scale 0-2) was observed in 6 of 12 patients (50%) with available follow-up. CONCLUSIONS: SAIL was feasible and achieved high reperfusion rates with a low rate of symptomatic intracranial hemorrhage despite frequent use as rescue therapy after failed thrombectomy. These findings support further evaluation of pharmacomechanical strategies for distal vessel occlusions.