INTRODUCTION
Accounting for 87% of all types of stroke, ischemic stroke has both fatal and disabling consequences for affected patients\cite{Sacco2006}. Ischemic stroke remains the leading cause of long term disability, however, advances made in the past decade offer significant potential to change this. Recent randomized controlled clinical trials have demonstrated the efficacy of endovascular intervention over tPA alone and have catalyzed the treatment of ischemic stroke, affording patients much more favorable outcomes than before. 
Landmark studies such as SWIFT-PRIME demonstrated that patients who suffered large vessel anterior circulation occlusions treated with IV tPA in conjunction with the Solitaire Stent retriever saw reductions in post stroke disability. Alongside the DAWN trial, acute ischemic stroke treatment underwent a paradigm shift leaning towards early and aggressive endovascular intervention. As the landscape has changed, newer stent retrievers have been introduced into the marketplace by various neurovascular companies offering providers different tools with the hope for improved recanalization rates and times and ultimately improved patient outcomes.
In addition to the proven efficacy of stent retrievers, a method known as a direct aspiration first pass technique (ADAPT) has emerged as an alternative technique for thrombectomy without the use of a stent retriever\cite{Turk_2013}. This technique relies heavily on large bore aspiration catheters (MAYBE MENTION THE NEW COMPASS TRIAL AND RESULTS).
Although the advancements in stroke care and intervention for ischemic stroke have undeniably changed and advanced in a positive direction, stroke intervention remains a high risk high reward process. From vessel access to recanalization of the affected vessels, complications may occur along various junctures during the intervention requiring complication avoidance. Even still, with extra effort and care to prevent complications, complications do invariably arise and the subsequent management of these events becomes crucial.
Overall, from recent randomized controlled trials, the risk of complications with sequelae for patient from mechanical thrombectomy is 15%\cite{Balami_2017}
Here we will discuss the specific approaches in the endovascular treatment of acute ischemic stroke with focus on the common complications, tips for avoidance, and strategies to employ when complications do occur.
Access, access, accesss
Arterial access, seemingly simple to some and often overlooked by neophyte interventionists, is the basis by which intervention may be undertaken  and the source of disastrous complications during thrombectomy. In the neurovascular space, the femoral artery remains the standard for gaining access, however novel techniques using the radial artery, brachial artery, and in rare instances the carotid artery have emerged.  In patients with intracranial vascular disease, it is not uncommon to see peripheral vascular disease thus rendering access difficult. Prior to intervention, tortuosity and age related changes to vessels may pose difficulties. Groin hematoma and even more concerning, retroperitoneal hematoma can significantly negatively alter the outcome of stroke intervention. Inadequate closure of the vessel at the end of the procedure can result in significant blood loss, especially in instances where larger sheaths are used. IN acute stroke intervention, like the cardiovascular space with myocardial infarction, time is of the essence.  Groin to recanalization times are key, therefore time lost in attempting to gain access can prolong the ischemia period and potentially altering clinical outcomes. If access is difficult to obtain within 2-3 minutes, there should be no hesitation to employ ultrasound for assisting in gaining vascular acesss, and if the standard transfemoral routes are deeemed inapprorpiate or tenuous, quick adjustments should be made to use radial, brachial, and even direct carotid access.  Incorrectly and misplaced sheaths may be temporarily left in place to avoid issues in order for the thrombectomy to proceed.  Close attention should be paid to pre-procedure imaging.  CTA of the head and neck or CT stroke studies reveal arch anatomy, anatomical variations of large vessels, and possible vascular tortuoisities that may hinder intracranial lesion access. Complications  pertaining to access are by and large avoidable if the neurointerventionist adequately anticipates the aforementioned factors even prior to the patient getting on the table.