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Ringer AJ, Hanel RA, Baig AA, Siddiqui AH, Lopes DK, Barros G, Bass DI, Levitt MR, Young CC, Naylor RM, Lanzino G, Crowley RW, Serrone JC, Kan PT, Binning MJ, Veznedaroglu E, Boulos A, Tawk R. Impact of duration of dual anti-platelet therapy on risk of complications after stent-assisted coiling of unruptured aneurysms. J Neurointerv Surg 2024:jnis-2024-021977. [PMID: 39137967 DOI: 10.1136/jnis-2024-021977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 07/30/2024] [Indexed: 08/15/2024]
Abstract
BACKGROUND The optimal duration for dual antiplatelet therapy (DAPT) after stent-assisted coiling (SAC) of intracranial aneurysms is unclear. Longer-term therapy may reduce thrombotic complications but increase the risk of bleeding complications. METHODS A retrospective review of prospectively maintained data at 12 institutions was conducted on patients with unruptured intracranial aneurysms who underwent SAC between January 1, 2016 and December 31, 2020, and were followed ≥6 months postprocedure. The type and duration of DAPT, stent(s) used, outcome, length of follow-up, complication rates, and incidence of significant in-stent stenosis (ISS) were collected. RESULTS Of 556 patients reviewed, 450 met all inclusion criteria. Nine patients treated with DAPT <29 days after SAC and 11 treated for 43-89 days were excluded from the final analysis as none completed their prescribed duration of treatment. Eighty patients received short-term DAPT. There were no significant differences in the rate of thrombotic complications during predefined periods of risk in the short, medium, or long-term treatment groups (1/80, 1.3%; 2/188, 1.1%; and 0/162, 0%, respectively). Similarly, no differences were found in the rate of hemorrhagic complications during period of risk in any group (0/80, 0%; 3/188, 1.6%; and 1/162, 0.6%, respectively). Longer duration DAPT did not reduce ISS risk in any group. CONCLUSIONS Continuing DAPT >42 days after SAC did not reduce the risk of thrombotic complications or in-stent stenosis, although the risk of additional hemorrhagic complications remained low. It may be reasonable to discontinue DAPT after 42 days following non-flow diverting SAC of unruptured intracranial aneurysms.
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Affiliation(s)
| | - Ricardo A Hanel
- Department of Neurosurgery, Lyerly Neurosurgery, Baptist Health, Jacksonville, FL, USA
| | - Ammad A Baig
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Adnan H Siddiqui
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
- Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | | | - Guilherme Barros
- Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - David I Bass
- Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Michael R Levitt
- Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Christopher C Young
- Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Ryan M Naylor
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Giuseppe Lanzino
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Joseph C Serrone
- Department of Neurological Surgery, Loyola University, Maywood, IL, USA
| | - Peter T Kan
- Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Mandy J Binning
- Global Neuroscience Institute, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Erol Veznedaroglu
- Global Neuroscience Institute, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Alan Boulos
- Department of Neurosurgery, Albany Medical Center, Albany, New York, USA
| | - Rabih Tawk
- Neurosurgery, Mayo Clinic Hospital Jacksonville, Jacksonville, Florida, USA
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Wadhwa A, Mensah E, Young M, Ogilvy CS. Variability patterns in dual antiplatelet therapy following endovascular repair of intracranial aneurysms: Insight into regimen heterogeneity and the need for a consensus. Acta Neurochir (Wien) 2024; 166:271. [PMID: 38888678 DOI: 10.1007/s00701-024-06137-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 05/20/2024] [Indexed: 06/20/2024]
Abstract
This comprehensive review delves into the evolving field of neurointervention for intracranial aneurysms, exploring the critical adjunct of Dual Antiplatelet Therapy (DAPT) to endovascular coiling, stent-assisted coiling (SAC), flow-diversion stents, and flow-disruption (intrasaccular) devices. Despite growing evidence supporting the success of DAPT in reducing thromboembolic events, the lack of consensus on optimal regimens, doses, and duration is evident. Factors contributing to this variability include genetic polymorphisms affecting treatment response and ongoing debates regarding the clinical significance of hemorrhagic complications associated with DAPT. This review analyzes pre- and post-procedural antiplatelet usage across various interventions. The imperative lies in ongoing research to define optimal DAPT durations, ensuring a nuanced approach to the delicate balance between thrombosis and hemorrhage in intracranial aneurysm management.
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Affiliation(s)
- Aryan Wadhwa
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St, Boston, MA, 02215, USA
| | - Emmanuel Mensah
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St, Boston, MA, 02215, USA
| | - Michael Young
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St, Boston, MA, 02215, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St, Boston, MA, 02215, USA.
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Lee IH, Ha SK, Lim DJ, Choi JI. Safety and efficacy of stent-assisted coil embolization with periprocedural dual antiplatelet therapy for the treatment of acutely ruptured intracranial aneurysms. Acta Neurochir (Wien) 2024; 166:216. [PMID: 38744753 DOI: 10.1007/s00701-024-06117-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 05/04/2024] [Indexed: 05/16/2024]
Abstract
PURPOSE Despite growing evidence for the effectiveness of stent-assisted coil embolization (SAC) in treating acutely ruptured aneurysms, the safety of stent placement in acute phase remains controversial because of concerns for stent-induced thromboembolism and hemorrhagic events attributable to the necessity of antiplatelet therapy. Therefore, we investigated the safety and efficacy of SAC with periprocedural dual antiplatelet therapy (DAPT) compared with the coiling-only technique to determine whether it is a promising treatment strategy for ruptured aneurysms. METHODS We retrospectively evaluated 203 enrolled patients with acutely ruptured aneurysms, categorizing them into two groups: SAC and coiling-only groups. Comparative analyses between the two groups regarding angiographic results, clinical outcomes, and procedure-related complications were performed. A subgroup analysis of procedural complications was conducted on patients who did not receive chronic antithrombotic medications to alleviate their influence before hospitalization. RESULTS 130 (64.0%) patients were treated using the coiling-only technique, whereas 73 (36.0%) underwent SAC. There was a trend to a higher complete obliteration rate (p = 0.061) and significantly lower recanalization rate (p = 0.030) at angiographic follow-up in the SAC group compared to the coiling-only group. Postprocedural cerebral infarction occurred less frequently in the SAC group (8.2%) than in the coiling-only group (17.7%), showing a significant difference (p = 0.044). Although the ventriculostomy-related hemorrhage rate was significantly higher in the SAC group than in the coiling-only group (26.2% vs. 9.3%, p = 0.031), the incidence of symptomatic ventriculostomy-related hemorrhage was comparable. Subgroup analysis excluding patients receiving chronic antithrombotic medications showed similar results. CONCLUSION SAC with periprocedural DAPT could be a safe and effective treatment strategy for acutely ruptured aneurysms. Moreover, it might have a protective effect on postprocedural cerebral infarction without increasing the risk of symptomatic hemorrhagic complications.
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Affiliation(s)
- In-Hyoung Lee
- Department of Neurosurgery, Korea University Ansan Hospital, Korea University College of Medicine, Gyeonggi-Do, Korea
| | - Sung-Kon Ha
- Department of Neurosurgery, Korea University Ansan Hospital, Korea University College of Medicine, Gyeonggi-Do, Korea
| | - Dong-Jun Lim
- Department of Neurosurgery, Korea University Ansan Hospital, Korea University College of Medicine, Gyeonggi-Do, Korea
| | - Jong-Il Choi
- Department of Neurosurgery, Korea University Ansan Hospital, Korea University College of Medicine, Gyeonggi-Do, Korea.
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Zandpazandi S, Matsukawa H, Porto G, Kicielinski K, Cunningham C, Sowlat MM, Elawady SS, Orscelik A, Lin S, Spiotta A. Endovascular Treatment of Small Anterior Communicating Artery Aneurysms: Safety and Efficacy in a Contemporary Cohort. Neurosurgery 2023:00006123-990000000-00984. [PMID: 38051040 DOI: 10.1227/neu.0000000000002771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 10/06/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Endovascular treatment (EVT) of small anterior communicating artery (ACoA) aneurysms accompanies a high risk of intraprocedural rupture (IR) because of anatomic location and aneurysm orientation. In this study, we aimed to investigate the safety and efficacy of EVT for small ACoA aneurysms in a contemporary cohort. METHODS ACoA aneurysms treated at the Medical University of South Carolina between April 2012 and March 2022 were retrospectively analyzed. Periprocedural baseline characteristics, aneurysm size, and clinical and radiological outcomes were collected. Aneurysms were dichotomized into <4 and ≥4 mm in maximum size. The IR rate, favorable occlusion rate (Raymond-Roy I and II), and the favorable outcome defined as modified Rankin Scale 0-2 were compared. RESULTS A total of 174 patients were identified, of whom 111 (63.8%) were female, and the median age was 57.7 (interquartile range 50.6-69.6) years. 98 (56.3%) aneurysms were ruptured, and 53 (30.5%) were <4 mm. IR was not observed in unruptured ACoA aneurysms, and there was no significant difference in the IR rates between <4 mm and ≥4 mm ruptured aneurysms (6.5% vs 4.5%, P = .65). Favorable occlusion rate and favorable outcome were observed in 94.7% and 78.2% of patients, respectively. CONCLUSION EVT of small ACoA aneurysms is safe and effective.
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Affiliation(s)
- Sara Zandpazandi
- Department of Neurological Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Hidetoshi Matsukawa
- Department of Neurological Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Guilherme Porto
- Department of Neurological Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Kimberly Kicielinski
- Department of Neurological Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Conor Cunningham
- Department of Neurological Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Mohammad Mahdi Sowlat
- Department of Neurological Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Sameh Samir Elawady
- Department of Neurological Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Atakan Orscelik
- Department of Neurological Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Steven Lin
- Department of Neurological Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Alejandro Spiotta
- Department of Neurological Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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Jang H, Cho BR, Jang DK, Kim DS. Feasibility and safety values of activated clotting time-guided systemic heparinization in coil embolization for unruptured intracranial aneurysms. Acta Neurochir (Wien) 2023; 165:3743-3757. [PMID: 37982897 DOI: 10.1007/s00701-023-05869-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 10/22/2023] [Indexed: 11/21/2023]
Abstract
OBJECTIVE This study aimed to evaluate the feasibility and safety values of activated clotting time (ACT)-guided systemic heparinization in reducing periprocedural thrombosis and bleeding complications during coil embolization of unruptured intracranial aneurysms. METHODS A total of 228 procedures performed on 213 patients between 2016 and 2021 were included in the retrospective analysis. The target ACT was set at 250 s. Logistic regression was performed to assess predictors for the occurrence of thrombosis and bleeding. Receiver operating characteristic (ROC) analyses were employed to determine the optimal cut-off values for ACT, heparinization, and procedure time. RESULTS Most (85.1%) of procedures were stent-assisted embolization. The mean baseline ACT was 128.8 ± 45.7 s. The mean ACT at 20 min after the initial intravenous heparin loading of 78.2 ± 18.8 IU/kg was 185 ± 46.4 s. The mean peak ACT was 255.6 ± 63.8 s with 51.3% (117 cases) achieving the target ACT level. Peak ACT was associated with symptomatic thrombosis (OR per second, 1.008; 95% CI, 1.000-1.016; P = 0.035) (cut-off value, 275 s; area under ROC (AUROC), 0.7624). Total administered heparin dose per body weight was negatively associated with symptomatic thrombosis (OR per IU/kg, 0.972; 95% CI, 0.949-0995; P = 0.018) (cut-off value, 294 IU/kg; AUROC, 0.7426) but positively associated with significant bleeding (OR, 1.008 per IU/kg; 95% CI, 1.005-1.012; P <0 .001) (cut-off value, 242 IU/kg; AUROC, 0.7391). Procedure time was significantly associated with symptomatic thrombosis (OR per minute, 1.05; 95% CI, 1.017-1.084; P value = 0.002) (cut-off value, 158 min; area under ROC, 0.8338). CONCLUSION This study demonstrated that ACT-guided systemic heparinization was feasible to achieve the target ACT value and proposes probable safety thresholds to prevent periprocedural complications through reducing procedure time during coil embolization of unruptured intracranial aneurysms in the stent era.
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Affiliation(s)
- Hyuk Jang
- Department of Neurosurgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 56, Dongsu-ro, Bupyeong-gu, Incheon, 21431, Republic of Korea
| | - Byung-Rae Cho
- Department of Neurosurgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 56, Dongsu-ro, Bupyeong-gu, Incheon, 21431, Republic of Korea
| | - Dong-Kyu Jang
- Department of Neurosurgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 56, Dongsu-ro, Bupyeong-gu, Incheon, 21431, Republic of Korea.
| | - Dong-Sub Kim
- Department of Neurosurgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 56, Dongsu-ro, Bupyeong-gu, Incheon, 21431, Republic of Korea
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Wang X, Luo L, Wang Y, An Z. Effect of Platelet Function Testing Guidance on Clinical Outcomes for Patients with Intracranial Aneurysms Undergoing Endovascular Treatment. AJNR Am J Neuroradiol 2023; 44:928-933. [PMID: 37414457 PMCID: PMC10411848 DOI: 10.3174/ajnr.a7923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 06/01/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Platelet function testing has been proposed to better adjust individualized antiplatelet treatment for patients undergoing endovascular treatment for intracranial aneurysms. Its clinical significance needs to be comprehensively evaluated. PURPOSE Our aim was to evaluate the impact of platelet function testing-guided versus standard antiplatelet treatment in patients receiving endovascular treatment for intracranial aneurysms. DATA SOURCES PubMed, EMBASE, and the Cochrane Library of clinical trials were searched from inception until March 2023. STUDY SELECTION Eleven studies comprising 6199 patients were included. DATA ANALYSIS ORs with 95% CIs were calculated using random effects models. DATA SYNTHESIS The platelet function testing-guided group was associated with a decreased rate of symptomatic thromboembolic events (OR = 0.57; 95% CI, 0.42-0.76; I2 = 26%). No significant difference was found in asymptomatic thromboembolic events (OR = 1.07; 95% CI, 0.39-2.94; I2 = 48%), hemorrhagic events (OR = 0.71; 95% CI, 0.42-1.19; I2 = 34%), intracranial hemorrhagic events (OR = 0.61; 95% CI, 0.03-10.79; I2 = 62%), morbidity (OR = 0.53; 95% CI, 0.05-5.72; I2 = 86%), and mortality (OR = 1.96; 95% CI, 0.64-5.97; I2 = 0%) between the 2 groups. Subgroup analysis suggested that platelet function testing-guided therapy may contribute to fewer symptomatic thromboembolic events in patients who received stent-assisted coiling (OR = 0.43; 95% CI, 0.18-1.02; I2 = 43%) or a combination of stent-assisted and flow-diverter stent placement (OR = 0.61; 95% CI, 0.36-1.02; I2 = 0%) or who changed from clopidogrel to other thienopyridines (OR = 0.64; 95% CI, 0.40-1.02; I2 = 18%), though the difference did not reach statistical significance. LIMITATIONS Heterogeneous endovascular treatment methods and adjusted antiplatelet regimens were limitations. CONCLUSIONS Platelet function testing-guided antiplatelet strategy significantly reduced the incidence of symptomatic thromboembolic events without any increase in the hemorrhagic events for patients undergoing endovascular treatment for intracranial aneurysms.
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Affiliation(s)
- X Wang
- From the Departments of Pharmacy (X.W., Z.A.)
| | - L Luo
- Department of Pharmacy (L.L.), Beijing Huairou Hospital, Beijing, China
| | - Y Wang
- Neurosurgery (Y.W.), Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Z An
- From the Departments of Pharmacy (X.W., Z.A.)
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