ESOC 2021 | Mechanical thrombectomy alone or in combination with intravenous thrombolysis?
Mechanical thrombectomy (MT) is a standard of care treatment option for patients with acute ischemic stroke from large vessel occlusions (LVO). However, controversy remains regarding the benefit of adjunctive intravenous thrombolysis in these patients. Georgios Tsivgoulis, MD, PhD, MSc, FESO, FEAN, FAAN, National and Kapodistrian University of Athens, Athens, Greece, outlines the data gathered to date on the role of pretreatment with systemic thrombolysis in LVO patients eligible for MT. Recently, the SKIP clinical trial (UMIN000021488), investigating the safety and utility of pretreatment with thrombolysis, failed to demonstrate noninferiority of MT alone compared to in combination with intravenous thrombolysis. Whereas the DIRECT-MT trial (NCT03469206) found MT alone to be non-inferior to MT preceded by intravenous thrombolysis with regard to functional outcomes. Prof. Tsivgoulis comments on the need for more data to provide a definitive answer to this question. This interview took place at the European Stroke Organisation Conference (ESOC), 2021.
Transcript (edited for clarity)
We’re going to discuss about the latest advancements regarding mechanical thrombectomy in a large vessel occlusion patient with acute ischemic stroke. We’re going to discuss about some clinical trials that evaluated the utility and safety of pretreatment with intravenous thrombolysis in LVO patients undergoing mechanical thrombectomy, and there are some controversial data. There are two trials from China showing that there is a non-inferiority between direct mechanical thrombectomy and bridging therapy, which is a combination of intravenous thrombolysis and mechanical thrombectomy...
We’re going to discuss about the latest advancements regarding mechanical thrombectomy in a large vessel occlusion patient with acute ischemic stroke. We’re going to discuss about some clinical trials that evaluated the utility and safety of pretreatment with intravenous thrombolysis in LVO patients undergoing mechanical thrombectomy, and there are some controversial data. There are two trials from China showing that there is a non-inferiority between direct mechanical thrombectomy and bridging therapy, which is a combination of intravenous thrombolysis and mechanical thrombectomy.
On the other hand, there is a Dutch trial and a Japanese trial showing that direct mechanical thrombectomy is non-inferior to bridging therapy. So, I think, this is a very controversial issue and we will be waiting the results of SWIFT DIRECT trial that would be presented in ESOC. And I think this will be the tiebreaker.
In clinical practice, I think we should currently adhere to all international recommendations, both issued by the American Heart Association and the European Stroke Organisation, that tPA-eligible candidates who will undergo mechanical thrombectomy should be pre-treated with intravenous thrombolysis for the time being. I don’t think we should change our management. And I want to remind you that in the pivotal trials of mechanical thrombectomy, when they set up, it was approved, all tPA-eligible patients were treated with intravenous thrombolysis.
Right now there are three or four clinical trials that will be providing more definitive answers regarding this question. The first one is SWIFT DIRECT, there is a second one that is currently being conducted in Australia. And then, there is a third one, which will be using tenecteplase instead alteplase, and this is also conducted in Canada. I think in the next few years, we will have more high quality data that can answer this question.
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