Intraoperative cangrelor during mechanical thrombectomy: is the systematic addition of aspirin needed?

Objectives In the hyperacute setting of mechanical thrombectomy (MT) for large-vessel-occlusion stroke, periprocedural platelet inhibition may be required in cases of refractory occlusions or underlying cervical or intracranial arterial disease at risk of reocclusion. Cangrelor is increasingly used in this context, although its use remains largely supported by observational evidence, and the impact of concomitant aspirin remains uncertain. This study investigated the safety and efficacy of the addition of intravenous aspirin to cangrelor during MT. Methods We conducted a retrospective analysis of the Endovascular Treatment in Ischemic Stroke (ETIS) Registry across 34 French comprehensive stroke centres. All consecutive MT patients receiving intraoperative cangrelor between July 2018 and April 2025 were included, irrespective of the indication for intravenous antiplatelet therapy. The primary endpoint was 90-day favourable outcome (modified Rankin Scale [mRS] 0–2 or equal to pre-stroke mRS). Secondary outcomes included excellent outcome, early neurological improvement, angiographic recanalisation, day-1 arterial patency and intracranial haemorrhage (ICH). Propensity-score overlap weighting was used to adjust for confounding. Results A total of 644 patients were analysed (cangrelor + aspirin combination: 226; cangrelor alone: 418). Favourable outcomes at 90 days were similar between groups (57.1% vs 58.8%; adjusted odds ratio [aOR] = 0.93; 95% confidence interval, 0.67–1.30; P = 0.69), as were excellent outcomes and early neurological improvement. Rates of successful and complete reperfusion were similar across groups. No differences were observed for symptomatic ICH (6.2% vs 9.2%; aOR = 0.66), any ICH, intra- and extracranial arterial patency on day-1 imaging, or 90-day mortality (22.3% vs 23.9%; aOR = 0.91). Conclusions No significant differences in clinical, angiographic or safety outcomes were observed between cangrelor monotherapy and cangrelor combined with intravenous aspirin during MT. These findings provide comparative evidence on two cangrelor-based strategies currently used in clinical practice, although they should not be interpreted as demonstrating equivalence or excluding a potential benefit of adjunctive aspirin. Further prospective studies are needed to clarify the role of aspirin coadministration in this setting.