Cangrelor versus GPIIb/IIIa inhibitors as adjunctive therapy in endovascular treatment of large vessel occlusion stroke

Background Endovascular treatment (EVT) failures and early reocclusions in stroke often result from arterial wall disease, incomplete thrombus withdrawal, or acute endothelial injury. Intracranial and extracranial atherosclerosis, in particular, poses a risk of reocclusion, sometimes requiring tailored interventions (eg, angioplasty, stenting). While glycoprotein (GP) IIb/IIIa inhibitors have been widely studied in ischemic stroke, cangrelor remains less explored. Objective To evaluate the safety and efficacy of cangrelor compared with GPIIb/IIIa inhibitors in large vessel occlusion stroke (LVOS). Methods This retrospective analysis from the Endovascular Treatment in Ischemic Stroke Registry included patients from 34 French centers who received cangrelor or GPIIb/IIIa inhibitors during EVT between July 2018 and September 2023. Eligible cases had refractory occlusions or arterial disease at risk of reocclusion. The primary outcome was a 90-day favorable outcome. Secondary outcomes included excellent functional outcome, early neurological improvement, intracranial hemorrhage (ICH), procedural complications, and day 1 arterial patency. Propensity score overlap weighting was used for comparisons. Results Of 559 patients, 160 received GPIIb/IIIa inhibitors and 399 received cangrelor. Favorable outcomes were comparable (41.7% vs 43.7%; OR=1.1; 95% CI 0.61 to 1.93), as were rates of excellent functional outcome and early neurological improvement. Angiographic efficacy was similar, with modified Thrombolysis in Cerebral Infarction ≥2b rates of 89.5% for GPIIb/IIIa and 90.1% for cangrelor. No significant differences were observed in day 1 patency, 90-day mortality, or symptomatic ICH. Conclusions Cangrelor showed comparable safety and efficacy to GPIIb/IIIa inhibitors. These results, along with the specific pharmacodynamics, make this drug a promising agent in the acute management of complex intracranial and extracranial LVOS. Trial registration number NCT03776877 .