Innovation and development of stent retrievers in acute ischemic stroke

Abstract

Acute ischemic stroke (AIS) is a cerebrovascular disease characterized by high morbidity, disability, and mortality, posing a significant threat to human health. Endovascular treatment has now been established as a key method for AIS management, in which stent retrievers that can mechanically remove blood clots play a key role in this technique. In recent years, stent retrievers have evolved in complexity and functionality to improve the ability of clot removing and surgical safety. However, the present instruments still have limitations on treatment efficiency, vascular adaptability, and operational precision, posing an urgent need for innovation in the design of stent retrievers. This paper systematically reviewed the structural features and working principles of AIS stent retrievers from the perspective of efficacy evaluation metrics, historical development, recent advancements in stent retrieval technology, and future prospects.

Keywords

stent retrievers / acute ischemic stroke / innovation / outlook

1 Introduction

Stroke is the second leading cause of death and disability among adults worldwide, of which acute ischemic stroke (AIS) accounts for more than 75% of all stroke cases [1–22]. AIS is caused by sudden interruption of blood flow and the brain cells are damaged due to insufficient blood and oxygen [23–30]. Therefore, promptly opening blocked blood vessels and allowing the brain tissue to regain reperfusion is of crucial importance [31–38]. Currently, intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) have become effective treatment methods for AIS [39–44].

Compared with IVT, MT has a broader time window and a higher rate of vessel recanalization [45–64]. MT is an endovascular treatment commonly used in the acute phase of AIS, during which thrombus is removed by stenting or direct aspiration [65–70]. For AIS with large vessel occlusion, MT achieves a stable successful recanalization rate of more than 80% [71–73]. The stent retriever is a minimally invasive metallic tool widely used as a thrombus extraction device [74–77]. The stent can be delivered through interventional procedures to the blocked blood vessel and removes the blood clot by retrieving the stent [78–80]. With the development of clinical applications, the design of stents has become more complex and functional.

2 Epidemiology and pathological mechanism of ischemic stroke

AIS is the most common type of stroke worldwide, accounting for approximately 75% of all stroke cases, resulting in approximately 6.4 million deaths per year and permanent disability in approximately one-third of cases [81,82]. The Global Burden of Disease (GBD) study shows that the total number of stroke cases in China in 2019 was 3.9 million, of which as many as 2.87 million were ischemic strokes [83].

There are numerous causes of AIS, primarily including atherosclerosis, cardiogenic thrombotic obstruction, circulatory dysfunction resulting from vascular spasm and occlusion, as well as vascular damage induced by autoimmune diseases [84–95]. Moreover, post-ischemic metabolic derangements and ion pump failure, coupled with immune microenvironment alterations, critically influence neuronal injury and subsequent tissue repair [96–99]. Furthermore, the risk of AIS is influenced by polygenic inheritance; relevant genes play a crucial role in regulating vascular function and inflammatory responses and exhibit familial heritability (Fig. 1) [100–106].

3 Structural characteristics and operating principle of stent retrievers

3.1 Structural features

AIS stents are usually tubular. This tubular structure conforms well to the shape of the inner wall of the blood vessel, making it easy to move within the vessel. The stent remains elongated before deployment, allowing it to be passed through the microcatheter to reach the lesion site within the vessel without any problem. When it reaches the location of the thrombus, it can be released from the microcatheter and unfolded into a tube that wraps around and engages the thrombus. Some stent retrievers may have a special design at the end, such as tapered or rounded edges. This design helps to minimize the possibility of damage to the vessel wall and improve the accuracy of stent implantation [107]. Stents are produced in various sizes to suit different vessel diameters and lesions. A stent of the appropriate length is vital to ensure that the thrombus can be completely covered and effectively removed [108–111].

Additionally, materials selection determines the structural properties and function of a stent. Stent retrievers are mostly made of biocompatible metal materials, such as nickel-titanium (nitinol) alloys [112,113]. Nitinol has unique properties; its shape-memory effect and superelasticity are two important features. The shape memory effect allows the stent to return to its predefined shape at a specific temperature (usually close to the body temperature), which helps the stent to unfold accurately within the vessel and secure the thrombus [114]. Microscopically, the stent retriever is a mesh structure made of woven metal wires [115]. When grasping the thrombus, the highly porous mesh structure allows different parts of the thrombus to be embedded in it, increasing the contact area with the thrombus and improving the firmness of the grasp. The weaving of the metal wires may adopt spiral and cross patterns, and the structure manifests differently in the flexibility, radial support and other properties of the stent. Self-expandable braided stents provide better radial support in the radial direction, while cross braiding may improve the flexibility of the stent [116].

3.2 Principle of operation

Endovascular thrombectomy was performed in a dedicated biplane angiography suite under conscious sedation or general anesthesia. After femoral or radial access, a 6F–8F guiding catheter was advanced to the cervical segment of the occluded vessel. A 0.014-inch microwire and 0.021-inch microcatheter were then coaxially navigated across the thrombus and positioned at least 1.5 vessel diameters distal to the thrombus under roadmap fluoroscopy. Once the microwire was removed, a stent retriever was deployed so that roughly two-thirds of its length enveloped the clot, and it was left in situ for 3–5 min to promote device-thrombus integration. During retrieval, continuous aspiration (≈ –70 kPa) was applied through the guiding catheter to mitigate distal embolization while the stent-microcatheter assembly was withdrawn. Recanalization was graded after each pass with the modified Thrombolysis in Cerebral Infarction Scale (mTICI), allowing up to three passes with optional adjunctive contact aspiration. Procedural times, angiographic success (mTICI 2b/3), and complications were prospectively recorded [117–123].

4 Evaluation of the efficacy of stent retrievers

Multiple randomized trials have firmly established the efficacy of stent retriever thrombectomy in AIS management. A patient-level meta-analysis by the HERMES collaboration, incorporating MR CLEAN, ESCAPE, REVASCAT, SWIFT PRIME, and EXTEND-IA demonstrated that stent retriever thrombectomy for anterior circulation large-vessel occlusion (LVO) significantly improves 90-d functional outcomes [124–129]. Further trials—DAWN and DEFUSE 3—extended the indication window to 6–24 h by using perfusion imaging to select patients with clinical-core mismatch, confirming comparable treatment efficacy [130,131]. The DIRECT-MT trial in China found no significant superiority in cost or outcomes between EVT alone and EVT plus IVT in anterior circulation LVO, supporting the feasibility of direct thrombectomy and informing guideline updates [132]. In posterior circulation strokes, the BAOCHE trial was the first to demonstrate thrombectomy benefit in basilar artery (BA) occlusion, while highlighting the need to weigh bleeding risk [133]. Together, these data have established stent retriever thrombectomy as the standard of care in AIS and shifted practice emphasis from rigid time windows to individualized tissue-based strategies.

5 Development of stent retrievers

Device development aims to address clinical challenges with greater efficacy (Table1). A comprehensive review of existing and historically significant stent retrievers is essential for understanding their evolution and impact. As illustrated in Fig. 2, each generation of classic stent retrievers has received either US Food and Drug Administration (FDA) or Conformité Européenne (CE) certification. The first-generation MERCI embolization device features a helical design, which has been shown to influence revascularization rates [134]. Clinical trials such as the Solitaire Versus MERCI Stent Retrievers for Acute Ischemic Stroke Trial (SWIFT) and the Trevo Versus MERCI Device for Acute Ischemic Stroke in Large Vessel Occlusion Trial (TREVO-2), demonstrated that second-generation devices like Solitaire and Trevo offer superior clinical performance compared to earlier models. These studies formally established Solitaire and Trevo as representative devices of the second generation. To expand patient access to this effective treatment, various technical approaches based on thrombus retrieval materials have emerged, including Stent with Intracranial Support Catheter for Mechanical Thrombectomy (SWIM) and Solumbra techniques derived from Solitaire, and the TRevo with Aspiration and Proximal flow control (TRAP) technique based on Trevo [135,136]. Furthermore, third-generation stent retrievers have been developed, exemplified by devices such as EmboTrap and Tigertriever [137,138]. One thing that all three generations of stent retrievers have in common is that the stents are available in longer lengths. The Tigertriever stent system allows the stent’s radial expansion to be adjusted according to the diameter of the target vessel, and the adjustable outer diameter (OD) dimensions allow for a better fit to the target vessel size [139–143]. EmboTrap employs a dual-layer design: an inner closed-loop structure provides high radial support, while the outer open-loop configuration incorporates increased mesh density [144–146]. In EmboTrap III, the external open-loop section is designed to flare outward, ensuring secure apposition to the vessel wall during retrieval. Additionally, the distal closed end is engineered to capture potentially mobile thrombi [147–149]. Despite these advancements, ongoing innovation and research continue. This paper reviews the structural characteristics and working principles of stent retrievers, evaluates their clinical efficacy, outlines current developmental trends, explores innovations in AIS thrombectomy stents, and discusses future prospects.

5.1 First generation of stent retrievers: MERCI

The FDA approved the MERCI stent retrievers for the clinical treatment of AIS, thus opening a new avenue for stroke treatment in 2004 [150]. It consists of three parts, namely the MERCI bolus extractor, the MERCI balloon catheter, and the MERCI microcatheter system. The MERCI bolus extractor consists of a superelastic nickel-titanium alloy conical guidewire with a looped tail and a helical distal end, on which a platinum coil is mounted. As shown in Fig. 3, its primary mode of action is to pull the thrombus out of the body through the mediation of the MERCI balloon guiding catheter. A clinical trial showed that after recanalisation with MERCI, the proportion of patients achieving a mTICI 2b/3 was 57.3%. The neurological outcome at 3 months postoperatively was favorable (modified Rankin Scale (mRS) ≤ 2)) in 36% of patients, with mortality rate of 34% and a symptomatic intracerebral hemorrhage (sICH) rate of 9.8% [151]. The MERCI trial published by Smith et al. showed a recanalisation rate of 48%, which was significantly higher than the 18% recanalisation rate in the control group (heparin-only treatment) in the PROACT-Ⅱ trial, with a symptomatic intracranial hemorrhage incidence of 7.8%, suggesting that MERCI can be safely used for thrombolysis of arteries with AIS [152]. Alshekhlee et al. [153] retrospectively analyzed data from 1226 patients treated with MERCI and found an overall mortality rate of 35.2%, a sICH rate of 7.3%, and a good 90-d outcome (mRS < 2) in 32% of patients. The era of thrombectomy using first-generation stent retrievers, which lasted roughly a decade, gradually ended with the publication of two negative clinical trials and two comparative trials in 2013. The results of these studies suggest that most first-generation stent retrievers failed to demonstrate patient benefit [154–157].

5.2 Second-generation stent retrievers: Solitaire, Trevo, and Revive SE

It has been reported that the vessel recanalization rate was significantly higher in the Solitaire group compared to the MERCI group (60.7% vs. 24.1%). Additionally, the rate of favorable outcomes, as measured by the mRS 0–2, was also significantly better in the Solitaire group than in the MERCI group (58.2% vs. 33.6%), accompanied by a notably lower mortality rate (17.2% vs. 38.2%) [156]. The TREVO-2 trial, published in the same year, randomly divided 178 patients with AIS within 8 h of onset into the Trevo group (88 patients) and the MERCI group (90 patients). The results demonstrated a higher vascular recanalization rate in the Trevo group compared to the MERCI group (86% vs. 60%). Furthermore, there was an increased rate of favorable prognosis at 90 d for those receiving Trevo treatment (mRS 0–2: 40.0% vs. 22.0%), while mortality rates did not differ significantly between groups (15% vs. 23%, P > 0.05) [157]. The Solitaire stent is a nickel-titanium closed-loop device (Fig. 4) that offers enhanced trackability and support for complex vascular anatomies. It facilitates single-operator delivery, making it suitable for both intracranial and extracranial thrombectomy, stent deployment at stenoses, vascular remodeling, and the restoration of cerebral blood flow [158]. Its retrievable and repositionable design allows for multiple deployments until successful thrombus removal, thereby promoting its clinical adoption [159]. As a second-generation device (Fig. 5), the Trevo closed-loop nitinol stent is characterized by its large-cell design and full-visualization capabilities, which facilitate intraoperative localization and assessment of stent expansion [160,161]. During retrieval, peak-waist displacement serves as an indicator of thrombus engagement, while changes in stent curvature are utilized to monitor vascular deformation, thereby preventing excessive expansion. The Revive SE stent (Codman & Shurtleff) employs a nickel-titanium closed-end mesh basket designed for thrombus trapping, featuring adjustable distal cells to facilitate luminal centralization [162,163]. A multicenter trial demonstrated an overall reperfusion rate (mTICI ≥ 2b) of 69%, with recanalization rates of 83.3% for the M2 segment and 82.4% for the BA. Thromboembolic complications and sICH were observed in 10% and 2% of cases, respectively, while satisfactory reperfusion was achieved in 92%, leading to a favorable outcome at 90 d (mRS 0–2) in 48% [164]. Further large-scale randomized controlled trials are necessary to validate these findings.

5.3 Third-generation stent retrievers: EmboTrap, 3D Revascularization Device, Eric, Nimbus, and Tigertriever

EmboTrap is a new stent retriever with proximal dual marker points for more precise stent placement. This device increases the number of external mesh cages from three to five and incorporates a closed-loop design at the cephalad end, which functions as a distal protection zone to enhance the capture of intact thrombus [165]. The results of a study on first-pass recanalization (FPE) of EmboTrap II in AIS (FREE-AIS) confirmed the safety and efficacy of EmboTrap II in MT and increased the incidence of FPE [166]. Laser-cut from nitinol tubing, the 3D Revascularization Device is an open-loop stent with adductor blades for wall apposition and four internal lumens for thrombus embedding. It optimizes conformity to cerebral vasculature. Mechanisms include physical support, vascular regeneration, and hemodynamic improvement [167,168]. Multicenter data show 74% recanalization (mTICI ≥ 2b), 36% first-pass recanalization, a 65-min puncture-to-reperfusion time, 4% sICH, 32% mortality, and 43% mRS ≤ 2 at 90 d [169]. Designed for fibrin-rich thrombi, Nimbus stent retrievers demonstrate safety and efficacy as an alternative revascularization tool [170]. A study reported 76.2% mTICI 2b/3, 57.1% mTICI 2c/3, with mean passes decreasing from 3.4 to 2.2 after Nimbus (overall 5.4). Half of failed thrombectomy cases achieved recanalization with Nimbus [171]. The tandem lantern-shaped Eric stent reduces distal embolization by central thrombus fixation, minimizing vessel wall trauma [172]. A comparative study showed higher complete recanalization in Eric users, though with more device readjustments, and comparable clinical outcomes to standard retrievers [173]. The braided open-loop Tigertriever 13 with adjustable filaments showed 94% mTICI ≥ 2b revascularization for M1 occlusions, 29% SAH, 12% parenchymal hemorrhage, and 65% mRS ≤ 2 at 90 d [174,175] These findings support the safety and efficacy of this device for managing MeVO.

6 Different innovations in stent retrievers for AIS

6.1 Stent retrievers for embolisation efficiency

As illustrated in Table 2, various innovative approaches to AIS stent retrievers are presented. Solitaire X is a self-expanding device equipped with a push wire integrated into a pre-assembled introducer sheath. Both components are fabricated from a nitinol alloy, which reverts to its pre-programmed configuration upon temperature change. The stent’s compliant construction facilitates atraumatic delivery into distal microvasculature. Clinically, the device exhibits excellent conformability and a long working segment, enhancing thrombus engagement efficiency; its precise deployment, controlled retrieval, and fine retraction capabilities markedly improve procedural safety and effectiveness. A comparative study evaluated endovascular therapy outcomes using Solitaire FR (pre-October 2020) versus Solitaire X (post-October 2020). Among 182 patients with large vessel occlusions, the Solitaire X cohort achieved a higher first-pass recanalisation rate (65.9% vs. 50.5%, P = 0.049). Solitaire X’s larger dilator push-wire diameter may augment suction, contributing to this improvement. At 24 h post-procedure, head CT revealed a higher Alberta Stroke Program Early CT Score (ASPECTS) (6.51 ± 2.9 vs. 5.49 ± 3.4; P = 0.042) and reduced hemorrhage volume (0.67 ± 2.1 mL vs. 1.20 ± 3.4 mL; P = 0.041). The authors concluded that Solitaire X’s reduced profile, minimized vessel trauma, and expedited distal access significantly enhanced procedural efficiency and shortened hospitalization (16.6 ± 13.1 d vs. 25.1 ± 23.2 d; P = 0.033). These data indicate that Solitaire X may yield superior outcomes and accelerated recovery in AIS patients treated with the Solumbra technique [176]. In a separate series of 3-mm Solitaire X, first-pass mTICI 2c/3 recanalization was achieved in 32.3%, with a final mTICI 2c/3 rate of 67.6%. No device failures or procedural complications occurred over 147 passes. The median number of passes was 1.5 (IQR 1–2), the median discharge National Institutes of Health Stroke Scale (NIHSS) score was 2 (IQR 0–7), and the in-hospital mortality rate was 10%. These findings underscore the efficacy and safety of the 3 mm Solitaire X in distal medium vessel occlusion (DMVO) management [177]. Trevo NXT ProVue stent retrievers are available in a broader size range to accommodate varied vessel anatomies. The hydrophilic polymer-coated guidewire reduces friction, facilitating smoother navigation through tortuous vessels while minimizing endothelial trauma and enabling reliable deployment and retrieval. Real-time visualization of thrombus engagement further enhances procedural control and extraction efficiency. A case report describes using an inflatable balloon-guide catheter (BGC) and Trevo NXT ProVue delivery system to straighten tortuous carotid segments, thereby facilitating stent deployment in challenging anatomy. In 44 cases, the 3-mm Trevo NXT was used initially in 56.9% of patients, achieving successful revascularization (mTICI ≥ 2b) in 72.4%; as a “rescue” device in 43.1% of patients, it achieved a 60% recanalization rate. The acute complication rate was 2.4%, and the median 24-h NIHSS score was 12 (IQR 4–20.8), reflecting high recanalization efficacy with minimal adverse events [178,179]. Both Solitaire X and Trevo NXT ProVue demonstrate enhanced efficiency, efficacy, and safety, rendering them appropriate for AIS MT. However, their mechanisms of procedural enhancement differ: Solitaire X leverages its material compliance and reduced profile to more precisely engage and stabilize thrombi—resulting in lower hemorrhage rates, superior outcomes, and accelerated recovery—whereas Trevo NXT ProVue’s broad size portfolio, hydrophilic sheath, and real-time visualization facilitate navigation in complex anatomies, minimize vessel trauma, and improve extraction efficiency as evidenced by clinical studies.

6.2 Stent retrievers for successful recanalisation of embolic procedures

The Tigertriever 13 is a novel, low-profile stent retriever designed for distal vessel occlusions in small-caliber intracranial arteries. Its principal innovation lies in a manually adjustable radial force within the mesh structure. An internal control wire, anchored at the distal end and actuated by a clicker-based handle, allows gradual opening and closing of the mesh. In a cohort of 43 patients with distal medium-vessel occlusions (DMVO), Tigertriever 13 achieved first-pass mTICI 2b/3 recanalization in 84.4% (38/45) of attempted passes. At discharge, 53.5% (23/43) achieved mRS 0–2, while 15.6% (7/45) remained at mTICI 0–2a, with symptomatic intracranial hemorrhage in 7.0% and subarachnoid hemorrhage in 14.0% [180]. These outcomes indicate high recanalisation efficacy but a notable incidence of hemorrhagic complications. A meta-analysis of 11 studies (n = 1402) revealed reperfusion success rates of 83.2% versus 81.6% (P > 0.05) and sICH rates of 7.2% versus 6.9% (P > 0.05) when comparing Tigertriever 13 to alternative devices [181].

EmboTrap III features a novel bilayer, segmented design that incorporates a larger proximal entry window and a reduced distal mesh aperture to optimize thrombus capture. Its dual-mesh basket dynamically engages thrombus, while a dedicated distal trap unit intercepts fragments. In an LVO cohort (n = 110), the median NIHSS score was 18; 58.2% received Intravenous tissue plasminogen activator (IV tPA) before MT. The median ASPECTS was 8, with a mean thrombus length of 20.2 mm. The first-pass effect occurred in 41.8% and modified FPE in 59.1%, with 43.8% achieving mRS ≤ 2 at 90 d [182]. Nagao et al. successfully treated a free-floating carotid thrombus in a 71-year-old man using ADAPT plus EmboTrap III, followed by carotid Wallstent deployment; no recurrence or in-stent protrusion was observed, and the patient was discharged on day 11 without deficits [183]. This case highlights EmboTrap III’s dual role in thrombectomy and distal embolic protection.

The domestically produced Swebus^® Intracranial Stent Retriever features an open-ring convoluted design, facilitating smooth delivery, rapid and precise deployment, effective thrombus embedding, and minimal endothelial irritation. Its “S+Straight” configuration enhances thrombus engagement and capture efficiency. Radial tension is optimized: elevated during curling for rapid expansion and thrombus integration, then reduced after deployment to minimize vessel injury.

6.3 Stent retrievers for improved safety

The APERIO^®Hybrid (APH) is an advanced thrombus extractor featuring a dual-unit architecture: a smaller closed mesh for vessel wall apposition and thrombus penetration, and a larger open mesh for thrombus integration. An integrated anchoring element secures thrombus engagement. Its double-helix radiopaque marker enables precise thrombus localization and aids lesion characterization. The interleaved open-and-closed loops balance thrombus retention with conformability in tortuous anatomy. This configuration minimizes intimal injury and branch vessel stress during retrieval, while the closed loops provide moderate radial support. In a study of 298 LVO stroke patients [APERIO^® (AP) n = 148; APH n = 150], successful recanalization rates were 75.7% (AP) versus 79.3% (APH), with no significant difference. Postoperative hemorrhagic complications, including subarachnoid hemorrhage, were significantly reduced in the APH cohort. No differences were observed in embolic pass count, puncture-to-first-pass time, puncture-to-recanalisation time, or the need for remedial device use [184]. Collectively, these findings suggest that the APH may offer safety advantages over its predecessor while maintaining comparable recanalisation efficacy.

6.4 Stent retrievers for structures

Contemporary stent retrievers incorporate intricate three-dimensional architectures—such as mesh baskets and helical coils—to enhance thrombus engagement and stabilization. For instance, EmboTrap II employs a bilayer construct with a specialized distal mesh optimized for emergent LVO in AIS [185]. Simultaneously, its flexibility and navigability have been markedly enhanced, enabling more precise positioning and control. A recent design iteration has been optimized for superior mechanical performance and vascular compatibility. Among prototypes, the Stent D proved optimal, demonstrating exceptional elasticity and conformability [159].

6.5 Stent retrievers for new materials

The materials employed in stent retrievers have evolved from simple metal wires to nickel–titanium alloys, polymers, and other advanced biomaterials. These materials exhibit superior elasticity and ductility, while mitigating vascular injury and inflammatory response. For example, the pRESET device is a self-expanding nitinol stent retriever engineered for MT for AIS with LVO [186]. To enhance biocompatibility, researchers have employed surface modifications—such as polymer coatings and drug-eluting technologies—on stent retrievers. Such modifications reduce thrombogenicity and promote endothelial cell proliferation and repair. Some investigators have developed nitinol alloys with titanium- or tantalum-enriched surface layers via advanced metallurgical processes. In vitro and in vivo studies demonstrate that these modified alloys are biocompatible and suitable for medical applications [187].

6.6 Stent retrievers for new technologies

As medical imaging advances, visualization techniques in stent deployment have become increasingly sophisticated and widespread. Modalities such as fluoroscopy, CT, and MRI permit real-time monitoring of stent position and configuration, enhancing procedural accuracy and safety. For example, dual-energy CT has been used for early detection and risk stratification of intracranial hemorrhage following MT in AIS [188]. MRI-detected “susceptible vessel signs” have been associated with improved outcomes in anterior circulation stroke patients receiving stent retriever therapy [189]. An initial case series evaluated a novel hybrid imaging suite combining a 64-slice CT scanner and mobile C-arm fluoroscopy. AIS patients underwent concurrent CT and angiographic imaging, and preliminary data demonstrate the system’s feasibility and safety [190].

6.7 Differences and clinical outcomes of stents across generations.

Significant technological progress and generational evolution in thrombectomy devices over recent decades underscore how technical differences critically influence clinical outcomes and patient prognosis. First-generation devices (e.g., MERCI) feature a simple helical mesh design. Although relatively easy to deploy, they demonstrate lower recanalization rates, increased complication risks from repeated passes, and prolonged procedural times. By contrast, second-generation devices (e.g., Solitaire, Trevo) exhibit substantially enhanced thrombus engagement and operational flexibility owing to design innovations. These enhancements yield higher recanalization rates and lower complication rates. Third-generation devices, such as EmboTrap and Tigertriever, further refine thrombus fixation and adaptability, enabling effective management of more complex occlusions. Consequently, this evolution markedly improves procedural efficacy and safety. Thrombectomy technology continues to advance, and future developments will increasingly emphasize clinical applicability in conjunction with patient-centered outcomes.

7 Outlook for stent retrievers

7.1 R&D of new generation of stents for thrombus extraction

With deeper insights into AIS pathophysiology, next-generation stent retrievers will prioritize enhanced thrombus capture efficiency, minimized vascular injury, and attenuated inflammatory responses. For instance, optimizing stent architecture and biomaterial composition can further enhance device flexibility and navigability [135,191]. Moreover, next-generation devices emphasize adaptive designs—incorporating shape-memory alloys or high-elasticity polymers, multilayer mesh constructs, ultra-thin guidewire-compatible designs, and anticoagulant coatings—to optimize thrombus engagement, enhance procedural flexibility, and reduce vascular trauma and re-occlusion risk.

7.2 Application of intelligent technology

Increasing demand for AIS therapy has driven the convergence of stent retriever innovation and advanced intelligent technologies. This integration is projected to produce major advancements across five domains: from a technological perspective, artificial intelligence (AI) will be seamlessly incorporated throughout the entire treatment process, while brain-computer interfaces will facilitate surgical manipulation. In terms of materials, biodegradable stents combined with nano-bionic structures are expected to enhance both safety and efficacy. Equipment upgrades will prioritize high-precision small-scale robots and comprehensive intelligent imaging platforms. Applications are projected to expand into multidisciplinary intersections as well as primary healthcare settings. Finally, collaboration between policymakers and industry stakeholders will accelerate technology translation. Despite challenges—such as personalized thrombus targeting and high implementation costs—these innovations hold promise to revolutionize neurointerventional care, enabling precise and efficient stroke management.

7.3 Multidisciplinary collaboration and comprehensive treatment

Management of AIS demands a multidisciplinary approach and multimodal therapy. Future stent retrievers are expected to be integrated with adjunctive therapies—including thrombolysis, antiplatelet regimens, and endovascular angioplasty—to enhance recanalization and reduce recurrence. Such collaborative, multimodal strategies may further improve therapeutic efficacy and patient prognosis [192–195].

7.4 Precision and personalized design

Despite extensive sizing options offered by devices such as Trevo NXT ProVue and Tigertriever 13, therapeutic efficacy may be constrained in patients with complex vascular anatomies or significant comorbidities. Patient presentations and procedural risk profiles are inherently heterogeneous. Future iterations of stent retrievers should emphasize personalized treatment strategies. By integrating patient-specific factors—such as age, sex, comorbid conditions, and vascular morphology—device selection and procedural technique can be tailored to optimize recanalisation outcomes. Device design must evolve toward greater precision and customization to meet individual anatomical and clinical requirements. This entails optimizing stent length, diameter, radial force, and material composition, alongside surface modifications to enhance thrombus engagement and minimize endothelial trauma, thereby improving procedural efficacy and safety [121,196–198].

8 Limitations

In stent retriever therapy, the risk of vascular injury remains a critical concern, especially during device deployment and manipulation. Procedural manipulation can cause mechanical endothelial trauma, increasing risks of hemorrhage, vasospasm, and vessel perforation. To mitigate these risks, recent innovations have focused on stent materials and design refinements. Incorporating superelastic, shape-memory nitinol, flexible closed-loop configurations, and adjustable-diameter architectures enhances vessel conformity and reduces device-wall friction. Moreover, intelligent navigation platforms and intraoperative feedback control enable real-time strategic adjustments, further minimizing vascular injury. However, these technologies demand advanced technical expertise, necessitating specialized clinicians and dedicated interventional teams. Complex vascular anatomies—with tortuous or stenotic segments—further exacerbate procedural difficulty, as navigating, deploying, and retrieving devices becomes more challenging.

These technological requirements limit adoption in resource-constrained settings—particularly in low-income regions—where limited infrastructure, variable operator expertise, and high costs impede widespread use. To address these barriers, future designs should optimize stent architecture and leverage cost-effective biomaterials to lower manufacturing costs and enhance accessibility. Concurrent advances in AI, microsensor integration, and telemedicine (e.g., 5G and 6G networks) will enhance device safety and efficacy via real-time monitoring and adaptive control. Furthermore, remote collaboration platforms and robotic-assisted interventions can mitigate reliance on local expertise, alleviating resource constraints and advancing AIS care in low-income areas.

Despite substantial progress in AIS management, stent-based interventions remain time-sensitive; therapeutic efficacy declines sharply beyond the optimal treatment window. Thus, future stent innovations must address not only material and design improvements but also strategies to extend therapeutic windows and enhance procedural adaptability and efficiency. In summary, continued technological progress, cost reductions, and international collaboration are expected to broaden global adoption of stent retrievers—especially in low-income regions—ultimately improving patient outcomes and quality of life.

9 Summary

This review examines stent retrievers’ structural characteristics, operating principles, efficacy evaluations, developmental status, recent innovations in AIS devices, and future prospects. Prominent recent devices and their supporting clinical evidence are also presented. Rapid advances in materials science, bioengineering, and medical imaging have yielded progressively sophisticated and capable stent retrievers. These developments enhance thrombus capture efficiency and procedural success while reducing complication rates and patient recovery times. As cutting-edge technologies emerge and clinical applications expand, the effectiveness and safety of novel stents and techniques are increasingly validated. Concurrently, innovative advancements in stent retrievers offer renewed hope for AIS patients. From foundational design innovations to advanced technological integrations and expanding clinical practice, stent retrievers continually achieve new milestones. They are poised to evolve toward greater precision, safety, and efficacy, promising improved treatment options and outcomes for AIS patients globally.

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