Safety of Endovascular Thrombectomy for Acute Ischaemic Stroke in Anticoagulated Patients Ineligible for Intravenous Thrombolysis

Wong, John Wp; Чурилов, Леонид; Dowling, Richard; Mitchell, Peter; Bush, Steven; Kanesan, Lasheta; Yan, Bernard

doi:10.1159/000493801

Cited by 26 publications

(28 citation statements)

References 25 publications

(26 reference statements)

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“…We found that therapeutic anticoagulation in AF patients at the time of stroke did not adversely influence outcome. This finding is similar to several studies, including thrombolysis-ineligible patients [23][24][25][26][27] .…”

Section: Discussionsupporting

confidence: 92%

Comparison of functional outcomes after endovascular thrombectomy in patients with and without atrial fibrillation

Fu¹,

Cappelen‐Smith²,

Edwards³

et al. 2021

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Aim: Patients with atrial fibrillation (AF) are over-represented in endovascular thrombectomy (EVT) populations, due to a high prevalence of large vessel occlusions (LVO) and contraindication to intravenous thrombolysis. This study aimed to: (1) compare 90-day functional outcomes [modified Rankin Score (mRS) 0-2] and mortality in AF vs. non-AF patients receiving EVT; (2) compare 90-day functional outcomes and mortality in AF patients on therapeutic vs. non-therapeutic anticoagulation receiving EVT; and (3) identify factors influencing outcomes in AF patients receiving EVT.Methods: A retrospective analysis of 394 consecutive patients who received EVT for anterior cerebral circulation LVO at an Australian comprehensive stroke center was performed. The main outcome measures [90-day dichotomized mRS (0-2 good; 3-6 poor functional outcome) and mortality] were compared between AF and non-AF patients, as well as between therapeutic and non-therapeutic anticoagulation cohorts.Results: In total, 171 (49%) EVT patients had AF. Patients with AF were older, had higher NIHSS, and had lower rates of thrombolysis administration. AF patients showed improved 90-day mRS on multivariate analysis [aOR 1.988 (1.167-3.387)], with similar symptomatic intracranial hemorrhage (sICH) [aOR 0.364 (0.064-2.086)] and mortality ]. There was no difference in 90-day mRS ], successful reperfusion rates )], or mortality [aOR 1.077 (0.429-2.705)] between AF patients on therapeutic vs. non-therapeutic anticoagulation. In patients with AF, advancing age and higher NIHSS were independent predictors of worse 90-day functional outcome (OR = 1.045, P = 0.020; OR = 1.086, P = 0.001) and mortality (OR = 1.138, P < 0.001; OR = 1.107, P = 0.002). On multivariate analysis, thrombolysis administration improved mortality (OR = 0.215, P = 0.016) but not functional outcomes. Conclusion:Patients with AF showed improved 90-day functional outcome, with similar mortality and sICH, after EVT. Therapeutic anticoagulation did not adversely influence EVT outcomes.

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Section: Discussionsupporting

confidence: 92%

Comparison of functional outcomes after endovascular thrombectomy in patients with and without atrial fibrillation

Fu¹,

Cappelen‐Smith²,

Edwards³

et al. 2021

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“…With regards to technical efficacy of ET, if reported, all studies showed similar reperfusion rates in OAC and non-OAC patients as in our GSR-ET cohort [2,5,9,11,16,19,21,22]. Nevertheless, the reperfusion rates were distributed heterogeneously among the different studies ranging from 64 to 93% [2,5,9,11,16,19,21,22]. Additionally, one study compared ET in VKA and NOAC patients and reported on better reperfusion rates among NOAC patients [12] which was not reflected by our data showing similar reperfusion rates among OAC and non-OAC patients.…”

Section: Discussionsupporting

confidence: 68%

“…Most studies published retrospectively collected data, but four studies were prospective cohort studies [2, 5, 9-17, 19, 21, 22]. With regards to technical efficacy of ET, if reported, all studies showed similar reperfusion rates in OAC and non-OAC patients as in our GSR-ET cohort [2,5,9,11,16,19,21,22]. Nevertheless, the reperfusion rates were distributed heterogeneously among the different studies ranging from 64 to 93% [2,5,9,11,16,19,21,22].…”

Section: Discussionmentioning

confidence: 69%

Endovascular stroke treatment in orally anticoagulated patients: an analysis from the German Stroke Registry-Endovascular Treatment

et al. 2020

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Background Endovascular treatment (ET) in orally anticoagulated (OAC) patients has not been evaluated in randomized clinical trials and data regarding this issue are sparse. Methods We analyzed data from the German Stroke Registry-Endovascular Treatment (GSR-ET; NCT03356392, date of registration: 22 Nov 2017). The primary outcomes were successful reperfusion defined as modified thrombolysis in cerebral infarction (mTICI 2b-3), good outcome at 3 months (modified Rankin scale [mRS] 0–2 or back to baseline), and intracranial hemorrhage (ICH) on follow-up imaging at 24 h analyzed by unadjusted univariate and adjusted binary logistic regression analysis. Additionally, we analyzed mortality at 3 months with adjusted binary logistic regression analysis. Results Out of 6173 patients, there were 1306 (21.2%) OAC patients, 479 (7.8%) with vitamin K antagonists (VKA) and 827 (13.4%) with non-vitamin K antagonist oral anticoagulation (NOAC). The control group consisted of 4867 (78.8%) non-OAC patients. ET efficacy with the rates of mTICI 2b-3 was similar among the three groups (85.6%, 85.3% vs 84.3%, p = 0.93 and 1). On day 90, good outcome was less frequent in OAC patients (27.8%, 27.9% vs 39.5%, p < 0.005 and < 0.005). OAC status was not associated with ICH at 24 h (NOAC: odd’s ratio [OR] 0.89, 95% confidence interval [CI] 0.67–1.20; VKA: OR 1.04, CI 0.75–1.46). Binary logistic regression analysis revealed no influence of OAC status on good outcome at 3 months (NOAC: OR 1.25, CI 0.99–1.59; VKA: OR 1.18, CI 0.89–1.56) and mortality at 3 months (NOAC: OR 1.03, CI 0.81–1.30; VKA: OR 1.04, CI 0.78–1.1.37). Conclusions ET can be performed safely and successfully in LVO stroke patients treated with OAC. Clinical trial registration-URL http://www.clinicaltrials.gov. Unique identifier: NCT03356392.

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“…To date, it has been a matter of controversy if EVT in AIS with prior anticoagulant treatment carries a major risk of bleeding. It is essential to select the best therapeutic approach in this subset of patients, because despite best medical treatment with anticoagulation 1-3% of patients will develop strokes annually (5).…”

Section: Introductionmentioning

confidence: 99%

Oral Anticoagulation and Risk of Symptomatic Hemorrhagic Transformation in Stroke Patients Treated With Mechanical Thrombectomy: Data From the Nordictus Registry

et al. 2020

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Introduction: We aimed to evaluate if prior oral anticoagulation (OAC) and its type determines a greater risk of symptomatic hemorrhagic transformation in patients with acute ischemic stroke (AIS) subjected to mechanical thrombectomy.Materials and Methods: Consecutive patients with AIS included in the prospective reperfusion registry NORDICTUS, a network of tertiary stroke centers in Northern Spain, from January 2017 to December 2019 were included. Prior use of oral anticoagulants, baseline variables, and international normalized ratio (INR) on admission were recorded. Symptomatic intracranial hemorrhage (sICH) was the primary outcome measure. Secondary outcome was the relation between INR and sICH, and we evaluated mortality and functional outcome at 3 months by modified Rankin scale. We compared patients with and without previous OAC and also considered the type of oral anticoagulants.Results: About 1.455 AIS patients were included, of whom 274 (19%) were on OAC, 193 (70%) on vitamin K antagonists (VKA), and 81 (30%) on direct oral anticoagulants (DOACs). Anticoagulated patients were older and had more comorbidities. Eighty-one (5.6%) developed sICH, which was more frequent in the VKA group, but not in DOAC group. OAC with VKA emerged as a predictor of sICH in a multivariate regression model (OR, 1.89 [95% CI, 1.01–3.51], p = 0.04) and was not related to INR level on admission. Prior VKA use was not associated with worse outcome in the multivariate regression model nor with mortality at 3 months.Conclusions: OAC with VKA, but not with DOACs, was an independent predictor of sICH after mechanical thrombectomy. This excess risk was associated neither with INR value by the time thrombectomy was performed, nor with a worse functional outcome or mortality at 3 months.

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Safety of Endovascular Thrombectomy for Acute Ischaemic Stroke in Anticoagulated Patients Ineligible for Intravenous Thrombolysis

Cited by 26 publications

References 25 publications

Comparison of functional outcomes after endovascular thrombectomy in patients with and without atrial fibrillation

Comparison of functional outcomes after endovascular thrombectomy in patients with and without atrial fibrillation

Endovascular stroke treatment in orally anticoagulated patients: an analysis from the German Stroke Registry-Endovascular Treatment

Oral Anticoagulation and Risk of Symptomatic Hemorrhagic Transformation in Stroke Patients Treated With Mechanical Thrombectomy: Data From the Nordictus Registry

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