Relationship between adverse events and antiplatelet drug resistance in neurovascular intervention: a meta-analysis

Ticagrelor Versus Clopidogrel in Endovascular Therapy for Cerebral Aneurysms: A Systematic Review and Meta-Analysis

BACKGROUND

Antiplatelet therapy is pivotal in endovascular treatment for intracranial aneurysms. However, there is a lack of studies comparing ticagrelor to clopidogrel in patients with aneurysms undergoing endovascular therapy. Additionally, the existing literature lacks adequate sample size, significant subgrouping, and follow-up, making our study important to cover these gaps.

METHODS

We searched 5 databases to collect all relevant studies. Categorical outcomes were pooled as relative risk (R.R.) with a 95% confidence interval (CI). In the single-arm meta-analysis, outcomes were pooled as proportions and their corresponding 95% CI.

RESULTS

This comprehensive analysis of 18 studies involving 2,427 patients. For thromboembolic events, the pooled (R.R.) did not show significant differences, whether considering overall events. A similar pattern was observed for thromboembolic events stratified by aneurysmal rupture status, with no significant differences in overall events. Hemorrhagic events did not also exhibit significant differences in previously mentioned stratifications. Furthermore, there were no substantial differences in death and mRS (0-2) on discharge between Ticagrelor and Clopidogrel. Single-arm meta-analyses for Ticagrelor demonstrated low rates of thromboembolic events, hemorrhage, death, and favorable mRS scores, with associated confidence intervals (CIs). Main line of endovascular treatment did not significantly affect either thromboembolic or hemorrhagic outcomes with Ticagrelor and Clopidogrel.

CONCLUSIONS

We found no significant differences in key outcomes like thromboembolic events, hemorrhagic events, mortality rates, and favorable mRS (0-2) upon discharge in the studied patients between Ticagrelor and Clopidogrel. Moreover, the single-arm meta-analysis for Ticagrelor revealed low rates of thromboembolic events, hemorrhage, mortality, and high rates of favorable mRS scores.

Effect of Chronic Anticoagulation on Outcomes of Endovascular Treatment for Unruptured Intracranial Aneurysms-A Propensity-Matched Multicenter Study

BACKGROUND AND OBJECTIVES

Endovascular treatment of unruptured intracranial aneurysms (UIAs) in patients receiving anticoagulant medications has not been well studied. Whether long-term anticoagulation (AC) use affects aneurysmal obliteration rates and treatment-related complications is unclear.

METHODS

Patients with endovascular treatment for UIA from 4 academic centers were identified and divided into AC and non-AC groups. Periprocedural complications, radiographic and clinical outcomes, and retreatment rates were compared between the 2 groups before and after propensity score matching.

RESULTS

The initial cohort consisted of 70 patients in the AC group and 355 in the non-AC group. After one-to-one nearest neighbor propensity matching, 38 pairs of patients were compared for periprocedural complications. The total number of complications were higher in the AC group yet not significant (18.4% vs 5.3%, P = .15). After adding imaging follow-up duration to matched variables, 36 pairs were obtained. There was no significant difference in Raymond-Roy occlusion rate between the 2 groups ( P = .74). However, retreatment rate trended higher in the AC group compared with the non-AC group (22.2% vs 5.6%, P = .09). When clinical follow-up duration was added among matched variables, 26 pairs of cases were obtained for long-term clinical outcomes. There was no significant difference in modified Rankin Scale score between the 2 groups ( P = .61). One-to-many nearest neighbor propensities matched analysis with bigger sample sizes yielded similar results.

CONCLUSION

The use of anticoagulants does not affect occlusion rates or long-term outcomes in endovascular treatment of UIAs. Retreatment rates were higher in the AC group; however, this was not statistically significant.

Antiplatelet Resistance in Patients Who Underwent Coronary Artery Bypass Grafting: A Systematic Review and Meta-Analysis

Antiplatelet therapy (APT) with aspirin and a P2Y12 inhibitor is commonly given to patients who underwent coronary artery bypass grafting (CABG) to reduce thrombotic events. APT resistance, the inadequate antiplatelet effect of these drugs, is a growing concern. This review aimed to assess APT resistance prevalence in patients who underwent CABG and its impact on clinical outcomes. We conducted a comprehensive search for relevant studies published to date. The included studies measured platelet function through laboratory assays and reported on clinical outcomes in patients who underwent CABG. The primary outcomes were major adverse cardiovascular events (MACEs) and mortality, whereas the secondary outcomes included acute coronary syndrome (ACS), stroke, and thromboembolic events. The meta-analysis used random-effects models, with heterogeneity assessed using the I2 statistic. The initial search identified 45 studies, with 11 meeting the inclusion criteria, involving 3,122 patients. The overall prevalence of APT resistance in patients who underwent CABG was 39%. Patients with APT resistance had significantly higher risks of MACEs and death (odds ratio [OR] 1.73, 95% confidence interval [CI] 1.06 to 2.83, p = 0.03) and postoperative myocardial infarction (OR 2.25, 95% CI 1.13 to 4.48, p = 0.02) than those without resistance. However, no significant association was found between APT resistance and stroke (OR 2.25, 95% CI 0.80 to 6.35, p = 0.12) or other thromboembolic events (OR 1.72, 95% CI 0.72 to 4.08, p = 0.22). In conclusion, APT resistance is prevalent in a significant proportion of patients who underwent CABG, increasing the risk of MACEs and postoperative myocardial infarction. These findings emphasize the need for further research to develop tailored antiplatelet strategies in this patient population.

Aspirin is a safe and effective thromboembolic prophylaxis after total knee arthroplasty: a systematic review and meta-analysis

PURPOSE

Patients undergoing total knee arthroplasty (TKA) are at high risk for thromboembolic events compared to non-surgical patients. Both anticoagulants and antiplatelet agents are used as antithrombotic prophylaxis in TKA. The aim of this review is to understand the role of aspirin in the prevention of thromboembolic events and to compare its efficacy and safety with the main anticoagulants used in antithromboembolic prophylaxis in TKA.

METHODS

A systematic review and meta-analysis was performed according to the PRISMA guidelines. An electronic systematic search was conducted using PubMed, Scopus, and the Cochrane Central Registry to evaluate studies that compared aspirin with other anticoagulants, in terms of deep venous thrombosis and pulmonary embolism after TKA. The meta-analysis compared the rate of complications between aspirin and other anticoagulants.

RESULTS

Thirteen studies were included in the systematic review for a total of 163,983 patients, and 10 studies were included in the meta-analysis. The meta-analysis demonstrated no statistically significant differences between aspirin and other anticoagulants in terms of the rate of deep venous thrombosis (OR 0.93, 95% CI 0.81-1.08, p = 0.35) and pulmonary embolism (OR 0.89, 95% CI 0.56-1.41, p = 0.61).

CONCLUSION

Aspirin is safe, effective, and not inferior to other main anticoagulants in preventing thromboembolic events following TKA.

Antiplatelet Therapy in Neurointervention

The aim of this review is to provide an overview of the use of antiplatelet medication in neurointervention, with a focus on the clinical indications for antiplatelet use in both preventing and reducing platelet aggregation. This review will cover current antiplatelet medications, pharmacokinetics, and pharmacodynamics. We will provide an overview of different endovascular devices and discuss the antiplatelet regimes in neurointervention, highlighting gaps in evidence and scope for future studies.Two randomized controlled trials have evaluated antiplatelet use in the setting of acute large vessel occlusion stroke, with neither demonstrating benefit in their overall cohorts. Evidence on antiplatelet medication for both acute and elective stenting for acute stroke and treatment of cerebral aneurysms is currently based on large case series, and practice in neurointervention has increasingly utilized dual antiplatelet regimes with clopidogrel and second-line agents like prasugrel and ticagrelor. Clopidogrel function testing has an increasing role in neurointerventional procedures, particularly for high metal surface area stents such as the braided flow diverter type stents. Intravenous glycoprotein IIB/IIIA inhibitors have been utilized for both acute bridging and rescue therapy.Antiplatelet decision making is complex, and there are few randomized control trials to guide clinical practice. Comparative trials to guide decision making remain important in both the acute and elective settings. Standardised protocols incorporating platelet function testing may play a role in assisting decision making until more robust clinical evidence is available, particularly in the context of acute neurointerventional stenting for stroke and ruptured cerebral aneurysms.

Antithrombotic therapies for neurointerventional surgery: a 2021 French comprehensive national survey

BACKGROUND

Neurointerventionists lack guidelines for the use of antithrombotic therapies in their clinical practice; consequently, there is likely to be significant heterogeneity in antithrombotic use between centers. Through a nationwide survey, we aimed to obtain an exhaustive cross-sectional overview of antithrombotic use in neurointerventional procedures in France.

METHODS

In April 2021, French neurointerventional surgery centers were invited to participate in a nationwide 51-question survey disseminated through an active trainee-led research collaborative network (the JENI-RC).

RESULTS

All 40 centers answered the survey. Fifty-one percent of centers reported using ticagrelor and 43% used clopidogrel as premedication before intracranial stenting. For flow diversion treatment, dual antiplatelet therapy was maintained for 3 or 6 months in 39% and 53% of centers, respectively, and aspirin was prescribed for 12 months or more than 12 months in 63% and 26% of centers, respectively. For unruptured aneurysms, the most common heparin bolus dose was 50 IU/kg (59%), and only 35% of centers monitored heparin activity for dose adjustment. Tirofiban was used in 64% of centers to treat thromboembolic complications. Fifteen percent of these comprehensive stroke centers reported using tenecteplase to treat acute ischemic strokes. Cangrelor appeared as an emergent drug in specific indications.

CONCLUSION

This nationwide survey highlights the important heterogeneity in clinical practices across centers. There is a pressing need for trials and guidelines to further evaluate and harmonize antithrombotic regimens in the neurointerventional field.

Ticagrelor versus clopidogrel dual antiplatelet therapy for unruptured intracranial aneurysms treated with flowdiverter

BACKGROUND AND PURPOSE

Antiplatelet therapy (APT) is a key element limiting the risk of thromboembolic events (TEE) in neuroendovascular procedures, including aneurysm treatment with flowdiverter. Clopidogrel combined with aspirin is the mostly reported dual APT (DAPT). However, resistance phenomenon and intraindividual efficacy fluctuation are identified limitations. In recent years, ticagrelor has been increasingly used in this indication. We compared these two DAPT regimens for intracranial aneurysm treated with flowdiverter.

METHODS

We conducted a multicentric retrospective study from prospectively maintained databases in two high volume centers extracting consecutive patients presenting unruptured intracranial aneurysm treated with flowdiverter and receiving DAPT (May 2015 to December 2019).  Two groups were compared according to their DAPT regimen: "ticagrelor+aspirin" and "clopidogrel+aspirin". Clopidogrel group was systematically checked with platelet test inhibition before endovascular procedure. The primary endpoint was composite, defined as any thrombo-embolic event (TEE) or major hemorrhagic event occurring the first 6 months during and after embolization RESULTS: 260 patients met our inclusion criteria. Baseline patients and aneurysms characteristics were comparable between groups, except for aneurysm location, median size and pre-treatment modified Rankin scale. No significant difference was observed regarding the primary composite outcome: 11.5% (12/104) in the ticagrelor group versus 10.9% (17/156) in the clopidogrel group (p = 1.000). There was also no significant difference in secondary outcomes including TEE (10.5 vs 9.0%; p = 0.673), major hemorrhage (0.9 vs 1.2%; p = 0.651) and clinical outcome (at least 1-point mRS worsening during follow up: 6.7% vs 8.3%; p = 0.813).

CONCLUSION

First-line DAPT with ticagrelor+aspirin seems as safe and effective as clopidogrel+aspirin regimen.

Stent-assisted coiling of acutely ruptured cerebral aneurysm: a multicenter prospective registry study (SAVE)

Background

Stent-assisted coiling (SAC) has been reported as a feasible and effective treatment of wide-neck cerebral aneurysms. However, the evidence of SAC of ruptured cerebral aneurysm is lacking. There are no prospective multicenter studies regarding SAC of acutely ruptured aneurysms within 72 hours after subarachnoid hemorrhage. The purpose of the study is to evaluate the safety and efficiency of SAC of acutely ruptured cerebral aneurysms.

Methods

This study is a prospective, multicenter, and observation registry of consecutive patients with acutely ruptured cerebral aneurysms treated with SAC. Acutely ruptured aneurysms were confirmed within 72 h after the onset of the syndrome. This study will enroll at least 300 patients in 7 high-volume tertiary hospitals (more than 150 cerebral aneurysms treated per year). The primary outcomes are treatment-related thromboembolic complications within 30 days of the treatment. The secondary outcomes are any hemorrhagic complications and aneurysm recurrence at 6 months of angiographic follow-up. The clinical outcomes are measured with the Modified Rankin Scale (mRS) at discharge and at the 6 months of follow-up. The favorable outcomes are defined as an mRS of grades 0 and 2.

Discussion

We will perform a prospective, multicenter, and observational registry study of consecutive patients with wide-neck acutely ruptured cerebral aneurysms to improve the safety strategy of SAC of acutely ruptured cerebral aneurysms.

Trial registration

Chinese Clinic Trial Registry: ChiCTR2000036972; Registration date: Aug 26, 2020

Macrostachyols A-D, oligostilbenes from Gnetum macrostachyum inhibited in vitro human platelet aggregation

Introduction: Gnetum macrostachyum is a known Thai medicinal plant as a source of bioactive oligostilbenes, which possess platelet inhibitory activities. The study aimed to evaluate the in vitro human platelet aggregation inhibitory activities of macrostachyols A-D (compounds 1-4) isolated from the roots of G. macrostachyum. Methods: The in vitro human platelet aggregation assay was assayed with a 96-well microtiter plate format. The well-known aggregating agents were used to investigate the possible mechanism of inhibition, including adenosine diphosphate (ADP), arachidonic acid (AA), thromboxane A2 analog (U-46619), collagen, thrombin, and thrombin receptor-activating peptide-6 (TRAP-6). Results: Compound 1 was more potent than ibuprofen (positive control) on the adenosine diphosphate- induced platelet aggregation assay (P < 0.05). Compound 3 was more potent than 1, 2, and 4 (P < 0.05), but all active oligostilbenes were less potent than the positive control (P < 0.05) on the arachidonic acid-induced platelet aggregation assay. The oligostilbenes 1, 2, 3, and 4 also displayed the inhibitory effects on the U-46619-induced platelet aggregation. The tetrameric stilbenes 1 was the only compound that exhibited inhibitory effects on thrombin-induced platelet aggregation without TRAP-6 mediated platelet aggregation. Conclusion: The findings revealed the inhibitory effects of oligostilbenes on human platelet aggregation through a target-specific experimental design. It suggests that oligostilbenes from this plant might be applied as antiplatelet aggregation agents in platelet hyperreactivity- related diseases.

Platelet function assays for the diagnosis of aspirin resistance

Aspirin, an antiplatelet drug, is commonly used at low doses for numerous indications, including prophylaxis of cardiovascular, neurovascular, and venous thromboembolic events. Due to review articles suggesting that aspirin resistance may result in poorer outcomes, interest in assessing platelet function is increasing. Despite this, platelet function tests are rarely used as part of routine clinical practice and therefore, a basic understanding of these tests may be lacking. Although aspirin resistance can be categorized as clinical or laboratory resistance, determining laboratory resistance is the only way to determine resistance before treatment failure occurs. Therefore, knowledge of platelet assays to determine aspirin resistance is of importance. The following review aims to provide a framework for clinicians to understand the main principles of platelet function tests. This includes comparison of the most frequently used platelet assays to diagnose aspirin resistance, including the basic mechanism, methodology, reference ranges, inter-assay comparison, and their respective clinical considerations when using.

Utility of platelet function testing in stent-assisted coiling of cerebral aneurysms

BACKGROUND

Thromboembolic complications are the primary risks of stent-coiling of cerebral aneurysms. The utility of platelet function testing in stent-assisted aneurysm coiling remains controversial. This study aimed to assess a pharmacy-mediated antiplatelet management protocol for stent-assisted coiling.

METHODS

Stent-coiled aneurysms at an academic institution in the United States between 2015 and 2018 were retrospectively reviewed. All patients were managed using a pharmacy-mediated antiplatelet protocol, which required repeated platelet function testing and subsequent dose adjustments. Medication dosage, number of adjustments, aspirin reaction units (ARU) and P2Y12 reaction units (PRU), as well as complication rates, angiographic and functional outcome were analyzed.

RESULTS

A total of 56 aneurysms (median size 5 mm, range 2.6-14.0 mm) in 54 patients (median age 58.5 years) were treated with stent-assisted coil embolization. Most aneurysms were located at the basilar tip (28.6%). Median pre-procedure ARU and PRU were 442.5 (range 363-594) and 123.5 (range 1-252), respectively. Approximately two-thirds of all procedures required at least one aspirin dose adjustment and 88.5% of procedures required at least one clopidogrel dose adjustment. There were two (3.6%) thromboembolic complications. One of the thromboembolic complications occurred in a patient where the pharmacy-mediated protocol was violated. There were no hemorrhagic complications. Last imaging follow-up demonstrated complete aneurysm occlusion in 83.9%.

CONCLUSION

In patients where the pharmacy-mediated antiplatelet protocol was followed, the thromboembolic complication rate was 1.8%. This complication rate compares favorably to those reported in large contemporary series. Nevertheless, the pharmacy-mediated protocol places a significant burden on both the patient and healthcare system.

Safety and efficacy of a pre-treatment antiplatelet regimen of unruptured intracranial aneurysms: a single-center experience

PURPOSE

Endovascular treatment of unruptured intracranial aneurysms with stent-assisted coiling or flow diverter stents requires a prophylactic antiplatelet premedication to avoid thrombo-embolic complications. Guidelines for optimal antiplatelet regimens are poorly defined. The aim of this study is to report our experience using a high dosage antiplatelet premedication regimen for patients with unruptured intracranial aneurysms undergoing endovascular treatment by stent-assisted coiling or flow diverter stents.

METHODS

From a retrospective analysis of a prospectively maintained database, we collected clinical and angiographic data of 400 procedures in 362 patients treated by stent-assisted coiling or flow diverter stents for 419 unruptured intracranial aneurysms. Descriptive and analytic statistics were performed to report morbidity, mortality, and complication rates and to demonstrate associations between variables and outcomes. Logistic multivariable regression was performed to rule out confounding factors between subgroups.

RESULTS

Thrombo-embolic complications occurred in 23/400 procedures (5.75%) and hemorrhagic complications in 19/400 procedures (4.75%). The majority of complications were minor and transient with overall procedure-related morbidity and mortality rates of 1.75% (n = 7/400) and 1.25% (n = 5/400) respectively. The co-existence of multiple cardiovascular risk factors among smoking, hypertension, dyslipidemia, and age > 65 years old was significantly associated with permanent procedure-related morbidity (p = 0.006) and thrombo-embolic complications occurrence (p = 0.034). Age alone was associated with higher permanent morbidity (p = 0.029) and was the only variable associated with higher hemorrhagic complication (p = 0.024).

CONCLUSION

In this study, the use of a high dosage antiplatelet premedication was safe and effective for the treatment of unruptured intracranial aneurysms with stent-assisted coiling or flow diverter stents. Mortality and morbidity rates compare favorably with the current literature. The thrombo-embolic complications rate is low and most of them were clinically silent. However, the hemorrhagic complications rate was substantial and a significant proportion of them were associated with mortality.

Coil Embolization for Unruptured Intracranial Aneurysms at the Dawn of Stent Era: Results of the Japanese Registry of Neuroendovascular Therapy (JR-NET) 3

Endosaccular coiling is recognized as a feasible method for treating unruptured intracranial aneurysms (UIAs). We retrospectively reviewed cases of UIAs treated by coiling in the Japanese Registry of Neuroendovascular Therapy (JR-NET) 3, a nationwide survey of NET between 2010 and 2014, the beginning period of intracranial stents in Japan. Data were extracted for 6844 UIAs (6619 procedures) from 40,169 registered records of all NETs in the JR-NET 3 databases. The features of the aneurysms and procedures, immediate radiographic findings, procedure-related complications, and clinical outcomes at 30 days after the procedures were assessed. Of 6844 UIAs, 81.8% were located in the anterior circulation. The mean patient age was 61.3 years (72.4% females). Compared with the preceding JR-NET 1 and 2, there were significant increases (P <0.05) in the rates of the following in JR-NET 3: wide-necked and small UIAs measuring <10 mm (from 56.4% to 58.8%), adjunctive techniques (54.8% to 71.8%), and stent usage (1.1% to 22.1%). Both pre- (85.6% to 96.7%) and post-procedural (84.0% to 94.6%) antiplatelet therapy were more frequently administered in JR-NET 3. Although procedure-related complication rates did not differ between the two groups, ischemic complication rates increased from 4.6% to 5.9%, leading to an increase in the 30-day morbidity (modified Rankin Scale >2) from 2.1% to 2.8%. In conclusion, introduction of neck-bridge stent was associated with an increase in cases of wide-necked aneurysms. However, the ischemic complication rate increased despite the greater use of periprocedural antiplatelet therapy.

Antiplatelet therapy for prevention of thromboembolic complications in coiling-only procedures for unruptured brain aneurysms

BACKGROUND AND PURPOSE

Thromboembolic events are recognized complications of aneurysm coiling.

OBJECTIVE

To identify any protective effects of antiplatelet therapy use before coiling of unruptured aneurysms.

METHODS

We conducted a meta-analysis of clinical studies published up to February 2019. We included studies reporting symptomatic thromboembolic events (defined as clinical stroke or transient ischemic attacks) in patients who received antiplatelet therapy before coiling of unruptured aneurysms using unassisted coiling, balloon assistance, or multiple microcatheters. We excluded ruptured aneurysms and those treated with stent coiling or flow diverters.

RESULTS

We identified 14 studies (2486 patients). All were single-center studies and four were prospective. In three studies with a control (no treatment) arm, the pooled risk ratio for symptomatic thromboembolic events with versus without antiplatelet therapy was 0.33 (95% CI 0.17 to 0.92, p= 0.035). The cumulative risk of symptomatic thromboembolic events with single antiplatelet agents was 5.0% '56/1122' (95% CI 1.6% to 8.4%, I²83.63%), and with dual or multiple agents 2.7% '33/1237' (95% CI 1.0% to 3.0%, I²39.9%). The incidence of diffusion lesions was reported in seven studies. It was 50.5% '96/190' (95% CI 7.3% to 93.9%, I²94.4%) with single agents compared with 43.9% '196/446' (95% CI 25.9% to 61.9%, I²73.4%) with dual or multiple agents.

CONCLUSION

Periprocedural antiplatelet therapy was associated with a low symptomatic thromboembolic event after coiling-only for unruptured aneurysms. However, available evidence is of limited quality with significant heterogeneity, requiring evidence from randomized controlled trials.

Outcome of intracranial flow diversion according to the antiplatelet regimen used: a systematic review and meta-analysis

Background

Thromboembolic complications are not uncommon in patients undergoing neurointerventional procedures. The use of flow diverting stents is associated with higher risks of these complications despite current dual antiplatelet regimens.

Objective

To explore contemporary evidence on the safety of emerging dual antiplatelet regimens in flow diverting stenting procedures.

Methods

We performed a systematic review and meta-analysis to identify relevant articles in electronic databases, and relevant references. Studies reporting the complications and mortality of flow diverting stenting procedures using acetyl salicylic acid (ASA) + ticagrelor or ASA + prasugrel compared with ASA + clopidogrel were included.

Results

Of 452 potentially relevant studies, we identified 49 studies (2526 patients) which reported the safety of ticagrelor or prasugrel for pooled analysis, and five studies (1005 patients) for meta-analysis. The pooled overall mortality in all studies was 2.14%, ischemic complications 6.89%, and hemorrhagic complications 3.68%. The use of ticagrelor or prasugrel was associated with a lower risk of mortality compared with clopidogrel (RR=4.57, 95% CI 1.23 to 16.99; p=0.02). Considering ischemic events, ASA + clopidogrel was as safe as ASA + prasugrel (RR=0.55, 95% CI 0.11 to 2.74; p=0.47) and ASA + ticagrelor (RR=0.74, 95% CI 0.32 to 1.74; p=0.49). ASA +ticagrelor was not associated with a higher risk of hemorrhagic complications (RR=0.92, 95% CI 0.27 to 3.16; p=0.89).

Conclusions

Evidence suggests that dual antiplatelet regimens including ticagrelor or prasugrel are safe for patients undergoing flow diversion procedures. Regimens using ticagrelor were associated with better survival than those using clopidogrel in the included studies.

The safety of triple antiplatelet therapy under thromboelastography guidance in patients undergoing stenting for ischemic cerebrovascular disease

OBJECTIVE

To investigate the safety of triple antiplatelet therapy (TAT) with cilostazol in patients undergoing stenting for extracranial and/or intracranial artery stenosis.

METHODS

A prospectively collected database was reviewed to identify patients who underwent stenting for extracranial and/or intracranial artery stenosis and showed resistance to aspirin and/or clopidogrel as assessed by pre-stenting thromboelastography (TEG) testing. Patients were assigned to a TAT group and a dual antiplatelet therapy (DAT) group. Major complications were defined as thromboembolic events (transient ischemic attack (TIA), ischemic stroke, and stent thrombosis) or major bleeding events within 30 days, and minor complications were defined as extracranial bleeding that did not require vascular surgery or transfusion within 30 days.

RESULTS

A total of 183 patients were identified. The incidence of major complications was significantly lower in the TAT group than in the DAT group (TAT group vs. DAT group, 1/110 vs. 6/73; P=0.017). TIAs occurred in four patients, with one in the TAT group and three in the DAT group (1/110 vs. 3/73; P=0.303). Ischemic strokes occurred in three patients in the DAT group (TAT group vs. DAT group, P=0.062). No major bleeding events or stent thrombosis was recorded in either group. Two patients (one in each group) experienced minor complications that resolved without additional treatment (1/110 vs. 1/73; P>0.999).

CONCLUSIONS

TAT under TEG guidance appears to be a safe antiplatelet strategy in patients undergoing stenting for extracranial and/or intracranial artery stenosis. By employing TAT under TEG guidance, favorable outcomes can be achieved in these patients.