1
|
Mitchell DL, McGuire LS, Khalid SI, Alaraj A. Assessing the efficacy of VerifyNow platelet-function testing in predicting postoperative thromboembolic complications of neuroendovascular surgery: A systematic review and meta-analysis (part 1). Interv Neuroradiol 2024:15910199231224008. [PMID: 38186294 DOI: 10.1177/15910199231224008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024] Open
Abstract
BACKGROUND Despite the heavily debated use of routine platelet-function testing, the VerifyNow Platelet Reactivity Unit (PRU) assay has been increasingly adopted as standard of care for assessing risk of postoperative thromboembolic complications of neuroendovascular surgery. OBJECTIVE We conducted a systematic review and meta-analysis to examine the relationship between platelet response and risk of ischemic events from neuroendovascular surgery, assess the efficacy of point-of-care platelet-function testing in predicting thromboembolic outcomes, and assess whether a clinically useful threshold for platelet response can be defined in order to standardize guidelines. METHODS PubMed, Embase, and Scopus were searched. Following deduplication, articles were first screened for relevance by title and abstract, followed by full text. RESULTS Of 735 resultant articles, 22 studies consisting of 3266 patients undergoing neuroendovascular intervention were included. Diagnoses included both intracranial and extracranial pathologies, of which 45.8% were treated with flow diversion, 16.4% with stent-assisted coil embolization, 15.8% with intracranial stenting, 12.0% with simple coil embolization, 3.4% with balloon-assisted coil embolization, 3.6% with extracranial stenting, and 3.0% with an alternate method. 54.5% (12/22) of studies determined platelet hyporesponse to be an independent predictor of postoperative thromboembolic complications, with 27.3% (6/22) of studies reporting a similar, but non-statistically significant trend. 18.2% (4/22) of studies found no relationship between platelet response and postoperative thromboembolic complications. The estimated clinical threshold for PRU to prevent thromboembolic complications varied greatly across studies (Range: > 144-295 PRU). Meta-analysis found platelet hyporesponse to have a 2.23-fold increased risk of thromboembolic complications compared to normoresponders (RR = 2.23, P = 0.03). CONCLUSION While PRU demonstrates a significant predictive value for postoperative thromboembolic complications of neuroendovascular surgery, the target therapeutic threshold for minimizing ischemic events remains unclear. Further studies, such as large multicenter cohorts of the existing data, are needed to standardize guidelines.
Collapse
Affiliation(s)
- Devon L Mitchell
- Chicago Medical School, Rosalind Franklin University, Chicago, IL, USA
| | | | - Syed I Khalid
- Department of Neurosurgery, University of Illinois, Chicago, IL, USA
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois, Chicago, IL, USA
| |
Collapse
|
2
|
Mitchell DL, McGuire LS, Khalid SI, Alaraj A. Assessing the efficacy of VerifyNow platelet-function testing in predicting postoperative hemorrhagic complications of neuroendovascular surgery: A systematic review and meta-analysis (part 2). Interv Neuroradiol 2024:15910199231225716. [PMID: 38192126 DOI: 10.1177/15910199231225716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND Dual antiplatelet therapy is used to reduce the risk of thromboembolic complications in neuroendovascular surgery. However, the predictive utility of preoperative platelet-sensitivity testing for decreasing bleed risk in patients undergoing endovascular neurointervention remains unclear. OBJECTIVE We conducted a systematic review and meta-analysis to illustrate the association between platelet response and risk of hemorrhagic complications from neuroendovascular surgery, examine the efficacy of the VerifyNow platelet reactivity unit (PRU) assay in predicting hemorrhagic outcomes, and assess whether a clinically useful threshold for platelet response can be defined to standardize guidelines. METHODS PubMed, Embase, and Scopus were searched. Articles were screened for relevance by title and abstract, followed by full text. RESULTS Of 735 resultant articles, 17 studies of 2084 patients undergoing neuroendovascular intervention were included. Diagnoses included both intracranial and extracranial pathologies, of which 37.8% were treated with flow diversion, 22.4% with stent-assisted coil embolization, 14.3% with intracranial stenting, 12.8% with simple coil embolization, 5.8% with balloon-assisted coil embolization, 2.0% with extracranial stenting, and 4.8% with an alternate method. Precisely, 52.9% (9 out of 17) of studies determined platelet hyperresponse to be an independent predictor of postoperative hemorrhagic complications, with 11.8% (2 out of 17) of studies reporting a similar but non-statistically significant trend. 35.3% (6 out of 17) of studies found no relationship between platelet response and postoperative hemorrhagic complications. The estimated clinical threshold for PRU to prevent hemorrhagic complications varied considerably across studies (range: <46-118 PRU). Meta-analysis found platelet hyperresponse to have more than a 3-fold increased risk of hemorrhagic complications compared to normoresponders (relative risk = 3.2, p = 0.001). CONCLUSION Although this meta-analysis shows the predictive utility of the P2Y12 assay for postoperative hemorrhagic complications in neuroendovascular surgery, the optimal therapeutic threshold for minimizing bleeding risk is still uncertain. To better understand the utility of the P2Y12 assay in the perioperative period, further prospective research is needed.
Collapse
Affiliation(s)
- Devon L Mitchell
- Chicago Medical School, Rosalind Franklin University, North Chicago, IL, USA
| | | | - Syed I Khalid
- Department of Neurosurgery, University of Illinois, Chicago, IL, USA
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois, Chicago, IL, USA
| |
Collapse
|
3
|
Schirmer CM, Bulsara KR, Al-Mufti F, Haranhalli N, Thibault L, Hetts SW. Antiplatelets and antithrombotics in neurointerventional procedures: Guideline update. J Neurointerv Surg 2023; 15:1155-1162. [PMID: 37188504 DOI: 10.1136/jnis-2022-019844] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 04/22/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Antiplatelet and antithrombotic medication management before, during, and after neurointerventional procedures has significant practice variation. This document updates and builds upon the 2014 Society of NeuroInterventional Surgery (SNIS) Guideline 'Platelet function inhibitor and platelet function testing in neurointerventional procedures', providing updates based on the treatment of specific pathologies and for patients with specific comorbidities. METHODS We performed a structured literature review of studies that have become available since the 2014 SNIS Guideline. We graded the quality of the evidence. Recommendations were arrived at through a consensus conference of the authors, then with additional input from the full SNIS Standards and Guidelines Committee and the SNIS Board of Directors. RESULTS The management of antiplatelet and antithrombotic agents before, during, and after endovascular neurointerventional procedures continues to evolve. The following recommendations were agreed on. (1) It is reasonable to resume anticoagulation after a neurointerventional procedure or major bleeding episode as soon as the thrombotic risk exceeds the bleeding risk in an individual patient (Class I, Level C-EO). (2) Platelet testing can be useful to guide local practice, and specific approaches to using the numbers demonstrate marked local variability (Class IIa, Level B-NR). (3) For patients without comorbidities undergoing brain aneurysm treatment, there are no additional considerations for medication choice beyond the thrombotic risks of the catheterization procedure and aneurysm treatment devices (Class IIa, Level B-NR). (4) For patients undergoing neurointerventional brain aneurysm treatment who have had cardiac stents placed within the last 6-12 months, dual antiplatelet therapy (DAPT) is recommended (Class I, Level B-NR). (5) For patients being evaluated for neurointeventional brain aneurysm treatment who had venous thrombosis more than 3 months prior, discontinuation of oral anticoagulation (OAC) or vitamin K antagonists should be considered as weighed against the risk of delaying aneurysm treatment. For venous thrombosis less than 3 months in the past, delay of the neurointerventional procedure should be considered. If this is not possible, see atrial fibrillation recommendations (Class IIb, Level C-LD). (6) For patients with atrial fibrillation receiving OAC and in need of a neurointerventional procedure, the duration of TAT (triple antiplatelet/anticoagulation therapy=OAC plus DAPT) should be kept as short as possible or avoided in favor of OAC plus single antiplatelet therapy (SAPT) based on the individual's ischemic and bleeding risk profile (Class IIa, Level B-NR). (7) For patients with unruptured brain arteriovenous malformations there is no indication to change antiplatelet or anticoagulant management instituted for management of another disease (Class IIb, Level C-LD). (8) Patients with symptomatic intracranial atherosclerotic disease (ICAD) should continue DAPT following neurointerventional treatment for secondary stroke prevention (Class IIa, Level B-NR). (9) Following neurointerventional treatment for ICAD, DAPT should be continued for at least 3 months. In the absence of new stroke or transient ischemic attack symptoms, reversion to SAPT can be considered based on an individual patient's risk of hemorrhage versus ischemia (Class IIb, Level C-LD). (10) Patients undergoing carotid artery stenting (CAS) should receive DAPT before and for at least 3 months following their procedure (Class IIa, Level B-R). (11) In patients undergoing CAS during emergent large vessel occlusion ischemic stroke treatment, it may be reasonable to administer a loading dose of intravenous or oral glycoprotein IIb/IIIa or P2Y12 inhibitor followed by maintenance intravenous infusion or oral dosing to prevent stent thrombosis whether or not the patient has received thrombolytic therapy (Class IIb, C-LD). (12) For patients with cerebral venous sinus thrombosis, anticoagulation with heparin is front-line therapy; endovascular therapy may be considered particularly in cases of clinical deterioration despite medical therapy (Class IIa, Level B-R). CONCLUSIONS Although the quality of evidence is lower than for coronary interventions due to a lower number of patients and procedures, neurointerventional antiplatelet and antithrombotic management shares several themes. Prospective and randomized studies are needed to strengthen the data supporting these recommendations.
Collapse
Affiliation(s)
| | - Ketan R Bulsara
- Division of Neurosurgery, University of Connecticut, Farmington, Connecticut, USA
| | - Fawaz Al-Mufti
- Neurology, Neurosurgery, and Radiology, Westchester Medical Center, Valhalla, New York, USA
| | - Neil Haranhalli
- Neurosurgery and Radiology, Montefiore Hospital and Medical Center, Bronx, New York, USA
| | - Lucie Thibault
- Scientific Committee, World Federation of Interventional and Therapeutic Neuroradiology, Paris, France
| | - Steven W Hetts
- Radiology, Biomedical Imaging, and Neurological Surgery, UCSF, San Francisco, California, USA
| |
Collapse
|
4
|
Predictors of Clopidogrel Hyper-Responsiveness in Neuro-Interventional Procedures. J Stroke Cerebrovasc Dis 2020; 30:105420. [PMID: 33161351 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 10/09/2020] [Accepted: 10/18/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Hyper-responsiveness to clopidogrel abnormally inhibits platelet aggregation and increases hemorrhagic complications. The present study investigated clinical factors related to clopidogrel hyper-responsiveness in neuro-interventional procedures. METHODS Two hundred twenty-four patients receiving clopidogrel for coil embolization to treat unruptured cerebral aneurysm or carotid artery stenting to treat carotid artery stenosis at the internal carotid artery origin were retrospectively reviewed for their P2Y12 reactivity unit (PRU) values and clinical characteristics. Hyper-responsiveness to clopidogrel was defined as a PRU of <95. RESULTS The mean PRU was 218.2 ± 77.8. Hyper-responsiveness to clopidogrel was observed in 12 patients (5.4%). Hyper-responsiveness was observed in younger patients, patients with a lower concentration of hemoglobin A1c, and patients with a higher low-density lipoprotein cholesterol (LDL-C) concentration compared with non-hyper-responsive patients (P = 0.01, P < 0.01, P < 0.01, respectively). On analysis of concomitant drugs, the patients in the hyper-responsive group were less frequently administered calcium channel blockers (CCBs) compared with the non-hyper-responsive group (P = 0.01). No significant differences in the usage of proton pump inhibitors or statins were observed. A LDL-C concentration of >120 mg/dL and no usage of CCBs were significant independent predictors of hyper-responsiveness to clopidogrel with a multivariate analysis (OR; 6.16, 95% CI, 1.57-26.64, P = 0.01, OR; 0.09, 95% CI, 0.01-0.82, P = 0.03, respectively). CONCLUSION The present study shows that a higher LDL-C concentration and no usage of CCBs are independent predictors of clopidogrel hyper-responsiveness. These results are useful to predict perioperative hemorrhagic complications. Considering dose reduction of clopidogrel or alternative drugs in high risk cases is necessary to prevent perioperative hemorrhagic complications.
Collapse
|
5
|
Cheung NK, Carr MW, Ray U, McKenzie D, Froelich JJ. Platelet Function Testing in Neurovascular Procedures: Tool or Gimmick? INTERVENTIONAL NEUROLOGY 2019; 8:123-134. [PMID: 32508894 DOI: 10.1159/000496702] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 01/07/2019] [Indexed: 12/12/2022]
Abstract
Background Platelet inhibitors are used to prevent thromboembolic complications related to neurovascular stenting (NVS) procedures. Despite substantial inter-individual variability of functional platelet inhibition, the value of platelet function tests (PFT) to assess inhibition remains controversial. Objective This study was conducted to compare differences in thromboembolic complication rates associated with NVS in platelet-inhibited patients with and without PFT. Clinical neurological outcomes were assessed by differences in the modified Rankin Scale (mRS). Materials and Methods One hundred seventeen consecutive patients underwent elective NVS procedures within a 7-year period. All patients received aspirin and clopidogrel 8 days before the procedure. Fifty-two patients were treated without assessment of platelet inhibition, and 65 patients were tested for clopidogrel resistance. When clopidogrel resistance was revealed, corresponding patients were converted to ticagrelor. Changes in mRS and thromboembolic event rates were compared between the 2 cohorts. Results Thirty-five percent of patients from the cohort subjected to PFT tests showed inadequate platelet inhi-bition under clopidogrel and were converted to ticagrelor. Compared to the non-PFT test -cohort, neurological deficits were significantly reduced (12 vs. 0%; p = 0.009) and a lower number of thromboembolic events was found (12 vs. 3%; p > 0.05) within the test cohort. Conclusion PFT appears to identify patients with clopidogrel resistance prior to NVS procedures. When non-responders are converted to alternative platelet inhibitors, neurological outcomes and thromboembolic complication rates may improve. Consequently, this study provides preliminary evidence that PFT may be a useful clinical tool to enhance procedural safety and improve clinical outcomes in NVS procedures.
Collapse
Affiliation(s)
- Nicholas K Cheung
- Department of Medical Imaging, Neuroradiology, Royal Hobart Hospital, Hobart, Tasmania, Australia.,Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Michael W Carr
- Department of Medical Imaging, Neuroradiology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Udayan Ray
- Department of Pathology, Royal Hobart Hospital, Hobart, Tasmania, Australia.,Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Duncan McKenzie
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia.,Department of Pharmacy, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Jens J Froelich
- Department of Medical Imaging, Neuroradiology, Royal Hobart Hospital, Hobart, Tasmania, Australia.,Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| |
Collapse
|
6
|
|
7
|
Narata AP, Amelot A, Bibi R, Herbreteau D, Angoulvant D, Gruel Y, Janot K. Dual Antiplatelet Therapy Combining Aspirin and Ticagrelor for Intracranial Stenting Procedures: A Retrospective Single Center Study of 154 Consecutive Patients With Unruptured Aneurysms. Neurosurgery 2018; 84:77-83. [DOI: 10.1093/neuros/nyy002] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 01/05/2018] [Indexed: 12/17/2022] Open
Affiliation(s)
- Ana Paula Narata
- Department of Radiology and Neu-roradiology, University Hospital of Tours, Tours, France
| | - Aymeric Amelot
- Department of Neurosurgery, University Hospital of Tours, Tours, France
| | - Richard Bibi
- Department of Radiology and Neu-roradiology, University Hospital of Tours, Tours, France
| | - Denis Herbreteau
- Department of Radiology and Neu-roradiology, University Hospital of Tours, Tours, France
| | - Denis Angoulvant
- Department of Cardiology, University Hospital of Tours, Tours, France
| | - Yves Gruel
- Department of Hematology, University Hospital of Tours, Tours, France
| | - Kevin Janot
- Department of Radiology and Neu-roradiology, University Hospital of Tours, Tours, France
| |
Collapse
|
8
|
Shim EJ, Ryu CW, Park S, Lee HN, Shin HS, Kim SB. Relationship between adverse events and antiplatelet drug resistance in neurovascular intervention: a meta-analysis. J Neurointerv Surg 2018; 10:942-948. [DOI: 10.1136/neurintsurg-2017-013632] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 12/27/2017] [Accepted: 01/02/2018] [Indexed: 12/16/2022]
Abstract
BackgroundThis meta-analysis aimed to evaluate the association between antiplatelet resistance and the risk of procedure-related complications in neurovascular interventions.MethodsWe identified relevant articles by searching electronic databases and reviewed the reference lists of selected papers. The risk of adverse events between antiplatelet responders and hyporesponders during neurointervention was compared in eligible clinical studies. Risk ratios (RRs) and 95% CIs were pooled using a random-effects meta-analysis.ResultsOf 2134 potentially relevant studies, our search identified 15 studies enrolling a total of 2365 patients. Pooled RRs showed thromboembolic events (TEE) were more frequent in hyporesponders (RR 2.634, 95% CI 1.465 to 4.734). However, hemorrhagic complications did not differ between the two groups (RR 1.236, 95% CI 0.642 to 2.380). In subgroup analysis, hyporesponders showed a higher prevalence of TEE with standard antiplatelet medication, but there was no obvious difference in TEE between the two arms when using a modified antiplatelet medication (RR 3.645, 95% CI 1.537 to 8.646; and RR 1.877, 95% CI 0.749 to 4.751). Studies using stent placement for aneurysms showed a higher TEE rate in hyporesponders (RR 3.221, 95% CI 1.899 to 5.464).ConclusionAntiplatelet resistance was significantly associated with TEE in neurointervention, and this adverse event was associated with individually-intensified antiplatelet medication as well as the type of neurointerventional procedure. Our findings support the use of antiplatelet resistance assays and tailored antiplatelet medications in neurovascular stent placement as a management strategy to reduce thromboembolic risk.
Collapse
|
9
|
Lubnin AY, Karnaukhov VV, Moshkin AV, Rylova AV, Shimansky VN. [Neurosurgery in a patient on dual antiplatelet therapy. Case report and the review of the literature]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2016. [PMID: 28635845 DOI: 10.17116/neiro201680391-98] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION A neurosurgical intervention in a patient on dual antiplatelet therapy is a serious challenge for both the neurosurgeon and anesthesiologist.. MATERIAL AND METHODS The article describes a clinical case of a successful urgent neurosurgical intervention (ventriculoperitoneostomy for obstructive hydrocephalus caused by a large meningioma of the posterior surface of the petrous pyramid) in a patient on dual antiplatelet therapy (DAT) due to a recently placed coronary stent.. CONCLUSION Given a high risk of coronary stent thrombosis, the surgery was performed in the presence of ongoing DAT. There were no intracranial hemorrhagic complications, but subcutaneous hemorrhagic complications developed. The article discusses the features of managing similar patients whose number is growing.
Collapse
Affiliation(s)
- A Yu Lubnin
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | - A V Moshkin
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - A V Rylova
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | |
Collapse
|