Endovascular thrombectomy for acute stroke in anticoagulated patients: systematic review and Meta-Analysis

Endovascular thrombectomy (EVT) is an effective treatment for acute ischemic stroke (AIS). Oral anticoagulants are used for stroke prevention in pro-embolic patients, but their impact on EVT outcomes, particularly symptomatic intracranial hemorrhage (sICH), remains uncertain. This study aims to evaluate the safety and efficacy of vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs) on EVT outcomes. We searched PubMed, Cochrane, and Embase from 2015 to August 2024 for studies comparing anticoagulated and non-anticoagulated AIS patients undergoing EVT. Safety outcomes included sICH and 90 days mortality. Efficacy outcomes included successful reperfusion rate and 90 days functional outcome. Subgroup analyses evaluated the effect of therapeutic-dose anticoagulation. Fifteen studies with 62,328 AIS patients were included; 9,977 were anticoagulated (6,879 VKA, 3,098 DOAC). VKA patients had a significantly higher rate of sICH (OR = 1.32, 95% CI [1.05, 1.66]) and 90 days mortality (OR = 1.61, 95% CI [1.25, 2.08]) compared to non-anticoagulated patients. DOACs showed no significant difference in sICH risk (OR = 0.83, 95% CI [0.48, 1.44]) or mortality (OR = 1.20, 95% CI [0.89, 1.61]). Functional outcomes at 90 days were significantly worse in both anticoagulated groups, but only VKA patients demonstrated worsened outcomes in the therapeutic-dose subgroup analysis. EVT success rates were comparable between all groups. DOACs offer a safer EVT profile than VKAs, with lower sICH risk and mortality. These findings support DOACs as the preferred anticoagulant for stroke prevention. Further research should assess long-term outcomes and distinguish procedure-related mortality from secondary causes.