抗凝治疗且不符合静脉溶栓条件的急性缺血性卒中患者血管内血栓切除术的安全性

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

作者信息

Wong John W P, Churilov Leonid, Dowling Richard, Mitchell Peter, Bush Steven, Kanesan Lasheta, Yan Bernard

机构信息

Royal Melbourne Hospital, Melbourne, Victoria, Australia.

Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia.

出版信息

Cerebrovasc Dis. 2018;46(5-6):193-199. doi: 10.1159/000493801. Epub 2018 Nov 1.

DOI:10.1159/000493801

PMID:30384367

Abstract

BACKGROUND/AIM: Endovascular thrombectomy may be performed in anticoagulated patients taking vitamin-K antagonists (VKA) or direct-acting oral anticoagulants (DOAC) in whom the use of intravenous tissue plasminogen activator (tPA) is contraindicated. We aimed to investigate the efficacy and safety of mechanical thrombectomy specifically in anticoagulated patients ineligible for thrombolysis.

METHODS

We performed a retrospective analysis of a prospectively collected database of consecutive ischaemic stroke patients undergoing mechanical thrombectomy from January 2008 to June 2017. Patients receiving any dose of intravenous or intra-arterial thrombolysis were excluded. Patients taking oral anticoagulants (VKAs or DOACs) were compared with non-anticoagulated patients. Outcomes compared between groups included the rate of intracerebral haemorrhage (ICH) on follow-up imaging (ICHany), symptomatic ICH, functional independence at 90 days (modified Rankin scale score, 0-2), mortality, and post-treatment recanalization (Thrombolysis in Cerebral Infarction score ≥2b).

RESULTS

In all, 102 patients undergoing mechanical thrombectomy without prior thrombolysis were included in the study. Sixty-six (64.7%) patients were not anticoagulated, 23 (22.5%) patients were taking VKAs, and 13 (12.7%) patients were taking DOACs. There were no significant differences in the rate of ICHany (11.1 vs. 13.6%, p = 0.93) or sICH (2.8 vs. 1.5%, p = 0.14) in anticoagulated patients compared to non-anticoagulated patients. No cases of sICH were observed among patients taking DOACs. After 90 days of follow-up, the rates of functional independence (50.0 vs. 43.1%) and mortality (27.8 vs. 25.8%) were also similar between the anticoagulation and the non-anticoagulation groups.

CONCLUSION

Mechanical thrombectomy appears to be safe and effective in anticoagulated patients ineligible for thrombolysis, with observed haemorrhage rates similar to those of patients not on anticoagulant therapy. However, further multicentre prospective studies are needed, due to the rising number of patients on warfarin and DOACs worldwide.

摘要

背景/目的：对于正在服用维生素K拮抗剂（VKA）或直接作用口服抗凝剂（DOAC）且静脉注射组织纤溶酶原激活剂（tPA）使用禁忌的抗凝患者，可进行血管内血栓切除术。我们旨在研究机械取栓术在不符合溶栓条件的抗凝患者中的疗效和安全性。

方法

我们对2008年1月至2017年6月连续接受机械取栓术的缺血性卒中患者的前瞻性收集数据库进行了回顾性分析。排除接受任何剂量静脉或动脉溶栓治疗的患者。将服用口服抗凝剂（VKA或DOAC）的患者与未抗凝患者进行比较。组间比较的结果包括随访影像上的脑出血（ICHany）发生率、症状性脑出血、90天时的功能独立性（改良Rankin量表评分，0 - 2）、死亡率以及治疗后再通情况（脑梗死溶栓评分≥2b）。

结果

总共102例未接受过溶栓治疗的机械取栓术患者纳入研究。66例（64.7%）患者未抗凝，23例（22.5%）患者服用VKA，13例（12.7%）患者服用DOAC。与未抗凝患者相比，抗凝患者的ICHany发生率（11.1%对13.6%，p = 0.93）或症状性脑出血（sICH）发生率（2.8%对1.5%，p = 0.14）无显著差异。服用DOAC的患者中未观察到症状性脑出血病例。随访90天后，抗凝组和未抗凝组的功能独立性发生率（50.0%对43.1%）和死亡率（27.8%对25.8%）也相似。