Carotid angioplasty and stent placement: a prospective analysis of perioperative complications and impact of intravenously administered abciximab

Safety of Glycoprotein IIb-IIIa Inhibitors Used in Stroke-Related Treatment: A Systematic Review and Meta-Analysis

Background:

Endovascular therapy and intravenous thrombolysis with recombinant tissue plasminogen activator are the 2 most recommended treatments for acute ischemic stroke (AIS). Glycoprotein (GP) IIb-IIIa inhibitors are short-acting selective reversible antiplatelet agents that emerged as promising therapeutic agents for AIS about 10 years ago. Given the unclear safety profile and application coverage of GP inhibitors, we conducted this meta-analysis to explore the same.

Methods:

We used GP IIb-IIIa inhibitors, intracranial hemorrhage, and mortality as the key words on Medline, Web of Science, and the Embase databases. Randomized controlled trials, prospective literatures, and retrospective studies in English published between 1990 and 2020 were screened. The outcomes were relative risk (RR) of death and 90-day intracerebral hemorrhage (ICH). We pooled the results in 2 categories and conducted a subgroup analysis stratified by different drugs. The choice of the effects model depended on the value of I².

Results:

In all, 3700 patients from 20 studies were included. No GP IIb-IIIa inhibitors were found to have a remarkable influence on the ICH rate. The RR values of symptomatic ICH for abciximab and eptifibatide were 4.26 (1.89, 9.59) and 0.17 (0.04, 0.69), respectively. Both tirofiban and abciximab could decrease the mortality rate within 90 days. Age > 70 years, National Institutes of Health Stroke Scale > 15, and overall dose > 10 mg are risk factors for ICH events with tirofiban usage. Thrombectomy combined with tirofiban was safe for arterial reocclusion prevention.

Conclusions:

In stroke-related treatment, administration of GP IIb-IIIa inhibitors could be safe, but care should be taken regarding drug species and doses. Abciximab can increase the risk of symptomatic intracranial hemorrhage. Tirofiban and eptifibatide can be considered safe in low doses. Suitable patients should be selected using strict criteria.

Predictors of Perioperative Stroke/Death after Carotid Artery Stenting: A Review Article

Carotid artery stenting (CAS) has been recommended as an alternative treatment to carotid endarterectomy for patients with significant carotid stenosis. Only a few studies have analyzed clinical/anatomical and technical variables that affect perioperative outcomes of CAS. Following a comprehensive Medline search, it was reported that clinical factors, including age of >80 years, chronic renal failure, diabetes mellitus, symptomatic indications, and procedures performed within 2 weeks of transient ischemic attack symptoms, are associated with high perioperative stroke and death rates. They also highlighted that angiographic variables, e.g., ulcerated and calcified plaques, left carotid intervention, >90% stenosis, >10-mm target lesion length, ostial involvement, type III aortic arch, and >60°-angulated internal carotid and common carotid arteries, are predictors of increased stroke rates. Technical factors associated with increased perioperative risk of stroke include percutaneous transluminal angioplasty (PTA) without embolic protection devices, PTA before stent placement, and the use of multiple stents. This review describes the most widely quoted data in defining various predictors of perioperative stroke and death after CAS. (This is a review article based on the invited lecture of the 45th Annual Meeting of Japanese Society for Vascular Surgery.)

Genetic determinations of variable responsiveness to clopidogrel and implications for neurointerventional procedures

Endovascular intervention is emerging as a substitute for open surgical procedures for the treatment of cerebrovascular disease. However, up to 9% of patients undergoing neurointerventional procedures develop thromboembolic complications. Strategies to reduce periprocedural thromboembolic events are dominated by the use of dual antiplatelet therapy (DAT) which has been validated based on studies of peripheral vascular and coronary intervention. Of note, DAT decreases adverse vascular outcomes by 75-80% in patients undergoing percutaneous coronary intervention (PCI). It follows that similar treatment effects would be observed in neurointerventional populations. However, a growing body of evidence demonstrates that a subgroup of patients respond suboptimally to DAT, and in particular to clopidogrel (termed clopidogrel hyporesponders). These patients may be at an increased risk of thromboembolic complications such as in-stent thrombosis following neurointerventional procedures. Previous studies report 5-30% suboptimal response to clopidogrel in the cardiovascular population, while a higher prevalence is seen in populations undergoing neurointerventional procedures, i.e. as much as 66%. Knowledge of the mechanism leading to clopidogrel hyporesponsiveness is accumulating. A number of genetic polymorphisms, in particular CYP 2C19*2, have been associated with clopidogrel hyporesponsiveness and clinical outcomes. In addition, there are significant differences in the prevalence of CYP 2C19*2 across racial groups. Approximately 50% of Asians and 25% of Caucasians harbor the CYP 2C19*2 allele. While no prospective randomized trials currently exist to demonstrate improved clinical outcomes with genotype-based treatment for carriers of the CYP 2C19*2 polymorphism, a number of studies show that an increased dose of clopidogrel improves platelet inhibition in hyporesponders. The aim of the review is to examine the current understanding of the genetic basis of clopidogrel hyporesponsiveness in patients undergoing neurointerventional procedures and to explore current efforts using genotype and phenotype testing as well as alternative strategies to overcome the clopidogrel hyporesponsiveness.

State of the art in carotid artery stenting: trial data, technical aspects, and limitations

The volume of carotid artery stenting (CAS) safety and efficacy data has grown exponentially over the last decade. Recent comparative data with carotid endarterectomy, the utility of embolic protection devices, peri-procedural medications, basic technical aspects of CAS, developments in carotid stent design, potential complications of CAS, and complication risk factors are discussed in this review.

Antiplatelet therapy for carotid artery stenting

Carotid artery stenting (CAS) is less invasive and has a lower incidence of systemic complications such as myocardial infarction compared with carotid endarterectomy. However, CAS is known to have a high incidence of ischemic complications due to distal thromboembolism. Progress has been made in the development of various distal protection devices and protection methods aimed at preventing thromboembolism. Similar to these methods, perioperative antiplatelet therapy is also able to play a very important role in the prevention of ischemic events. Dual antiplatelet therapy has become standard for perioperative management of CAS.

How Safe is Eptifibatide during Urgent Carotid Artery Stenting?

Background: Glycoprotein IIB/IIIA inhibitors are occasionally utilized during carotid artery stenting (CAS) in the presence or absence of a visualized intra-operative thrombus.

Objective: We assess the hemorrhagic and clinical outcomes associated with the use of eptifibatide during CAS.

Methods: A retrospective analysis of prospectively collected data on patients with the diagnosis of carotid artery stenosis underwent CAS in a single center. We identified those who received intravenous eptifibatide intra-operatively and compared to the rest of the cohort. Hemorrhagic outcomes included intracerebral hemorrhage (ICH) or groin hematoma that occurred during the hospital stay.

Results: In this analysis, 81 patients had CAS during a 3-year span; 16 of those had received 15 mg of intravenous eptifibatide intra-operatively. The mean age of the treated and untreated patients was similar (65.6 ± 13.4 versus 65.4 ± 10.2; P = 0.13). One patient (1.2%) in this series had ICH in the perioperative period that occurred in the non-eptifibatide group. Five patients (6.2%) in this series had groin hematoma; only one in the non-eptifibatide group required surgical repair. No mortality was reported and clinical outcomes including discharge modified Rankin scale, NIH stroke scale, as well as discharge destination were similar in both groups. A stratified analysis among those who underwent an urgent CAS showed no significant differences in the risks of hemorrhages or any clinical outcome (P > 0.05).

Conclusion: The use of eptifibatide during CAS is safe. The risk of any hemorrhagic complication is rare in this series; however, a prospective study to validate this observation will be helpful.

Classification for carotid artery stenting complications: manifestation, management, and prevention

Carotid artery stenting is a rapidly evolving method for treating carotid artery disease. Various intraprocedural and postprocedural complications have been reported in the literature. However, the absence of a unified classification scheme for these complications makes it difficult, if not impossible, to study their precise incidence, predictors, and management. The aim of this article is to propose the first joint classification of periprocedural complications, to analyze their incidence and etiology, and suggest possible ways to manage and prevent them. This classification is intended to be used as a common platform for prompt recognition, evaluation, treatment, and universal study of the complications during carotid stenting procedures. For this purpose, the opinions of the major experts on carotid interventions worldwide were merged with all the available information reported in the English-language literature to present as accurately as possible the management and prevention of carotid stenting complications according to this proposed classification.

Nontraumatic skull base defects with spontaneous CSF rhinorrhea and arachnoid herniation: imaging findings and correlation with endoscopic sinus surgery in 27 patients

BACKGROUND AND PURPOSE

Defects at the skull base leading to spontaneous CSF rhinorrhea are rare lesions. The purpose of our study was to correlate CT and MR findings regarding the location and content of CSF leaks in 27 patients with endoscopic sinus surgery observations.

MATERIALS AND METHODS

Imaging studies in 27 patients with intermittent CSF rhinorrhea (CT in every patient including 10 examinations with intrathecal contrast, plain CT in 2 patients, and MR in 15 patients) were analyzed and were retrospectively blinded to intraoperative findings.

RESULTS

CT depicted a small endoscopy-confirmed osseous defect in 3 different locations: 1) within the ethmoid in 15 instances (53.6% of defects) most commonly at the level of the anterior ethmoid artery (8/15); 2) adjacent to the inferolateral recess of the sphenoid sinus in 7 patients including one patient with bilateral lesions (8/28 defects, 28.6%); 3) within the midline sphenoid sinus in 5 of 28 instances (17.9%). Lateral sphenoid defects (3.5 +/- 0.80 mm) were larger than those in ethmoid (2.7 +/- 0.77 mm, P < or = 0.029) or midsphenoid location (2.4 +/- 0.65 mm, P < or = 0.026). With endoscopy proven arachnoid herniation in 24 instances as reference, MR was correct in 14 of 15 instances (93.3%), CT cisternography in 5 of 8 instances (62.5%). Plain CT in 1 patient was negative.

CONCLUSION

In patients with a history of spontaneous CSF rhinorrhea, CT was required to detect osseous defects at specific sites of predilection. MR enabled differentiating the contents of herniated tissue and allowed identification of arachnoid tissue as a previously hardly recognized imaging finding.

Rescue use of tirofiban for acute carotid in-stent thrombosis

Carotid artery stenting is widely performed for extracranial carotid artery stenosis. In-stent thrombosis is a rare but potentially devastating complication. We present a case of acute in-stent thrombosis immediately following stent insertion and post-balloon dilatation in a 64-year-old male. Thrombosis was successfully treated by intravenous tirofiban, a glycoprotein IIb/IIIa receptor inhibitor.

Management of recurrent cerebral arterial occlusion in a patient with cardiac decompensation

We describe a woman with congestive heart failure who presented with acute cardiac decompensation followed by ischemic stroke. The management of the patient posed unique challenges for thrombolytic treatment (due to existing coagulopathy) and subsequent optimization of hemodynamic status. Issues related to rethrombosis and use of platelet glycoprotein IIB/IIIA inhibitors are also discussed.

Embolic protection filters for carotid stenting: differences in flow obstruction depending on filter construction

PURPOSE

To investigate the pressure gradient and degree of flow reduction associated with embolus protection filters for carotid stenting in an in vitro experiment.

METHODS

Three filter devices with a perforated membrane design and one wire mesh type filter were tested. At a pressure of 70 mmHg, the flow reduction and pressure gradient were measured in a 5-mm tube using blood-mimicking fluid.

RESULTS

The pressure gradient in the wire mesh filter was 1.65+/-0.49 mmHg (95% CI 1.32 to 1.86). The mean pressure gradient in the perforated membrane filters was 6.88+/-2.62 mmHg (95% CI 6.22 to 7.55, p<0.0001). There was also a significant correlation between pressure gradient and flow reduction (r=-0.77, p<0.01).

CONCLUSION

Embolic protection filters cause a pressure gradient and obstruct blood flow. This effect is marked in perforated membrane filters and almost absent in the wire mesh filter.

Angioplasty of symptomatic high-grade internal carotid artery stenosis with intraluminal thrombus: therapeutic approach

Intraluminal thrombus in the internal carotid artery (ICA) is usually found in patients with severe atheromatous stenosis. Having reviewed 300 carotid angioplasties for symptomatic >70% ICA stenosis, we found three patients (1%) with intraluminal thrombus. Conservative treatment with anticoagulants and double antiplatelet coverage can result in lysis of the thrombus without severe risks. Percutaneous transluminal angioplasty and stenting, preferably with distal protection, can be an excellent alternative to carotid endarterectomy.