1
|
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.
Collapse
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
| |
Collapse
|
2
|
Ozaki T, Yamagami H, Morimoto M, Imamura H, Hatano T, Oishi H, Haraguchi K, Yoshimura S, Satow T, Sugiu K, Iihara K, Matsumaru Y, Hayakawa M, Matsumoto Y, Sakai C, Miyamoto S, Kitagawa K, Kagimura T, Sakai N. Relation between duration of dual antiplatelet therapy and risk of ischemic stroke after stent-assisted treatment of cerebral aneurysm (DAPTS ACE-registry). J Neurointerv Surg 2024; 16:691-697. [PMID: 37433663 PMCID: PMC11228190 DOI: 10.1136/jnis-2023-020495] [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: 04/28/2023] [Accepted: 06/18/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND The optimal duration of dual antiplatelet therapy (DAPT) in patients with cerebral aneurysm who undergo stent-assisted coil embolization (SACE) has not been established. We aimed to clarify the association between duration of DAPT and incidence of ischemic stroke in patients with cerebral aneurysm. METHODS We registered patients with cerebral aneurysm who underwent SACE in 27 hospitals in Japan. Those treated with DAPT (aspirin and clopidogrel) were eligible for inclusion in a previously reported randomized control trial (RCT). Patients who were ineligible or refused to participate to the RCT were followed-up for 15 months after SACE as the non-RCT cohort. Our study examined both the RCT and non-RCT cohorts. The primary and secondary outcomes were ischemic stroke and hemorrhagic events. RESULTS Among the 313 patients registered, 296 were included for analysis (of these, 136 were RCT patients and 160 were non-RCT patients). Patients who were treated with DAPT for more than 6 months (n=191) were classified as the long-term DAPT group. Those treated less than 6 months (n=105) were classified as the short-term group. The incidence of ischemic stroke did not significantly differ between the long-term group (2.5 per 100 person-years) and the short-term group (3.2 per 100 person-years); nor did incidence of hemorrhagic events (0.8 and 3.2 per 100 person-years, respectively). The period of DAPT was not significantly associated with incidence rates of ischemic stroke or hemorrhagic events. CONCLUSIONS Duration of DAPT was not associated with the incidence of ischemic stroke in the first 15 months after SACE.
Collapse
Affiliation(s)
- Tomohiko Ozaki
- Neurosurgery, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Hiroshi Yamagami
- Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Masafumi Morimoto
- Neurosurgery, Yokohama Shintoshi Neurosurgical Hospital, Yokohama, Kanagawa, Japan
| | - Hirotoshi Imamura
- Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Taketo Hatano
- Neurosurgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Hidenori Oishi
- Department of Neurosurgery, Juntendo University, Faculty of Medicine, Tokyo, Japan
| | | | | | - Tetsu Satow
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kenji Sugiu
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Kita-ku, Okayama, Japan
| | - Koji Iihara
- Neurosurgery, National Cerebral and Cardiovascular Center Hospital, Suita, Osaka, Japan
| | - Yuji Matsumaru
- Department of Neurology, Institute of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Mikito Hayakawa
- Department of Neurology, Institute of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Yasushi Matsumoto
- Division of Development and Discovery of Interventional Therapy, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Chiaki Sakai
- Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Susumu Miyamoto
- Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kazuo Kitagawa
- Neurology, Tokyo Women's Medical University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Tatsuo Kagimura
- Foundation for Biomedical Research and Innovation at Kobe, Translational Research Center for Medical Innovation, Kobe, Hyogo, Japan
| | - Nobuyuki Sakai
- Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| |
Collapse
|
3
|
Ozaki T, Yamagami H, Morimoto M, Hatano T, Oishi H, Haraguchi K, Yoshimura S, Sugiu K, Iihara K, Matsumaru Y, Matsumoto Y, Satow T, Hayakawa M, Sakai C, Miyamoto S, Kitagawa K, Daimon T, Kagimura T, Sakai N. Short- versus long-term Dual AntiPlatelet Therapy for Stent-Assisted treatment of CErebral aneurysm (DAPTS ACE): a multicenter, open-label, randomized clinical trial. J Neurointerv Surg 2024; 16:171-176. [PMID: 37068941 PMCID: PMC10850618 DOI: 10.1136/jnis-2022-019867] [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: 11/12/2022] [Accepted: 04/02/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND The optimal duration of dual antiplatelet therapy (DAPT) after stent-assisted coil embolization (SACE) for cerebral aneurysm remains uncertain. This randomized trial of short- versus long-term Dual AntiPlatelet Therapy for Stent-Assisted treatment of CErebral aneurysm (DAPTS ACE) aimed to clarify whether long-term DAPT can reduce the occurrence of ischemic stroke in patients with cerebral aneurysms treated by SACE compared with short-term DAPT. METHODS Patients treated for cerebral aneurysm with SACE were enrolled from 17 hospitals in Japan. Patients were enrolled within 30 days after SACE and assigned in a 1:1 ratio to receive long-term (12 months) or short-term (3 months) DAPT with aspirin and clopidogrel. Randomization was performed centrally through a web-based system. The primary outcome was the time to ischemic stroke event during 3 to 12 months after SACE. This trial was registered with the Japan Registry of Clinical Trials (jRCTs051180141). RESULTS A total of 142 patients were recruited from November 4, 2016 to January 7, 2019. Among them, 65 and 68 patients assigned to the long- and short-term DAPT groups, respectively, were included in the full analysis set. Ischemic stroke occurred in no patients in the long-term DAPT group and in one patient in the short-term DAPT group. The incidence rate did not differ between the groups (0.0 vs 2.1/100 person-years; log rank test, P=0.33). CONCLUSIONS In this multicenter randomized controlled trial, there was not a statistically significant difference in the rate of ischemic strokes between long- and short-term DAPT.
Collapse
Affiliation(s)
- Tomohiko Ozaki
- Neurosurgery, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Hiroshi Yamagami
- Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Masafumi Morimoto
- Neurosurgery, Yokohama Shintoshi Neurosurgical Hospital, Yokohama, Kanagawa, Japan
| | - Taketo Hatano
- Neurosurgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Hidenori Oishi
- Neurosurgery, Juntendo University, Faculty of Medicine, Tokyo, Japan
- Neuroendovascular Therapy, Juntendo University, Faculty of Medicine, Tokyo, Japan
| | | | | | - Kenji Sugiu
- Neurosurgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Koji Iihara
- Neurosurgery, National Cerebral and Cardiovascular Center Hospital, Suita, Osaka, Japan
| | - Yuji Matsumaru
- Division of Stroke Prevention and Treatment, Department of Neurosurgery, University of Tsukuba Faculty of Medicine, Tsukuba, Ibaraki, Japan
| | - Yasushi Matsumoto
- Division of Development and Discovery of Interventional Therapy, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Tetsu Satow
- Neurosurgery, Kindai University, Osaka-Sayama, Osaka, Japan
| | - Mikito Hayakawa
- Division of Stroke Prevention and Treatment, Department of Neurosurgery, University of Tsukuba Faculty of Medicine, Tsukuba, Ibaraki, Japan
| | - Chiaki Sakai
- Neurosurgery, Kobe City Medical Center General Hospital, Kobe-city, Japan
| | - Susumu Miyamoto
- Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kazuo Kitagawa
- Neurology, Tokyo Women's Medical University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Takashi Daimon
- Biostatistics, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Tatsuo Kagimura
- Foundation for Biomedical Research and Innovation at Kobe, Translational Research Center for Medical Innovation, Kobe, Hyogo, Japan
| | - Nobuyuki Sakai
- Neurosurgery, Kobe City Medical Center General Hospital, Kobe-city, Hyogo, Japan
| |
Collapse
|
4
|
Zhou Y, He S, Hu Y. One year clinical outcome of dual anti-platelet therapy with the Novel Ticagrelor plus Aspirin versus Clopidogrel plus Aspirin for Endovascular Intervention of patients with Intracranial Aneurysm: A meta-analysis. J Stroke Cerebrovasc Dis 2024; 33:107491. [PMID: 37988833 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107491] [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: 09/23/2023] [Revised: 11/08/2023] [Accepted: 11/14/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND The use of stents to treat un-ruptured intracranial aneurysms was first approved in the year 2002 in the United States as a Humanitarian Device Exemption. Antiplatelet therapy is mandatory following stent placement. Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel has been the first line agents for the prevention of thromboembolic events following neuro-endovascular procedures. However, clopidogrel hypo-responsiveness has often been observed. In this analysis, we aimed to systematically compare one year clinical outcome of DAPT with the Novel Ticagrelor plus Aspirin versus Clopidogrel plus Aspirin for Endovascular Intervention of patients with Intracranial Aneurysm. METHODS Online electronic databases were searched from June 2023 till July 2023 for relevant studies which compared DAPT with ticagrelor or clopidogrel for endovascular intervention in patients with intracranial aneurysm. The endpoints which were analyzed were classified into thromboembolic and hemorrhagic events. A fixed and a random effect statistical model were used during data analysis respectively. Risk ratio (RR) with 95 % confidence interval (CI) was used to represent the data following analysis. RESULTS Five studies with a total number of 893 participants were included in this analysis. Three hundred and fifty eight (358) participants were assigned to the ticagrelor group whereas 535 participants were assigned to clopidogrel group. Participants' enrollment period ranged from the year 2009 to 2019. Our results showed that during a mean follow-up time period of one year, DAPT with ticagrelor was associated with significantly lower thromboembolic events with RR: 0.33, 95 % CI: 0.16 - 0.68; P = 0.003. In addition, at one year, DAPT with ticagrelor was not associated with any increase in hemorrhagic events (RR: 0.66, 95 % CI: 0.29 - 1.50; P = 0.32) when compared to DAPT with clopidogrel. CONCLUSION At one year, DAPT with ticagrelor was associated with significantly lower thromboembolic events without any increase in hemorrhagic events when compared to clopidogrel associated DAPT for endovascular intervention of patients with intracranial aneurysm. However, even though ticagrelor-associated DAPT use appeared to be more effective and safe, this hypothesis should only be confirmed in larger upcoming trials.
Collapse
Affiliation(s)
- Yunxia Zhou
- Zhejiang Chinese Medical University, Hangzhou, Zhejiang, 310053, PR China
| | - Shenglan He
- Department of Pharmacy, Central People's Liberation Army Hospital, Wuhan, Hubei, 430014, PR China
| | - Yanhong Hu
- Department of Neurosurgery, Hangzhou Red Cross Hospital, Hangzhou, Zhejiang, 310000, PR China.
| |
Collapse
|
5
|
Results of Temporary Stent-assisted Coil Embolization (CATS) for the Treatment of Wide-neck Aneurysms : A 10-year Single Center Experience. Clin Neuroradiol 2023; 33:219-226. [PMID: 36028628 PMCID: PMC10014755 DOI: 10.1007/s00062-022-01206-6] [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: 01/30/2022] [Accepted: 07/22/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE In intracranial wide-neck aneurysms, simple coil embolization is often not a feasible treatment option. Balloon-assisted coiling comes with the drawback of blood flow impairment, whereas permanent stent placement requires long-term antiplatelet therapy. Temporary stent-assisted coiling (coiling assisted by temporary stenting, CATS) is an alternative that eliminates both disadvantages. Because prior studies included only small numbers of patients, it was our aim to analyze the safety and effectiveness of this technique in a larger cohort of patients. METHODS We retrospectively evaluated all endovascular aneurysm treatments at our institution from 2011 to 2020. Out of a total of 688 aneurysm treatments, we intended to perform 95 (14%) with temporary stent-assisted coiling and included them in our study. RESULTS Sixty-four (64)% of aneurysms were acutely ruptured, 3% were symptomatic but unruptured, and 33% were incidental. Successful stent recovery was possible in 93% of treatments. Initial complete and adequate occlusion rate were 53% and 82%, respectively. Long-term follow-up at 6 and 12 months was available for 71% and 44% of cases. Aneurysm recurrence was observed in 10% of cases after 6 months, and in 17% after 1 year or later. Periprocedural complications were noted in 12 cases (13%), of which only 1 complication was definitely associated with temporary stent-assisted coiling (1%). One of the periprocedural complications resulted in neurological damage, the other complications were asymptomatic. CONCLUSION Temporary stent-assisted coiling appears to be a safe and effective treatment method in intracranial wide-neck aneurysms. Procedural safety appears to be comparable with balloon remodeling or permanent stent-assisted coiling, but it comes with the further benefit of diminished need for posttreatment antiplatelet therapy, which may improve the outcome of patients. However, to define the true value and potential benefit of this technique, further prospective studies are required.
Collapse
|
6
|
Matsubara H, Mizutani D, Egashira Y, Enomoto Y. Perioperative Antiplatelet Therapy for the Stent-Assisted Coil Embolization: Results of the Questionnaire Survey. JOURNAL OF NEUROENDOVASCULAR THERAPY 2023; 17:56-60. [PMID: 37502130 PMCID: PMC10370526 DOI: 10.5797/jnet.oa.2022-0053] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 11/23/2022] [Indexed: 07/29/2023]
Abstract
Objective This study aimed to determine the status of perioperative antiplatelet therapy in stent-assisted coil embolization (SAC) in Japan. Methods The questionnaire consisted of 13 questions and used Google forms, and was sent to institutions where endovascular specialists were employed. The results were analyzed. Results The responses from 307 centers indicated that the timing of initiation of antiplatelet therapy was 14 days-1 month before treatment in half of centers, and 7-14 days before treatment in the other half. Platelet function tests were performed at 165 centers (56.2%), of which 136 centers (46.3%) performed these tests for all patients, with the VerifyNow system being the most widely used tool. The duration of postoperative dual antiplatelet therapy was 6, 3, and 12 months in 169 (57.7%), 70 (23.5%), and 42 (14.3%) centers, respectively. The antiplatelet agents used for monotherapy were P2Y12 receptor antagonists or aspirin, with a postoperative period of up to 12 months in 139 centers (47.3%), 24 months in 68 centers (23.1%), and longer than 24 months in 50 centers (17%). Conclusion Current antiplatelet therapy for SAC in Japan varies widely among institutions. Moreover, each center has its own empirical rules for SAC. Therefore, the findings of this survey suggest the need to establish guidelines for optimal periprocedural antiplatelet therapy for SAC.
Collapse
Affiliation(s)
- Hirofumi Matsubara
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Gifu, Japan
| | - Daisuke Mizutani
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Gifu, Japan
| | - Yusuke Egashira
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Gifu, Japan
| | - Yukiko Enomoto
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Gifu, Japan
| |
Collapse
|
7
|
Sarathy D, Elghareeb M, Clark A, Zelmanovich R, Lucke-Wold B. Update on Clinical Management with Neurovascular Stents. JOURNAL OF EXPERIMENTAL NEUROLOGY 2022; 3:49-59. [PMID: 36578295 PMCID: PMC9793883 DOI: 10.33696/neurol.3.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Endovascular stenting has continued to evolve given the new trials. Several new stents have recently been developed to address specific purposes. In this focused review, we discuss the concepts of neurointerventional stents and address the clinical implications. Furthermore, each type of stent is discussed with supporting evidence for clinical utility. In the final component, we argue for continued development and utilization.
Collapse
Affiliation(s)
- Danyas Sarathy
- Department of Neurosurgery, University of Florida, Gainesville, USA
| | | | - Alec Clark
- Department of Neurosurgery, University of Florida, Gainesville, USA
| | | | | |
Collapse
|