June 21, 2022Thrombosis JournalOpen Access

Safety and efficacy of endovascular thrombectomy in acute ischemic stroke treated with anticoagulants: a systematic review and meta-analysis

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Why the study?

The safety and efficacy of endovascular thrombectomy in acute ischemic stroke patients receiving oral anticoagulants remained unclear, particularly regarding the risk of symptomatic intracranial hemorrhage.

Does prior use of oral anticoagulants increase the risk of symptomatic intracranial hemorrhage or affect functional outcomes in acute ischemic stroke patients undergoing endovascular thrombectomy?

Structured PICO

Does prior use of oral anticoagulants increase the risk of symptomatic intracranial hemorrhage or affect functional outcomes in acute ischemic stroke patients undergoing endovascular thrombectomy?

Population

Acute ischemic stroke (AIS) patients with large vessel occlusion undergoing endovascular thrombectomy (EVT). 15 non-randomized studies included. Mean ages ranged from 62 to 79 years, mean NIHSS scores ranged from 10 to 18.

Intervention

Prior use of oral anticoagulants (OACs), specifically vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs)

Comparator

No oral anticoagulant (OAC) use prior to EVT

Outcome

Primary safety outcome: symptomatic intracranial hemorrhage (sICH) after EVT. Primary efficacy outcome: functional status at 3 months (modified Rankin scale score).safety

Prior use of vitamin K antagonists, but not DOACs, is associated with an increased risk of symptomatic intracranial hemorrhage and mortality in patients with acute ischemic stroke undergoing endovascular thrombectomy.

Limitations

All enrolled studies were retrospective, lacking adjustment for confounding factors
Heterogeneity across studies due to differences in populations, underlying diseases, and device usage
Atrial fibrillation was more common in patients who received OACs
Dosage of OAC was not frequently reported
Use of idarucizumab for dabigatran reversal was not reported

Implication

Prior VKA use signals heightened EVT risk; supports anticoagulant-specific risk stratification in observational meta-analyses.

Abstract

BACKGROUND: Endovascular thrombectomy (EVT) is an effective therapy in acute ischemic stroke (AIS) with large vessel occlusion, especially for those who are unsuitable for intravenous thrombolysis. However, the safety and efficacy of EVT in AIS patients who receiving oral anticoagulants (OACs) is unclear, especially for the risk of symptomatic intracranial hemorrhage (sICH). METHODS: Database of PubMed, Embase, and Cochrane Library were searched from Jan 1, 2000, through the final search date of Jun 2, 2021. Eligible studies for enrollment required outcomes reported for events of sICH, mortality, functional status, and successful reperfusion. Meta-analysis was conducted to compare the outcomes difference after EVT between AIS patients with or without OACs use. The primary safety outcome was sICH after EVT, and the primary efficacy outcome was functional status at 3 months. RESULTS: One thousand nine hundred forty studies were screened for eligibility and 15 of them were included in the meta-analysis. Compared the OACs group to control arm, vitamin K antagonists (VKAs) was associated with higher risk of sICH (OR 1.49, 95% CI 1.10-2.02) and mortality (OR 1.67, 95% CI 1.35-2.06). Poor functional outcomes were noted both in the VKAs and direct oral anticoagulants (DOACs) groups (OR 0.62, 95% CI 0.54-0.71 and OR 0.61, 95% CI 0.53-0.71, respectively). No differences in successful reperfusion were observed. CONCLUSIONS: Comparing with DOACs, VKAs use was associated with a higher risk of sICH and mortality after EVT. Patients who did not receive OACs exhibited more favorable outcomes. The successful reperfusion did not differ between groups. However, results for mortality and functional outcomes have to be interpreted with caution since they are based on non-randomized data and unadjusted proportions.