Is mechanical thrombectomy possible for someone on a Direct Oral Anticoagulant (DOAC)?

Mechanical Thrombectomy in Patients on DOACs

Mechanical thrombectomy is safe and feasible in patients on DOACs and should be performed without delay, regardless of DOAC timing, plasma levels, or reversal agent use. 1, 2

Key Recommendation

Proceed directly to mechanical thrombectomy in patients with large vessel occlusion on DOACs without requiring specific selection criteria, coagulation testing, or reversal agents. 2, 3

Evidence-Based Approach

Thrombectomy Safety Profile

• Mechanical thrombectomy demonstrates similar safety outcomes in anticoagulated versus non-anticoagulated patients, with no significant difference in intracerebral hemorrhage rates (11.1% vs. 13.6%, p=0.93) or symptomatic ICH (2.8% vs. 1.5%, p=0.14) 3
• Functional independence rates at 90 days are comparable between anticoagulated and non-anticoagulated groups (50.0% vs. 43.1%), as are mortality rates (27.8% vs. 25.8%) 3
• No cases of symptomatic ICH were observed among patients taking DOACs who underwent thrombectomy 3

Clinical Decision Algorithm

For patients on DOACs presenting with acute ischemic stroke and large vessel occlusion:

1. Confirm large vessel occlusion using non-invasive angiography (CTA) 1
2. Proceed immediately to mechanical thrombectomy if the patient meets standard criteria: age ≥18 years, pre-stroke mRS 0-1, causative occlusion of internal carotid artery or MCA (M1), NIHSS ≥6, ASPECTS ≥6, and treatment can be initiated within 6 hours of symptom onset 1
3. Extended window (6-24 hours): Use advanced imaging (CTP or DW-MRI) to identify sizable mismatch between ischemic core and clinical deficits or hypoperfusion area 1
4. Do NOT delay thrombectomy for: DOAC plasma level measurement, reversal agent administration, or evaluation of response to IV thrombolysis 1, 2

Critical Timing Considerations

• Do not evaluate responses to IV thrombolysis before proceeding with catheter angiography for mechanical thrombectomy 1
• In patients with large vessel occlusion on DOACs, the decision regarding intravenous thrombolysis should not delay thrombectomy—consider direct thrombectomy or immediate transfer to a thrombectomy-capable center 2
• The technical goal should be reperfusion to modified Thrombolysis in Cerebral Infarction (mTICI) grade 2b/3 1

Distinction from IV Thrombolysis

While current guidelines recommend against IV thrombolysis in patients with DOAC intake within 48 hours 1, mechanical thrombectomy operates under different risk-benefit considerations:

• Thrombectomy appears safe without specific selection criteria applied, unlike IV thrombolysis which requires careful patient selection 2
• Recent research demonstrates that mechanical thrombectomy can be performed safely in anticoagulated patients ineligible for thrombolysis 3
• The mechanism of thrombectomy (mechanical clot removal) poses less systemic bleeding risk compared to pharmacological thrombolysis 2, 3

Common Pitfalls to Avoid

• Do not delay thrombectomy while waiting for DOAC plasma levels or coagulation testing—these are not required for thrombectomy decisions 2, 3
• Do not withhold thrombectomy based solely on recent DOAC intake—timing since last dose is not a contraindication for mechanical intervention 2, 4
• Do not administer reversal agents prior to thrombectomy—they are unnecessary and cause delays without improving safety 2, 3
• Do not assume that anticoagulation status requires different thrombectomy technique or approach—standard thrombectomy protocols apply 3

Special Considerations

• Patients with cervical ICA occlusion or stenosis in addition to intracranial large vessel occlusion may still be considered for mechanical thrombectomy 1
• The rising number of patients on DOACs worldwide makes this a clinically relevant scenario requiring clear protocols 3
• Precision medicine approaches combining clinicoradiological information (penumbra and vessel status) with anticoagulant activity may be reasonable for IV thrombolysis decisions, but should not impact thrombectomy decisions 2