Endovascular Thrombectomy In Patients With Acute Ischemic Stroke And Recent Use Of Oral Vitamin K-Antagonists: The Get With The Guidelines-Stroke Program

Introduction: Emergent endovascular thrombectomy (EVT) is effective in improving outcomes in patients with stroke caused by large vessel occlusion. However, there are limited data on the use of EVT in patients taking an oral vitamin K antagonist (VKA), constraining guideline development around EVT use in this vulnerable population. Methods: To address this knowledge gap, we performed a retrospective, observational, cohort study based on a population-based sample of stroke admissions in the US (the AHAs “Get With The Guidelines-Stroke" Program) between October 2015 and March 2020. We aimed to determine whether use of VKA was associated with the risk of symptomatic intracranial hemorrhage (sICH) and functional outcomes in patients undergoing EVT within 6 hours of time last known well after adjusting for pre-specified confounders. Results: Of 32,715 patients (median age 72 years; 50.7% female), 3,087 were taking a VKA and 29,628 were not on an OAC prior to stroke. Patients taking VKAs were older (median age 78 vs. 71 years) but stroke severity was similar between the groups (median NIHSS 18 vs. 17). Of patients taking a VKA, 211 (6.8%) suffered a sICH whereas 1,904 (6.4%) patients not on OAC developed a sICH. VKA was not associated with sICH (adjusted odds ratio 1.20, 95% CI: 0.96-1.49). VKA use was associated with a higher risk of life-threatening systemic hemorrhage (1.2% vs. 1.02%; aOR 1.93 (1.17-3.19)) but not with mortality/discharge to hospice (27.1% vs. 20.6%; aOR 1.02 (0.90-1.14)). Patients taking a VKA prior to EVT were more likely to be able to be ambulatory at discharge (aOR 1.24 [1.11-1.39]) and to have an mRS of 0-2 (aOR 1.23 [1.07-1.42]). Conclusions: Among patients with acute ischemic stroke on VKA, EVT appears to be well tolerated without prohibitive risks of sICH. Our results provide support for the deployment of this critical, disability-reducing therapy in this population of patients with a large vessel occlusion presenting within 6 hours of time last known well.