All procedures were performed under local anesthesia. No heparin loading was performed, except for a heparinized saline flush. On detecting DMVO on the control angiogram performed during the procedure, a microcatheter (Excelsior XT-27, Stryker, Fremont, CA, USA; Marksman, Medtronic, Irvine, CA, USA) with a microwire (Synchro-14, Stryker, Fremont, CA, USA) was inserted into the guiding catheter. While the microcatheter approached the thrombus, we ensured that the thrombus was untouched by the microwire, and manual aspiration was performed with a 50 ml syringe. When aspirating the blood, we slowly pushed the microcatheter toward the thrombus. Suction was maintained all through the procedure, and maximum suction was achieved when blood aspiration stopped. After 1 min, the microcatheter was removed while suctioning with a 50 ml syringe through a guiding catheter. Angiography was performed after checking the tip, inside the microcatheter, and inside the syringe.

An 81-year-old woman was admitted complaining of drowsiness and left-sided weakness. The patient had atrial fibrillation and was treated with aspirin. The initial National Institutes of Health Stroke Scale (NIHSS) score was 15. Magnetic resonance angiography (MRA) revealed right MCA M1 occlusion. Intravenous tissue plasminogen activator (IV-tPA) was administered, and femoral artery puncture was performed within 3 h of onset. The initial angiogram revealed simultaneous right M1 and distal anterior cerebral artery (ACA) occlusions. The right MCA M1 occlusion was successfully recanalized by suction thrombectomy using a 5MAX (Penumbra, Alameda, CA, USA) suction catheter. For right distal ACA segment occlusion, an Excelsior XT-27 microcatheter was delivered with a Synchro-14 microwire just proximal to the thrombus and manual suction using a 50 ml syringe was performed as previously described. After the withdrawal of the microcatheter, a thrombus was found at the microcatheter tip. Follow-up angiography revealed complete recanalization of the ACA. The NIHSS score at discharge after rehabilitation was 6 (Table 1, Fig. 1).

A 67-year-old man presented to the emergency department with right hemiplegia. He was diagnosed with an acute infarction in the left MCA territory caused by atrial fibrillation one year prior and was prescribed a non-vitamin K oral anticoagulant. He had an NIHSS score of 5 with aphasia but was able to live independently. The initial NIHSS score was 13 points. MRI and MRA showed a left posterior inferior cerebellar artery (PICA) territory ischemic signal change with left vertebrobasilar occlusion. On the initial left vertebral artery (VA) angiogram, the left VA V4 segment was not visualized because of distal VA occlusion. On follow-up, left VA angiography after suction thrombectomy using an intermediate catheter (Navien, Medtronic, Irvine, CA, USA) on the distal left VA, the PICA was completely recanalized. However, left distal posterior cerebral artery (PCA) occlusion was noted, which was intact on the right VA angiogram. A Marksman microcatheter was placed at the occlusion site using a Synchro-14 wire. After suction with a 50 ml syringe and withdrawal of the microcatheter, a thrombus was noted at the microcatheter tip. A follow-up angiogram showed partial recanalization of the left distal PCA with relatively good leptomeningeal collaterals. The operator decided to stop the procedure, and a minimal new lesion was noted on post-thrombectomy diffusion-weighted imaging (DWI) in the left PCA territory. The patient was discharged and was able to walk independently on postoperative day 7 (Table 1, Fig. 2).

An 86-year-old male patient was transferred from another hospital with decreased consciousness, left-sided weakness, and dysarthria. Occlusion of the top of the basilar artery (BA) was noted on MRA with restriction of diffusion in the right pons, midline of the midbrain, and left thalamus. The initial NIHSS score was 14 points. IV-tPA was started before mechanical thrombectomy. Right PCA and left superior cerebellar artery (SCA) distal occlusions were noted on the initial angiogram, while the BA top occlusion was recanalized. After introducing the Marksman microcatheter into the right distal PCA occlusion, suction thrombectomy was successfully performed. However, it was not possible to insert the same microcatheter into the left SCA because of acute angulation. A Prowler Select Plus microcatheter (Cerenovus, Irvine, CA, USA) was introduced, and recanalization was accomplished with stent retriever thrombectomy. Contrast-enhanced MRA performed 24 h later confirmed successful recanalization. The NIHSS score at discharge was 1 (Table 1, Fig. 3).