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Periprocedural heparin use in acute ischemic stroke endovascular therapy: the TREVO 2 trial
  1. Melanie J Winningham1,
  2. Diogo C Haussen2,
  3. Raul G Nogueira2,
  4. David S Liebeskind3,
  5. Wade S Smith4,
  6. Helmi L Lutsep5,
  7. Tudor G Jovin6,
  8. Bin Xiang7,
  9. Fadi Nahab8
  1. 1Department of Neurology, Emory University, Atlanta, Georgia, USA
  2. 2Department of Neurology, Neurosurgery, Radiology, Emory University, Atlanta, Georgia, USA
  3. 3Department of Neurology, University of California, Los Angeles, California, USA
  4. 4Department of Neurology, University of California, San Francisco, California, USA
  5. 5Department of Neurology, Oregon Health and Science University, Portland, Oregon, USA
  6. 6Department of Neurology and Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
  7. 7Department of Clinical Research, ProSpect Analytical Technology, San Jose, California, USA
  8. 8Department of Neurology and Pediatrics, Emory University, Atlanta, Georgia, USA
  1. Correspondence to Dr Fadi Nahab, Department of Neurology and Pediatrics, Emory University School of Medicine, Atlanta, Georgia 30322, USA; fnahab{at}


Background The use of periprocedural heparin has previously been reported to be safe and potentially beneficial during thrombectomy with older generation devices. We aimed to evaluate the safety and clinical outcomes of heparin use in the stent retriever era.

Methods A post hoc analysis of the TREVO 2 trial was performed comparing baseline characteristics and clinical outcomes between patients who received (HEP+) and those who did not receive periprocedural heparin (HEP−) while undergoing MERCI or TREVO clot retrieval.

Results Of 173 patients, 58 (34%) received periprocedural heparin including 40 who received one preprocedural bolus (median 3000 units). Baseline characteristics among HEP+ and HEP− patients were similar except HEP+ patients had a lower NIH Stroke Scale (NIHSS) score (17 vs 19; p=0.04), lower IV tissue plasminogen activator use (38% vs 64%; p<0.01), and a higher median ASPECTS score (8.0 vs 7.0; p=0.02). HEP+ patients were more likely to have vertebrobasilar and middle cerebral artery (MCA)-M1 occlusions but less likely to have internal carotid artery and MCA-M2 occlusions (p=0.04). Time from symptom onset to puncture was similar in the two groups while procedure duration was longer in HEP+ patients (99 vs 83 min; p<0.01). Thrombolysis In Cerebral Infarction (TICI) 2b–3 reperfusion rates, embolization to unaffected territories, access site complications, and intracranial hemorrhages were similar between the groups. In multivariable logistic regression, a good outcome (90-day modified Rankin Scale score 0–2) was independently associated with heparin bolus use (OR 5.30; 95% CI 1.70 to 16.48), TICI 2b–3 reperfusion (OR 6.56; 95% CI 2.29 to 18.83), stent retriever use (OR 3.54; 95% CI 1.38 to 9.03) and inversely associated with intubation (OR 0.10; 95% CI 0.03 to 0.33), diabetes (OR 0.11; 95% CI 0.03 to 0.39), NIHSS (OR 0.84; 95% CI 0.75 to 0.93), time from symptom onset to puncture (OR 0.64; 95% CI 0.45 to 0.89), and heart failure (OR 0.23; 95% CI 0.06 to 0.83).

Conclusions The use of periprocedural heparin in stent retriever thrombectomy is associated with a good clinical outcome at 90 days and similar rates of symptomatic intracranial hemorrhage. Further studies are warranted.

Clinical trial registration URL: Unique identifier: NCT01270867;Post-results.

  • brain
  • complication
  • stroke
  • thrombectomy

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  • Contributors Conception and design: FN, DCH. Acquisition of data: all authors. Analysis and interpretation of data: all authors. Drafting the manuscript: MJW, DCH, FN. Critical revision of the manuscript: all authors. Final approval of the manuscript: all authors.

  • Competing interests None declared.

  • Ethics approval IRBs at participating institutions.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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