A Multicenter Preliminary Study of Cangrelor following Thrombectomy Failure for Refractory Proximal Intracranial Occlusions

Abstract

BACKGROUND AND PURPOSE: Rescue endovascular and pharmacologic approaches are increasingly being adopted after recanalization failure of acute large-vessel occlusion strokes with mechanical thrombectomy, with encouraging results. The safety and efficacy of glycoprotein IIb/IIIa inhibitors in ischemic stroke have been investigated, though cangrelor, a recent intravenous P2Y12receptor inhibitor with a rapid onset/offset of action and a short half-life, may be a valuable option. We compared the safety and efficacy of cangrelor with those of glycoprotein IIb/IIIa inhibitors for refractory occlusions. MATERIALS AND METHODS:We performed a retrospective analysis of the ongoing prospective, multicenter, observational Endovascular Treatment in Ischemic Stroke Registry in France between May 2012 and February 2020. Refractory intracranial occlusions of the anterior and posterior circulation were included and defined as recanalization failure of large-vessel occlusion stroke, perioperative target artery reocclusion, or high risk of early reocclusion related to an arterial wall lesion. The primary end point was a favorable outcome, defined as a 90-day mRS of 0-2. Secondary end points were reperfusion, intracranial hemorrhage, and procedural complications.RESULTS: Among 69 patients, 15 were treated with cangrelor, and 54, with glycoprotein IIb/IIIa inhibitors. The favorable outcome (adjusted OR ¼ 2.22; 95% CI, 0.42-11.75; P ¼ .348) and mortality (adjusted OR ¼ 0.44; 95% CI, 0.06-3.16; P ¼ .411) rates were similar in both groups. There was no difference in the rates of any intracranial hemorrhage (adjusted OR ¼ 0.40; 95% CI, 0.08-2.09; P ¼ .280), symptomatic intracranial hemorrhage (6.7% versus 0.0%, P ¼ .058), or procedural complications (6.7% versus 20.4%, P ¼ .215). Reperfusion rates were higher in the cangrelor group, though the difference did not reach statistical significance (93.3% versus 75.0% for modified TICI 2b-3; adjusted OR ¼10.88; 95% CI, 0.96-123.84; P ¼ .054). CONCLUSIONS:Cangrelor seems to be as safe as glycoprotein IIb/IIIa inhibitors for managing refractory intracranial occlusion and leads to satisfactory brain reperfusion. Cangrelor is a promising agent in this setting, and additional studies are warranted to confirm our findings.

Safety and Efficacy of Cangrelor in Acute Stroke Treated with Mechanical Thrombectomy: Endovascular Treatment of Ischemic Stroke Registry and Meta-analysis

“…Thus, we recently published a comparison between these 2 acute antiplatelet therapies. 21 Yet, data for safety and efficacy profiles still have to be explored.…”

24-Hour Carotid Stent Patency and Outcomes After Endovascular Therapy: A Multicenter Study

“…A stent occlusion was observed in 47/225 patients (20.9%). Patients with stent patency had a lower baseline National Institutes of Health Stroke Scale (median [interquartile range]: 13 [7-17] versus 18 [12][13][14][15][16][17][18][19][20][21]) and had more often stroke of atherothrombotic origin (77.0% versus 53.2%). A higher stent patency rate was found for patients treated with P2Y 12 antagonists at the acute phase (odds ratio [OR]‚ 2.95 [95% CI‚ 1.10-7.91]; P=0.026) and treated with angioplasty (OR‚ 2.42 [95% CI‚ 1.24-4.67]; P=0.008).…”

“…Baseline characteristics are reported in Table 1 according to the stent patency within 24 (±12) hours. Compared with the patients with stent occlusion, patients with stent patency had a lower stroke severity assessed by pre-treatment NIHSS score (median [interquartile range]: 13 [7][8][9][10][11][12][13][14][15][16][17] versus 18 [12][13][14][15][16][17][18][19][20][21]) and had more often a stroke of atherothrombotic origin (77.0% versus 53.2%).…”

“…13 Trials are needed to evaluate the optimal antiplatelet strategy. Small series reported a good safety profile of Cangrelor used during emergent CAS, [14][15][16][17] especially when compared with GpIIb/IIIa inhibitors. 18 The intravenous use, rapid timeto-effect, and short half-life profile (eg, platelet function restoration within 1 hour after drug interruption) of Cangrelor seems ideal in the context of EVT.…”

Comparison of three antithrombotic strategies for emergent carotid stenting during stroke thrombectomy: a multicenter study

“…Cangrelor is a fast-acting IV P2Y12 receptor inhibitor which might represent an alternative to GP2b3a inhibitors. There are very limited data regarding administration of cangrelor in the setting of acute ischemic stroke; however, recent publications34 35 in relatively small retrospective cohorts suggest a promising safety and efficacy profile. A multitude of combinations of drugs and dosing regimens can be considered, and this is reflected in the highly heterogeneous current clinical practice 36.…”