Bridging Thrombolysis Versus Direct Mechanical Thrombectomy in Acute Ischemic Stroke - SWIFT DIRECT

Jul 18, 2022
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Author/Summarized by Author:
Anthony A. Bavry, MD, MPH, FACC
Summary Reviewer:
Deepak L. Bhatt, MD, MPH, MBA, FACC
Trial Sponsor:
Medtronic and University Hospital Bern
Date Published:
07/09/2022
Original Posted Date:
07/18/2022
References

Contribution To Literature:

The SWIFT DIRECT trial failed to show noninferiority of thrombectomy alone compared with alteplase plus thrombectomy.

Description:

The goal of the trial was to evaluate stent-retriever thrombectomy compared with intravenous (IV) alteplase plus stent-retriever thrombectomy among individuals presenting with acute ischemic stroke.

Study Design

  • Randomization
  • Parallel
  • Open-label
  • Stratified

Patients with acute ischemic stroke were randomized to stent-retriever thrombectomy (n = 201) versus IV alteplase plus stent-retriever thrombectomy (n = 207). Alteplase was given at a dose of 0.9 mg/kg to maximum of 90 mg.

  • Total number of enrollees: 408
  • Duration of follow-up: 90 days
  • Mean patient age: 73 years
  • Percentage female: 52%

Inclusion criteria:

  • Patients presenting with acute ischemic stroke due to large vessel occlusion within 4.5 hours of symptom onset

Principal Findings:

The primary outcome, Rankin score 0−2 at 90 days, occurred in 57% of the thrombectomy group vs. 65% of the alteplase plus thrombectomy group (adjusted risk difference −7.3%, 95% CI −16.6 to 2.1, lower limit of one-sided 95% CI −15.1%).

Secondary outcomes:

  • Symptomatic intracranial hemorrhage: 2% of the thrombectomy group vs. 3% of the alteplase plus thrombectomy group (risk difference −1.0%, 95% CI −4.8 to 2.7)

Interpretation:

Among patients presenting with acute ischemic stroke, SWIFT DIRECT failed to show noninferiority of stent-retriever thrombectomy. Symptomatic intracranial hemorrhage was similar between treatment groups. Among patients with acute ischemic stroke undergoing stent-retriever thrombectomy, omitting IV alteplase cannot be recommended.

References:

Fischer U, Kaesmacher J, Strbian D, et al., on behalf of the SWIFT DIRECT Collaborators. Thrombectomy alone versus intravenous alteplase plus thrombectomy in patients with stroke: an open-label, blinded-outcome, randomized non-inferiority trial. Lancet 2022;400:104-15.

Clinical Topics: Cardiac Surgery, Dyslipidemia, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Vascular Medicine, Lipid Metabolism, Interventions and Vascular Medicine

Keywords: Coronary Occlusion, Geriatrics, Intracranial Hemorrhages, Ischemic Stroke, Risk, Stents, Stroke, Thrombectomy, Tissue Plasminogen Activator, Vascular Diseases


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