Reader response: MT in anticoagulated patients: Direct oral anticoagulants versus vitamin K antagonists

L'Allinec et al.¹ identified another potential benefit of direct oral anticoagulants (DOACs) compared with vitamin K antagonists (VKA)—in addition to lower rates of stroke, systemic embolism, and intracranial hemorrhage²—by showing higher rates of successful recanalization among patients who underwent mechanical thrombectomy. As a consequence of better recanalization, 90-day rates of excellent outcome (modified Rankin Scale [mRS] score 0–1) and mortality were significantly better in the DOAC group. However, the primary outcome (mRS 0–2) was not significantly different, and the rates of withdrawal of life-sustaining therapy were not accounted for in mortality outcomes. Although the authors hypothesized that variations in clot substance underlie higher reperfusion rates in DOAC users, as many as 50% of VKA users may have been inadequately anticoagulated (28% had international normalized ratio [INR] 1.7%–2.0% and 24% had no available INR data), potentially leading to harder clots that are more difficult to retrieve. The authors did not mention if more VKA-treated patients were enrolled earlier in the study when endovascular technology was less sophisticated. However, the authors' previous ASTER trial suggested that the differences in the use of stent retrievers and direct aspiration among DOAC- and VKA-treated patients is inconsequential.³ Further study of clot composition and its impact on recanalization among anticoagulated patients is needed to enable more targeted thrombectomy techniques.