Abstract Number: Esoc2026a1072 Intravenous Thrombolysis Before Endovascular Thrombectomy in Distal Medium Vessel Occlusion: Analysis From the Iretas Registry

Abstract Background and aims The optimal acute treatment for distal medium vessel occlusions (DMVOs) remains uncertain. We evaluated the effectiveness and safety of intravenous thrombolysis (IVT) plus endovascular thrombectomy (EVT) versus EVT alone in patients with DMVOs. Methods Patients with DMVOs were identified from the Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS). Patients were classified as EVT alone or IVT + EVT. The primary outcome was 90-day ordinal mRS. Secondary outcomes included mTICI, dichotomized 90-day functional outcomes, sICH, peri-procedural complications, and early reperfusion. Analyses were performed with IPTW models. Prespecified subgroup analyses explored effect modification by workflow-related variables. Results Among 4365 patients, 2046 were treated with EVT alone and 2319 with IVT + EVT. Median age was 76. 6 (IQR 67. 6-82. 7), 2208 (50. 6%) were females. IVT + EVT was not associated with shift at the 90-day mRS (acOR: 1. 12; 95%CI, 0. 96–1. 31), but it was associated with higher rates of mRS 0–3 (aOR: 1. 26; 95%CI, 1. 04–1. 52), lower 90-day mortality (aOR: 0. 65; 95%CI, 0. 50–0. 85), and increased early reperfusion (aOR: 2. 39; 95%CI, 1. 44–3. 98). Final reperfusion, sICH, and peri-procedural complications did not differ. A significant interaction (pᵢnteraction = 0. 022) with onset-to-groin puncture was observed, favoring IVT + EVT in patients treated within 270 minutes. Conclusions In this large real-world cohort of patients with DMVOs, functional outcomes were comparable between IVT + EVT and EVT alone; IVT + EVT was safe and associated with higher early reperfusion and lower mortality, with a time-dependent benefit in early treated patients. Conflict of interest The authors declare no conflicts of interest.