Mastering the Maze: A Narrative Guide on Advanced Tips and Tricks for the Management of Complex Thrombectomy

Endovascular therapy has revolutionized the treatment of acute ischemic stroke with large vessel occlusion, becoming the standard of care across anterior and posterior circulation. With expanding indications, including large infarct cores, extended time windows, and older patients, the number and complexity of procedures are steadily increasing worldwide. Although overall rates of successful reperfusion approach 90%, the remaining 10% of failed endovascular therapy highlight the technical challenges still confronting interventionalists. Procedural failure may occur at multiple stages, from arterial puncture to supra-aortic catheterization, intracranial navigation, or closure, each requiring tailored strategies. This review gathers advanced tips and tricks to manage demanding situations, reflecting both published evidence and the long-standing oral transmission that often occurs during fellowships. Practical solutions are described for frequent challenges, including complex femoral access and closure, tortuous supra-aortic vessels, difficult carotid siphons, and hostile intracranial anatomy. Techniques such as buddy-wire, balloon anchoring, stent-anchoring, balloon tracking, direct carotid puncture, and the flossing technique are detailed, alongside structured escalation strategies. Beyond technical skills, this review emphasizes the importance of comprehensive training. Mastery of complex diagnostic cerebral angiographies, supported by simulation-based learning, is considered more relevant than procedural counts to determine readiness for on-call independence. Ultimately, competence is defined not by the number of endovascular therapies performed, but by the ability to anticipate and safely manage complications in unpredictable anatomic settings. Future training should integrate procedural volume, case complexity, and simulation to prepare the next generation of interventionalists to perform endovascular therapy and navigate the unexpected with safety and confidence.