Abstract 013: Optimizing Periprocedural Antiplatelet Therapy: Clinical Outcomes Of Intravenous Versus Oral P2y12 Inhibitors In Neurovascular And Cardiovascular Interventions

Intravenous P2Y12 inhibition with cangrelor provides immediate and complete platelet ADP‐receptor blockade (100% bioavailability) and rapid offset, whereas newer oral P2Y12 inhibitors (ticagrelor and prasugrel) achieve high platelet inhibition within 30‐60 minutes of loading (prasugrel requires metabolic activation, ticagrelor is direct‐acting) . We performed a comprehensive review and meta‐analysis of studies in the past decade comparing cangrelor versus ticagrelor/prasugrel in percutaneous coronary intervention (PCI) and mechanical thrombectomy contexts. In PCI, cangrelor's fast‐on/fast‐off profile translated to reduced periprocedural thrombotic events compared to clopidogrel (e.g. 48‐hour stent thrombosis 0.8% vs 1.4%, OR≈0.62, 95% CI 0.43‐0.90) , but when directly or indirectly compared to potent oral agents, clinical outcomes were comparable . The risk of early myocardial infarction or stroke within 48 hours was low and did not differ significantly between IV and oral P2Y12 strategies . Pooled analyses showed no advantage of cangrelor over ticagrelor/prasugrel in preventing ischemic events or reducing mortality (e.g. OR for 48h thrombosis ∼0.9, 95% CI 0.2‐4.1; OR for mortality ∼1.0‐1.9, p>0.1) . Major bleeding and procedural complication rates were also similar (cangrelor vs oral: OR ∼1.0, 95% CI 0.5‐1.9) , with no excess of severe hemorrhage from IV administration in cardiac interventions . In neurointerventional procedures (acute ischemic stroke with stenting), literature is limited but indicates that periprocedural cangrelor achieves effective platelet inhibition and safety outcomes comparable to oral dual‐antiplatelet loading . Small series report low thromboembolism rates (∼5%) and manageable hemorrhagic risk (∼10% intracerebral hemorrhage, often asymptomatic) with cangrelor in acute stroke stenting . No significant differences in 90‐day outcomes were observed when cangrelor was used versus oral P2Y12 in this setting . These findings suggest that cangrelor offers a fast, efficacious alternative to oral P2Y12 inhibitors without compromising efficacy or safety in the immediate peri‐procedural period. However, large randomized studies in neurointervention are needed. A standardized protocol for P2Y12 inhibitor use in both cardiology and neurovascular procedures could streamline care—ensuring timely platelet inhibition for stenting in emergent cases—rather than relying on individual physician discretion . Our results underscore the potential for unified antiplatelet strategies across specialties to improve early ischemic outcomes while maintaining low bleeding risk.