The Source for Neurovascular News and Education

September 17, 2019

 

A post hoc analysis of TREVO 2 shows it may improve outcomes without increasing complications.

 

Use of periprocedural heparin during clot removal with a stent retriever in patients with acute ischemic stroke is safe and may increase the likelihood of achieving a good functional outcome, according to a post hoc analysis of the TREVO 2 trial. The findings were published online recently ahead of print in the Journal of NeuroInterventional Surgery.

“There is no current standard of care established for the use of periprocedural heparin in acute ischemic stroke endovascular treatment,” senior author Fadi Nahab, MD (Emory University, Atlanta, GA), told Neurovascular Exchange in an email. “The objective of our study was to evaluate the safety and efficacy of periprocedural heparin with the use of stent retrievers.”

In a post hoc analysis, Nahab along with Melanie J. Winningham, MD (Emory University), and colleagues compared baseline characteristics and clinical outcomes between patients who did and did not receive heparin during thrombectomy with the Merci or Trevo stent retrievers (Stryker Neurovascular).

Of the 173 patients in the trial, 34% received periprocedural heparin, including 40 who received a single preprocedural bolus (median 3,000 units). There were some differences in baseline characteristics between the patients who were or were not treated with heparin, including a lower National Institutes of Health Stroke Scale (NIHSS) score, a reduced likelihood of receiving IV tPA, and a higher median ASPECTS in the heparin-treated group. In addition, patients who received heparin were more likely to have vertebrobasilar and middle cerebral artery (MCA)-M1 occlusions, but less likely to have internal carotid artery and MCA-M2 occlusions.

 

Baseline Characteristics: With vs Without Intraprocedural Heparin

 

Heparin

(n= 58)

No Heparin

(n= 115)

P Value

Mean NIHSS Score

17.2

18.9

0.04

IV tPA

38%

64%

< 0.01

Median ASPECTS

7.6

7.1

0.02

M1 Occlusions

70.7%

55.7%

0.04

M2 Occlusions

10.3%

17.4%

0.04

 

The time from symptom onset to puncture was similar in the two groups, but the procedure duration was significantly longer among patients treated with heparin (99 vs 83 min; P < 0.01).

Rates of TICI 2b-3 reperfusion, embolization to unaffected territories, access-site complications, and symptomatic intracranial hemorrhages (sICH) were similar in the groups.

 

Outcomes With vs Without Intraprocedural Heparin

 

Heparin

(n= 58)

No Heparin

(n= 115)

P Value

TICI 2b-3

65.5%

62.6%

0.74

Embolization to Unaffected Territory

5.2%

6.1%

1.00

Access site Complications

1.7%

1.7%

1.00

ECASS HI1/HI2

27.6%

24.3%

0.71

Parenchymal Hemorrhage

22.4%

25.2%

0.85

 

Multivariate analysis revealed that independent predictors of good outcome, defined as a modified Rankin Scale score 0-2 at 90 days, were heparin bolus use (OR 5.30; 95% CI 1.70-16.48), TICI 2b-3 reperfusion (OR 6.56; 95% CI 2.29-18.83), and use of the Trevo rather than the Merci device (OR 3.54; 95% CI 1.38-9.03). A good outcome was inversely correlated with intubation (OR 0.10; 95% CI 0.03-0.33), diabetes (OR 0.11; 95% CI 0.03-0.39), baseline NIHSS score (OR 0.84; 95% CI 0.75-0.93), time from symptom onset to puncture (OR 0.64; 95% CI 0.45-0.89), and congestive heart failure (OR 0.23; 95% CI 0.06-0.83).

“This study supports our previous findings in [a post-hoc analysis of the] Multi MERCI trial, where we found that periprocedural heparin during thrombectomy was associated with increased likelihood of good outcome at 90 days [compared with] patients who did not receive heparin,” said Nahab. “Our results suggest that there may be an important role for periprocedural heparin use during thrombectomy and further study in a randomized trial is warranted.”

 

Nahab acknowledged that there are limitations to the study. “The use of periprocedural heparin was left to the discretion of the local neurointerventionist and not randomized,” he explained. “Further, no prespecified dosage of heparin and timing was recommended and no activated clotting time was collected to evaluate the effects of the heparin. Our study was [also] limited to thrombectomy treatment within 8 hours of their last seen well time, and it remains unclear whether periprocedural heparin is safe when used beyond the 8-hour treatment window.”

 


Source:

Winningham MJ, Haussen DC, Nogueira RG, et al. Periprocedural heparin use in acute ischemic stroke endovascular therapy: the TREVO 2 trial. J NeuroInterv Surg. 2017;Epub ahead of print.

 

Disclosures:

Winningham and Nahab report no relevant conflicts of interest.