According to the 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes, intravenous cangrelor may be reasonable for patients with ACS undergoing PCI who have not received a P2Y12 inhibitor, as it can help reduce periprocedural ischemic events. The CHAMPION PHOENIX trial demonstrated that cangrelor significantly lowers the 48-hour incidence of the composite endpoint of death, myocardial infarction, ischemia-driven revascularization, or stent thrombosis compared with a 300–600 mg clopidogrel loading dose, with consistent benefits observed in both NSTE-ACS and STEMI patients. Importantly, the guideline recommendations for cangrelor are not specifically stratified by angiographic assessment of clot burden. [1]
A 2018 investigation evaluated the impact of cangrelor, a potent intravenous platelet adenosine diphosphate receptor antagonist, on peri-procedural adverse events in patients undergoing percutaneous coronary intervention (PCI). This large-scale analysis from the CHAMPION PHOENIX trial involved 10,854 randomized patients, with angiographic core laboratory analysis completed for 13,418 target lesions. The primary aim was to determine whether the efficacy of cangrelor varied in patients with simple versus complex coronary artery lesions characterized by high-risk features. Patients were categorized based on the number of high-risk features in their target lesions, including long lesions, left main lesions, bifurcation lesions, thrombotic lesions, tortuous lesions (moderate or severe), angulated lesions (moderate or severe), eccentric lesions, calcified lesions (moderate or severe), and multi-lesion treatment. In this investigation, the 48-hour major adverse cardiac event (MACE) rate for clopidogrel-treated patients significantly increased with lesion complexity, rising from 3.3% in patients with no high-risk features to 8.7% in those with three or more features. Cangrelor reduced the 48-hour MACE rate by 21% compared to clopidogrel, with an odds ratio of 0.79 and a P-value of 0.006, demonstrating consistent efficacy regardless of lesion complexity or patient presentation with stable ischemic heart disease or acute coronary syndrome. Multivariable analysis identified the number of high-risk PCI characteristics and treatment with cangrelor versus clopidogrel as independent predictors of the primary 48-hour MACE endpoint. The incidence of major bleeding was unrelated to lesion complexity and was not significantly increased by cangrelor use, underscoring the therapeutic benefit of cangrelor during PCI, especially in patients with complex coronary anatomy. Notably, clot burden was not assessed or considered a high-risk feature in this investigation. [2]
A 2025 study provided an analysis detailing the use of cangrelor as a bailout strategy during percutaneous coronary interventions (PCI). This eight-year observational study, conducted at the MedStar Washington Hospital Center, screened 2,680 patients who received cangrelor during PCI from 2016 to 2023. Of these, 67 patients (2.5%) were administered cangrelor as bailout therapy due to thrombotic complications such as slow flow, no-reflow, stent thrombosis, and acute side branch occlusion. Cangrelor, administered after initial balloon angioplasty or stent deployment, significantly enhanced mean TIMI flow from 1.3 to 2.7, demonstrating improvement in patients who initially presented with TIMI-0 flow. The 2025 investigation into cangrelor's efficacy highlighted several critical outcomes: complete or partial thrombus resolution was observed in patients experiencing stent thrombosis, and procedural efficacy was supported by adjunctive nonpharmacological strategies, including aspiration thrombectomy and additional stenting. This descriptive analysis reported an in-hospital ischemic event rate of 11.9%, a major bleeding incidence of 4.5%, and an average hospital stay of 5.8 days. The compelling findings suggest that cangrelor provides a viable alternative to glycoprotein IIb/IIIa inhibitors for managing thrombotic complications during PCI, paving the way for further investigation into its routine use in all-comer PCI settings. [3]
A 2019 exploratory registry was conducted at a high-volume tertiary care center to evaluate the angiographic and in-hospital clinical outcomes of administering cangrelor immediately before percutaneous coronary intervention (PCI). The research included 223 consecutive patients with angiographic evidence of intracoronary thrombus who underwent PCI. Cangrelor, a rapid-onset intravenous P2Y12 receptor inhibitor, was given at the time of PCI decision-making, followed by a transition to oral antiplatelet therapy post-procedure. The study stratified patients based on their pre-procedure clinical status into either cardiogenic shock or no shock, with further lesion-level analysis according to pre-procedure TIMI-Flow grades. The registry revealed significant improvements in angiographic indices with the use of cangrelor, showing restoration of TIMI-Flow 3 in 96% of cases post-PCI and an absence of angiographic thrombus in 96% of treated lesions. The study demonstrated cangrelor's efficacy in enhancing myocardial perfusion and blush grades, particularly in patients with initial TIMI-Flow 0/1. Major bleeding events occurred in 2.0% of cases, indicating a favorable safety profile. Overall, the research suggests that cangrelor is effective in managing intracoronary thrombus, with a low incidence of major adverse cardiovascular events, supporting its consideration for patients undergoing PCI with visible thrombus. See Table 1 for full study details. [4]