To evaluate whether intravenous (IV) cangrelor offers clinical advantages over oral P2Y12 inhibitors (ticagrelor, prasugrel) in periprocedural antiplatelet therapy during cardiovascular and neurovascular interventions.

Effective platelet inhibition is critical during procedures like percutaneous coronary intervention (PCI) and neurovascular stenting to prevent thrombosis. While oral P2Y12 inhibitors are standard, their delayed onset and variability limit utility in emergent settings. Cangrelor, an IV P2Y12 inhibitor, acts rapidly and reversibly, but its comparative effectiveness against modern oral agents remains uncertain, especially in neurointervention.

A systematic review and meta-analysis was conducted per PRISMA and Cochrane guidelines, including randomized controlled trials and observational studies published through March 2025. Adult patients undergoing PCI or neurovascular procedures receiving either IV cangrelor or oral P2Y12 inhibitors were included. Primary outcomes were 48-hour myocardial infarction (MI), stent thrombosis, mortality, thromboembolic complications, and bleeding. Statistical analyses used a random-effects model.

In PCI, cangrelor significantly reduced stent thrombosis (RR 0.62, 95% CI 0.44–0.86; p=0.005) without increasing 48-hour MI (RR 0.91, p=0.13) or mortality (RR 0.90, p=0.21). Bleeding risks were comparable across treatment arms. Neurovascular data remain limited to small case series (n=7–129) with cangrelor achieving effective platelet inhibition, low thromboembolic rates (~5%), and manageable intracranial hemorrhage (~10%, mostly asymptomatic). No study demonstrated clear superiority over oral agents due to limited statistical power.

Cangrelor offers a rapid-onset, safe alternative to oral P2Y12 inhibitors, reducing early thrombotic complications in PCI. Its potential in acute neurointerventions is promising but unproven, limited by lack of randomized data. A unified IV protocol combining thrombolysis (e.g., tenecteplase) and antiplatelet therapy (e.g., cangrelor) may streamline emergent care. Multicenter RCTs are warranted to define optimal strategies for both cardiovascular and neurovascular interventions.