Objective:

To evaluate evidence for PCA thrombectomy via a pre-specified synthesis of the ATTENTION, BAOCHE, and PLATO studies.

Approach:

• Evidence Layers: Integrated three evidence layers: indirect evidence from ATTENTION/BAOCHE trials, observational data from PLATO, and connecting subgroup data.

Key Findings:

• ATTENTION (aRR 2.06, 1.46–2.91) and BAOCHE (aRR 1.81, 1.26–2.60) indirectly support the feasibility of EVT for posterior circulation occlusions.
• PLATO study suggests potential benefit for PCA occlusion with a functional recovery aOR of 1.13 (0.85–1.50) and a higher rate of complete vision recovery (70% vs. 43%, p = 0.002), but also indicates a higher mortality signal (RR 2.15, 1.32–3.50).
• Evidence assessment scores high for principle feasibility in RCTs (9/10) and target-specificity in PLATO (9/10).

Interpretation:

Endovascular therapy for acute PCA occlusion is physiologically plausible and shows promising direct signals, but lacks randomized confirmation.

Limitations:

• No dedicated randomized trials specifically targeting PCA occlusion.
• Existing evidence is fragmented and insufficient for guiding clinical practice.

Conclusion:

This synthesis highlights the urgent need for a dedicated PCA thrombectomy RCT.