Safety and Efficacy of Heparinization During Mechanical Thrombectomy in Acute Ischemic Stroke

Abstract

Background: The benefits of heparization during mechanical thrombectomy (MT) with newer generation thrombectomy devices, and if it is counterbalanced by the increased risk of intracranial hemorrhage (ICH) remain unknown. Methods: We included eligible patients who underwent MT from the ANGEL registry study (2015-2017) in China. Subjects in the current analysis were dichotomized into two groups according to whether adequate heparinization during MT was performed. In the heparinization group, unfractionated heparin was infused at 50–100 IU/Kg at first and additional 1,000 IU at intervals of an hour during the operation. Safety outcomes (symptomatic intracerebral hemorrhage [sICH], ICH and distal embolization) and efficacy outcomes (artery recanalization and functional outcomes at 3-month follow-up) were compared between groups. Results: We included 619 patients from the entire cohort of 917 patients. The average age of them was 63.9 ± 13.7 years, 269 (43.5%) were treated with heparinization during MT. Heparinization during MT didn't significantly influence recanalization rates, total ICH and long-term mortality (adjusted p > 0.05 for all). But sICH and distal embolization occurred more frequently (9.3 vs. 5.1%, adjusted p = 0.02; 7.1 vs. 3.1%, adjusted p = 0.04, respectively), while functional independence appeared less likely (39.8 vs. 47.4%, adjusted p = 0.01) in heparinization group than that in non-heparinization group. Multivariable logistic regression analyses showed that heparinization during MT was an independent predictor for sICH (Odds ratio 2.36 [1.19–4.67], p = 0.01) in addition to cardio-embolism stroke and posterior circulation stroke (PCS), and an independent predictor for poor outcome (Odds ratio 1.79 [1.23–2.59], p < 0.01) besides age, bridging intravenous thrombolysis, admission NIHSS, drinking and PCS. Conclusion: Heparinization during MT may be associated with increased risk of safety outcomes over sICH and distal embolization, as well as efficacy outcomes over long-term poor outcome. Further randomized controlled trials are needed.

Safety and efficacy of aspirin, unfractionated heparin, both, or neither during endovascular stroke treatment (MR CLEAN-MED): an open-label, multicentre, randomised controlled trial

“…20,21 Observational studies found that unfractionated heparin might improve functional outcomes in patients with ischaemic stroke treated with endovascular treatment. 3,5,11 In our trial, we did find higher recanalisation rates in the unfractionated heparin group. However, this benefit did not outweigh the increased risk of symptomatic intracranial haemorrhage.…”

“…3,4 However, for aspirin and heparin, the potential benefits are not known on whether its periprocedural use outweigh the potentially increased risk of symptomatic intracranial haemorrhage. 3,5 Guidelines advise against the early administration of aspirin after treatment with intravenous thrombolytics because of its increased risk of sympto matic intracranial haemorrhage without evidence for a beneficial effect in a previous trial. 6,7 However, this trial was done in patients with ischaemic stroke treated with intravenous thrombolytics before the introduction of endovascular treatment, and the 4•3% risk of symptomatic intracranial haemorrhage in the intervention group was low.…”

Low‐dose rescue tirofiban in mechanical thrombectomy for acute cerebral large‐artery occlusion

“…All our participants were enrolled from the Acute Ischemic Stroke Cooperation Group of Endovascular Treatment (ANGEL) study, a multicentre prospective registry study aiming to evaluate MT delivery and to improve the MT algorithm in clinical practice from June 2015 to December 2017 in China. Details about the design of the ANGEL study have been reported [10,11]. (The design, inclusion/exclusion criteria, data collection and endovascular treatment of the study are described in the Supporting information.)…”

Use of heparinized saline flush during endovascular thrombectomy for acute ischemic stroke; a survey of clinical practice in the Netherlands

“…The TREVO 2-tial (Winningham et al, 2018 ) and multi-MERCI trial (Nahab et al, 2012 ) found neutral effects of periprocedural heparin on sICH and mortality, but a positive effect on functional outcome. The ANGEL- collaborators from China (Yang et al, 2019 ) however showed a higher rate of sICH and distal embolization with increasing total heparin dose (the latter could be due to a higher frequency of intracranial atherosclerosis). Regarding the sole impact of heparin in flush fluids during EVT, there are hardly any data available.…”