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Meta-Analysis
. 2025 Jun 1;17(e2):e237-e244.
doi: 10.1136/jnis-2023-021244.

Safety and efficacy of adjunctive intra-arterial antithrombotic therapy during endovascular thrombectomy for acute ischemic stroke: a systematic review and meta-analysis

Omar Marei  1 , Anna Podlasek  2 , Emma Soo  1 , Waleed Butt  3 , Benjamin Gory  4 , Thanh N Nguyen  5   6 , Jason P Appleton  7   8 , Sébastien Richard  9 , Hal Rice  10 , Laetitia de Villiers  10 , Vinicius Carraro do Nascimento  10 , Luis Domitrovic  10 , Norman McConachie  11 , Robert Lenthall  11 , Sujit Nair  11 , Luqman Malik  11 , Jasmin Panesar  11 , Kailash Krishnan  7   12 , Pervinder Bhogal  13 , Robert A Dineen  1   14 , Timothy J England  12   15 , Bruce C V Campbell  16   17 , Permesh Singh Dhillon  18   10
Affiliations
Meta-Analysis

Safety and efficacy of adjunctive intra-arterial antithrombotic therapy during endovascular thrombectomy for acute ischemic stroke: a systematic review and meta-analysis

Omar Marei et al. J Neurointerv Surg. .

Abstract

Background: Half of patients who achieve successful recanalization following endovascular thrombectomy (EVT) for acute ischemic stroke experience poor functional outcome. We aim to investigate whether the use of adjunctive intra-arterial antithrombotic therapy (AAT) during EVT is safe and efficacious compared with standard therapy (ST) of EVT with or without prior intravenous thrombolysis.

Methods: Electronic databases were searched (PubMed/MEDLINE, Embase, Cochrane Library) from 2010 until October 2023. Data were pooled using a random-effects model and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Risk of bias was assessed using ROBINS-I and ROB-2. The primary outcome was functional independence (modified Rankin Scale (mRS) 0-2) at 3 months. Secondary outcomes were successful recanalization (modified Thrombolysis In Cerebral Infarction (TICI) 2b-3), symptomatic intracranial hemorrhage (sICH), and 90-day mortality.

Results: 41 randomized and non-randomized studies met the eligibility criteria. Overall, 15 316 patients were included; 3296 patients were treated with AAT during EVT and 12 020 were treated with ST alone. Compared with ST, patients treated with AAT demonstrated higher odds of functional independence (46.5% AAT vs 42.6% ST; OR 1.22, 95% CI 1.07 to 1.40, P=0.004, I2=48%) and a lower likelihood of 90-day mortality (OR 0.71, 95% CI 0.61 to 0.83, P<0.0001, I2=20%). The rates of sICH (OR 1.00, 95% CI 0.82 to 1.22,P=0.97, I2=13%) and successful recanalization (OR 1.09, 95% CI 0.84 to 1.42, P=0.52, I2=76%) were not significantly different.

Conclusion: The use of AAT during EVT may improve functional outcomes and reduce mortality rates compared with ST alone, without an increased risk of sICH. These findings should be interpreted with caution pending the results from ongoing phase III trials to establish the efficacy and safety of AAT during EVT.

Keywords: Embolic; Hemorrhage; Stroke; Thrombectomy; Thrombolysis.

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Conflict of interest statement

Competing interests: TNN reported research support from Medtronic and SVIN; advisory board with Idorsia. PB reported travel support from Perflow; compensation from Cerenovus, Balt USA, LLC, Vesalio, Phenox Inc, and Brainomix for consultant services. BG has received grants from the French Ministry of Health and is the primary investigator of the TITAN, DIRECT ANGIO, and IA-RESCUE trial, and consulting fees from Air Liquide, MIVI, Medtronic, Boerhinger Ingelheim, Microvention, and Penumbra. JPA is supported, in part, by an NIHR Health and Care Research Scholarship. KK is a recipient of a research fellowship awarded by the Nottingham University Hospitals NHS Trust. There are no other disclosures or competing interests declared by the remaining authors.

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