EVT for MeVO or Distal Occlusion

ESCAPE-MeVO (M2/M3, ACA, PCA) and DISTAL both failed their primary functional outcome endpoints, suggesting that EVT benefit does not extend reliably to medium-vessel and distal occlusions under current evidence. Routine EVT for MeVO cannot be recommended based on these RCTs.

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Clinical Question

Does my MeVO or distal-occlusion patient benefit from EVT?

Synthesises 2 trialsfirst two RCTs in medium-vessel and distal occlusions. Both define the negative end of EVT

What does the guideline say?

§4.7.2· 2026
In selected patients with AIS from anterior circulation proximal LVO of the ICA or M1, presenting between 6 and 24 hours from onset, with age <80 years, NIHSS ≥6, prestroke mRS 0–1, ASPECTS 3–5, and without significant mass effect, EVT should be used (COR 1, LOE A). In selected patients with AIS from anterior circulation proximal LVO of the ICA or M1, presenting within 6 hours, with age <80 years, NIHSS ≥6, prestroke mRS 0–1, ASPECTS 0–2, and without significant mass effect, EVT can reasonably be considered (COR 2a, LOE B-R).
Source: 2026 AHA/ASA Guideline — §4.7.2 (Anterior-circulation EVT eligibility, including large-core)

The trials cited in the guideline's supportive text appear below.

Trials in this question· 2

ESCAPE-MeVO2025

No benefitaRR 0.95

Routine EVT for medium-vessel occlusion shows no functional benefit and higher sICH (5.4% vs 2.2%).

No benefitaRR 0.95

DISTAL2025

NeutralaOR 0.90

EVT for medium/distal vessel occlusion did not improve outcome and trended toward harm.

NeutralaOR 0.90