A Stepwise Procedural Guide Based on Angiographic Signs during Temporary Stent Retriever Deployment for Intracranial Atherosclerotic Disease-Related Large Vessel Occlusion.
While temporary stent retriever deployment (TSRD) is an increasingly utilized option for intracranial atherosclerotic disease-related large vessel occlusion (ICAD-LVO), standardized criteria to guide the intraprocedural decision between device retrieval, resheathing, and rescue therapies remain undefined. We systematically evaluated real-time angiographic signs to guide this decision-making process. We retrospectively reviewed consecutive patients with ICAD-LVO treated using TSRD at 2 centers. Two angiographic signs were operationalized: the instent thrombotic sign (IST), representing intra-stent filling defects observed during dwell time; and post-resheathing distal flow deterioration (PR-DFD), defined as a temporal reduction in distal opacification after resheathing compared to maximal deployment. The primary outcome was acute procedural success, defined as successfully maintaining target lesion patency. Secondary outcomes included final successful reperfusion (modified Thrombolysis in Cerebral Infarction, mTICI 2b-3), early neurological deterioration (END), and symptomatic intracranial hemorrhage (sICH). Eight patients were included. IST was observed in 3 patients, prompting immediate stent retrieval. In the remaining 5 patients without IST, the device was resheathed; among this subset, PR-DFD occurred in 3. Regarding the primary outcome, acute procedural success was achieved in all 8 patients, although 1 patient with PR-DFD required rescue angioplasty for early reocclusion. Notably, END occurred exclusively in the 2 patients with PR-DFD who did not undergo rescue angioplasty. Secondarily, all patients ultimately achieved final mTICI 2b-3 without sICH. These preliminary observations suggest that IST and PR-DFD may provide practical angiographic cues reflecting thrombotic burden and hemodynamic instability during TSRD.