Acute Ischemic Stroke Large-Vessel Occlusion: Vascular-Surgery Interface

33.1Where vascular surgery actually enters the LVO pathway

In acute ischemic stroke with large-vessel occlusion, it is essential to establish clinical responsibilities. Recognition of disabling stroke, emergency imaging, intravenous thrombolysis eligibility when relevant, thrombectomy selection, the intracranial procedure, and early neurocritical care remain stroke-team functions under the acute stroke guideline framework AHA 2019 · AHA 2018. Vascular surgery should not recast the whole LVO pathway as a carotid chapter. Its value is more specific: the vascular surgeon enters when extracranial arterial anatomy changes the ability to reach or maintain intracranial reperfusion, or when the patient will require later carotid revascularization and surveillance.

That interface is clinically narrow but high consequence. The first entry point is tandem cervical carotid disease. A proximal cervical internal carotid stenosis or occlusion may sit in front of the intracranial occlusion, so the team must decide whether acute carotid stenting is needed to create durable inflow for thrombectomy or whether the cervical lesion can be managed after the brain has declared its infarct and hemorrhagic-transformation risk. The second entry point is access rescue. Hostile arch anatomy, severe ilio-femoral tortuosity, or failed transfemoral catheter progress can turn an otherwise eligible thrombectomy into an abandoned procedure unless a carotid cutdown or direct carotid puncture is available. The third entry point is the post-reperfusion transition: antithrombotic intensity, timing of delayed CEA or CAS, carotid duplex surveillance, and recurrent-stroke prevention have to be aligned after the acute brain-risk window has been assessed.

The ESVS 2023 carotid guidance places acute carotid disease in the stroke setting rather than treating it as an isolated elective carotid problem Editor's Choice European 2023. Consequently, vascular surgery should be present early enough to influence tandem-lesion and access decisions, but disciplined enough not to override the stroke team’s imaging-based thrombectomy selection. A mature service therefore defines the consult trigger before the patient arrives: tandem cervical carotid occlusion or critical stenosis, anticipated hostile access, failed femoral progress, or need for early planning of carotid revascularization after intracranial reperfusion.

33.2Four thrombectomy evidence lanes, not one expanded envelope

Thrombectomy evidence is safest to use when it is separated into four clinical lanes. The early-window anterior-circulation lane is the foundation. MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, and REVASCAT randomized patients with anterior-circulation LVO to endovascular thrombectomy plus best medical therapy versus best medical therapy alone, with most patients treated within 6 hours of onset and with consistent improvement in disability outcomes Randomized Assessment Rapid 2015 · Endovascular Therapy Ischemic 2015 · Randomized Trial Intraarterial 2015 · Thrombectomy within Hours 2015 · Stent-Retriever Thrombectomy after 2015. HERMES then pooled individual-patient data from the five major early trials and confirmed a large treatment effect across the 90-day modified Rankin scale, with benefit broadly consistent across prespecified subgroups Endovascular thrombectomy after 2016. For the vascular surgeon, this lane explains why rapid restoration of access and inflow matters: a mechanically reachable intracranial occlusion in a favorable early-window anterior-circulation patient is a time-sensitive disability problem rather than an isolated angiographic target.

The second lane is late-window mismatch selection. DAWN enrolled patients 6 to 24 hours from last known well when the clinical deficit was disproportionately severe relative to the measured infarct core, and it showed benefit on functional outcome at 90 days in that selected anterior-circulation population Thrombectomy Hours after 2018. DEFUSE-3 enrolled patients 6 to 16 hours from last known well using perfusion imaging to demonstrate a salvageable-penumbra to infarct-core mismatch, also showing functional benefit Thrombectomy Stroke 2018. A common error is to rely solely on the clock. These trials did not make time alone the eligibility criterion; they made persisting tissue-at-risk the criterion, with time as the outer frame.

The third lane is the large-core expansion. RESCUE-Japan LIMIT in 2022, SELECT2 in 2023, and ANGEL-ASPECT in 2023 tested thrombectomy in patients with larger infarct cores or low ASPECTS who would often have been excluded from earlier trials, and they reported disability benefit with a smaller margin and greater symptomatic intracerebral hemorrhage concern ANGEL-ASPECT · 2023 · SELECT2 · 2023 · Endovascular Therapy Acute 2022. This lane changes the conversation but does not erase risk. A low-ASPECTS patient with a tandem cervical carotid lesion may still be a thrombectomy candidate in selected circumstances, yet the decision to add acute carotid stenting and dual antiplatelet therapy should be weighed against the already increased hemorrhagic vulnerability of a large infarct.

The fourth lane is basilar-artery occlusion. ATTENTION supported endovascular treatment in selected basilar-artery occlusion populations, whereas BASICS was overall negative on its primary endpoint ATTENTION · 2022 · Endovascular Therapy Stroke 2021. Posterior-circulation occlusion carries a different natural history, different clinical presentation, and different trial signal from anterior-circulation LVO. Patient selection and local expertise remain decisive for basilar occlusions, and anterior-circulation selection rules cannot be directly transplanted.

These lanes should be kept separate during vascular consultation. A patient with an early-window middle cerebral artery occlusion, favorable ASPECTS, and failed femoral access is not the same problem as a late-window mismatch patient with tandem carotid disease, a large-core anterior-circulation patient in whom hemorrhage risk is central, or a basilar-artery occlusion with uncertain extrapolation from anterior trials. The vascular surgeon’s contribution is to make the extracranial solution fit the trial lane rather than to force every patient into a single enlarged thrombectomy category.

33.3Imaging selection and the boundaries it actually draws

Imaging selection is the grammar of the LVO pathway. ASPECTS is the early infarct-extent language for anterior-circulation stroke: it assigns a ten-region non-contrast CT score, with lower scores reflecting more extensive early ischemic change Validity reliability quantitative 2000. Historically, higher ASPECTS supported early-window thrombectomy eligibility because it identified patients with smaller established infarcts and a larger safety margin. The large-core trials changed the boundary by deliberately studying patients with lower ASPECTS or larger cores, but they did not make ASPECTS irrelevant; RESCUE-Japan LIMIT, SELECT2, and ANGEL-ASPECT showed that selected low-ASPECTS or large-core patients can benefit while carrying a narrower therapeutic margin and greater hemorrhage concern ANGEL-ASPECT · 2023 · SELECT2 · 2023 · Endovascular Therapy Acute 2022.

Perfusion imaging draws a different boundary. In late presenters, the critical question is whether there is still threatened tissue that can be saved, rather than how many hours have elapsed. DAWN used a clinical-imaging mismatch between deficit severity and infarct core for patients 6 to 24 hours from last known well, while DEFUSE-3 used perfusion mismatch for patients 6 to 16 hours from last known well Thrombectomy Hours after 2018 · Thrombectomy Stroke 2018. Exact volume thresholds and software-derived outputs should be interpreted within the trial and platform context rather than memorised as universal vascular-surgery rules. The vascular surgeon must ask an essential question: has the stroke team shown a tissue profile in which restoring access or treating the cervical carotid lesion is likely to preserve function rather than reperfuse completed infarct?

Reperfusion grading by modified TICI belongs to the other end of the pathway. The modified Thrombolysis in Cerebral Infarction scale is the angiographic language for how much of the downstream territory has been reperfused after thrombectomy Recommendations on Angiographic 2013. It is not an eligibility test and should not be used as if it selected the patient. A strong mTICI result may confirm procedural success; a poor result may explain persistent deficit or recurrent risk; neither replaces ASPECTS, perfusion mismatch, clinical severity, or hemorrhage assessment before the procedure.

The imaging framework is therefore threefold. ASPECTS estimates established early infarct; perfusion mismatch estimates salvageable tissue in later windows; mTICI reports the angiographic result. When these categories are confused, the tandem carotid decision becomes unsafe: acute stenting may be overused in a patient with little salvageable tissue, or access rescue may be abandoned in a patient whose imaging still supports meaningful recovery. Correct imaging language helps vascular surgery support the stroke pathway without exceeding the evidence behind it.

33.4Tandem cervical carotid disease and access rescue

Tandem cervical carotid disease is the central vascular-surgery problem in acute anterior-circulation LVO. The cervical internal carotid lesion may be the embolic source, the inflow obstruction, and the mechanical barrier to intracranial thrombectomy at the same time. Two strategies are usually considered: acute carotid stenting during thrombectomy, or staged carotid revascularization after neurological and hemorrhagic risk have stabilised. Acute stenting can create a stable conduit for intracranial device work and may reduce early re-occlusion of the cervical inflow, but it usually requires immediate dual antiplatelet therapy in a patient whose reperfused brain may still be vulnerable to hemorrhagic transformation. Staged CEA or CAS preserves antithrombotic flexibility during the acute infarct period but accepts an interval risk of carotid re-occlusion or recurrent embolisation. ESVS 2023 guidance frames this tandem problem inside the acute stroke setting, where the carotid decision must be integrated with thrombectomy and early brain risk rather than treated as routine delayed carotid stenosis Editor's Choice European 2023.

The decision is fundamentally a question of sequence. If the cervical lesion prevents access to the intracranial occlusion or repeatedly compromises inflow, acute stenting may be the only way to complete reperfusion in a selected patient. If the intracranial target can be treated without stabilising the neck lesion, and the infarct burden or hemorrhagic risk is substantial, delaying CEA or CAS may be safer. If a large-core profile is present, the antiplatelet cost of acute stenting should be weighed particularly carefully because large-core trials showed benefit with a narrower safety margin and greater symptomatic intracerebral hemorrhage concern ANGEL-ASPECT · 2023 · SELECT2 · 2023 · Endovascular Therapy Acute 2022.

Access rescue is the other point where vascular surgery can change the outcome of an otherwise stroke-team-led case. Transfemoral access may fail because of a hostile arch, tortuous aorto-iliac anatomy, severe ilio-femoral disease, or inability to deliver the device system safely. In that setting, common-carotid cutdown provides controlled exposure and hemostasis, while percutaneous direct carotid puncture provides a faster but less surgically controlled route. Both approaches require a team that understands carotid access, neck hemostasis, anticoagulation and antiplatelet exposure, and the neurological urgency of the occlusion. AHA/ASA 2019 and ESVS carotid guidance support locating these access-rescue decisions within the acute stroke pathway rather than after the procedure has failed completely Editor's Choice European 2023 · AHA 2019.

The post-procedure transition should be planned at the time the access or carotid choice is made. After thrombectomy alone, antithrombotic therapy can usually follow the stroke team’s acute infarct and hemorrhage assessment. After thrombectomy plus acute carotid stenting, the patient has a cervical stent that needs antiplatelet protection but also a newly reperfused infarct that may not tolerate unnecessary antithrombotic intensity. The vascular team should define the carotid surveillance plan, decide whether staged CEA or CAS remains necessary, and coordinate antithrombotic de-escalation with stroke neurology rather than defaulting to a generic post-carotid-stent regimen.