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Miyama M, Matsukawa H, Sakakibara F, Uchida K, Shirakawa M, Yoshimura S. Perioperative Antiplatelet Management in the Flow-Diverter Treatment for Unruptured Cerebral Aneurysms: A Single-Center, Retrospective Analysis. World Neurosurg 2024; 183:e44-e50. [PMID: 37918564 DOI: 10.1016/j.wneu.2023.10.128] [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: 10/16/2023] [Revised: 10/25/2023] [Accepted: 10/26/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Although periprocedural antiplatelet therapy for the treatment of unruptured intracranial aneurysms (UIAs) using flow-diverter stents (FDSs) is necessary to avoid thromboembolic complications, a definite antiplatelet therapy has not been established. We aimed to evaluate the safety and efficacy of periprocedural antiplatelet management in UIA treatment with FDS. METHODS A single-center retrospective analysis of consecutive patients with UIAs treated with FDSs between September 2013 and January 2022 was conducted. Patients received dual antiplatelet therapy (DAPT) (aspirin and clopidogrel) for 14-day before and 3-6 months after FDS placement. Platelet aggregation was evaluated prior to treatment using light transmission aggregometry, which was classified into 3 grades; 1-3: promoted, 4-6: appropriate, and 7-9: non-responder, for adenosine diphosphate (ADP) and collagen. By this classification, the antiplatelet regimen was modified. Outcome included hemorrhagic and ischemic events. RESULTS 193 patients with 200 UIAs underwent 213 FDSs placement. The median platelet aggregability grade before treatment was 5 for ADP and 4 for collagen. Antiplatelet therapy modification was performed in 62 patients (32.1%). The median postoperative DAPT duration was 94 days. Antiplatelet medicine-related hemorrhagic events occurred in 4 patients (2.1%) and ischemic events occurred in 6 patients (3.1%). These patients had no morbido-mortality. CONCLUSIONS Periprocedural antiplatelet management based on the value of platelet aggregability was relatively safe and effective for treating UIA with FDS.
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Affiliation(s)
- Masataka Miyama
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Hidetoshi Matsukawa
- Department of Neurosurgery, Takarazuka City Hospital, Takarazuka, Hyogo, Japan
| | - Fumihiro Sakakibara
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Kazutaka Uchida
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Manabu Shirakawa
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Hyogo, Japan.
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Complementary Tools in Cerebral Bypass Surgery. World Neurosurg 2022; 163:50-59. [PMID: 35436579 DOI: 10.1016/j.wneu.2022.03.146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 03/15/2022] [Accepted: 03/16/2022] [Indexed: 12/15/2022]
Abstract
Cerebral revascularization surgery has been advanced by the refinement of several adjunctive tools. These tools include perioperative blood thinners, intraoperative spasmolytic agents, electrophysiological monitoring, and methods for assessing bypass patency or marking arteriotomies. Despite the array of options, the proper usage and comparative advantages of different complements in cerebral bypass have not been well-cataloged elsewhere. In this literature review, we describe the appropriate usage, benefits, and limitations of various bypass adjuncts. Understanding these adjuncts can help surgeons ensure that they receive reliable intraoperative information about bypass function and minimize the risk of serious complications. Overall, this review provides a succinct reference for neurosurgeons on various cerebrovascular bypass adjuncts.
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Antiplatelet Drugs for Neurointerventions: Part 1 Clinical Pharmacology. Clin Neuroradiol 2020; 30:425-433. [DOI: 10.1007/s00062-020-00910-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 04/27/2020] [Indexed: 12/31/2022]
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Chung JW, Kim SJ, Hwang J, Lee MJ, Lee J, Lee KY, Park MS, Sung SM, Kim KH, Jeon P, Bang OY. Comparison of Clopidogrel and Ticlopidine/ Ginkgo Biloba in Patients With Clopidogrel Resistance and Carotid Stenting. Front Neurol 2019; 10:44. [PMID: 30761076 PMCID: PMC6363652 DOI: 10.3389/fneur.2019.00044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 01/14/2019] [Indexed: 11/25/2022] Open
Abstract
Background and Purpose: Patients undergoing carotid artery stenting (CAS) who show low responsiveness to clopidogrel may have a higher risk of peri-procedural embolic events. This study aimed to compare the effectiveness and safety of clopidogrel and ticlopidine plus Ginkgo biloba in clopidogrel-resistant patients undergoing CAS. Methods: In this multi-center, randomized, controlled trial, we used platelet reactivity test to select patients undergoing CAS who showed clopidogrel resistance, and compared treatments using clopidogrel and ticlopidine plus ginkgo. The primary outcome was the incidence of new ischemic lesion in the ipsilateral hemisphere of CAS. Detection of microembolic signal on transcranial Doppler was the secondary outcome. The clinical outcomes were also monitored. Results: This trial was discontinued after 42 patients were randomized after preplanned interim sample size re-estimation indicated an impractical sample size. The primary endpoint occurred in 12/22 patients (54.5%) in the clopidogrel group and 13/20 patients (65.0%) in the ticlopidine–ginkgo group (P = 0.610). No significant differences in the presence of microembolic signal (15.0 vs. 11.8%, P = 0.580), clinical outcomes (ischemic stroke or transient ischemic attack, 0.0 vs. 5.5%; acute myocardial infarction 0.0 vs. 0.0%; all-cause death, 4.5 vs. 0.0%), or incidence of adverse events were found in the two groups. In terms of resistance to clopidogrel, treatment with ticlopidine–ginkgo significantly increased the P2Y12 Reaction Units (difference, 0.0 [−0.3–3.0] vs. 21.0 [6.0–35.0], P < 0.001). Conclusions: In patients who showed clopidogrel resistance, ticlopidine–ginkgo treatment was safe and increased P2Y12 Reaction Units; however, compared to clopidogrel, it failed to improve surrogate and clinical endpoints in patients undergoing CAS. This multimodal biomarker-based clinical trial is feasible in neurointerventional research. Clinical Trial Registration:http://www.clinicaltrials.gov. Unique identifier: NCT02133989.
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Affiliation(s)
- Jong-Won Chung
- Department of Neurology, Samsung Medical Center Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Suk Jae Kim
- Department of Neurology, Samsung Medical Center Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jaechun Hwang
- Department of Neurology, Kyungpook National University School of Medicine Kyungpook National University Chilgok Hospital, Daegu, South Korea
| | - Mi Ji Lee
- Department of Neurology, Samsung Medical Center Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jun Lee
- Department of Neurology Yeungnam University Medical Center, Daegu, South Korea
| | - Kyung-Yul Lee
- Department of Neurology, Gangnam Severance Hospital Yonsei University College of Medicine, Seoul, South Korea
| | - Man-Seok Park
- Department of Neurology Chonnam National University Medical School, Gwangju, South Korea
| | - Sang Min Sung
- Department of Neurology Busan National University Hospital, Busan, South Korea
| | - Keon Ha Kim
- Department of Radiology, Samsung Medical Center Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Pyoung Jeon
- Department of Radiology, Samsung Medical Center Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center Sungkyunkwan University School of Medicine, Seoul, South Korea
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Abstract
Management of anticoagulation and antiplatelet medications after neurosurgery can be complex, especially given that these patients have multiple medical comorbidities. In turn, neurosurgical patients are at high risk for the development of venous thromboembolism after surgery, so neurosurgeons must consider the use of pharmacologic prophylaxis. Developments in endovascular neurosurgery have produced therapies that require close management of antiplatelet medications to prevent postoperative complications. Any of these patient populations may need intrathecal access. This article highlights current strategies for managing these issues in the neurosurgical patient population.
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Affiliation(s)
- Joel Z Passer
- Department of Neurosurgery, Temple University Hospital, 3401 North Broad Street, Suite C540, Philadelphia, PA 19140, USA
| | - Christopher M Loftus
- Department of Neurosurgery, Lewis Katz School of Medicine, Temple University, Temple University Hospital, 3401 North Broad Street, Suite C540, Philadelphia, PA 19140, USA.
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Chen HY, Chou P. Associations Between PFA-Measured Aspirin Resistance, Platelet Count, Renal Function, and Angiotensin Receptor Blockers. Clin Appl Thromb Hemost 2018; 24:63S-68S. [PMID: 29996660 PMCID: PMC6714849 DOI: 10.1177/1076029618786588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Aspirin resistance is used to describe patients who are undergoing aspirin therapy but fail for the inhibition of thromboxane biosynthesis in platelets. Although the true mechanism is unclear, drug–drug interaction remains a possible factor. The study aimed to determine whether there was association between aspirin resistance and the concomitant cardiovascular medication. Using the Platelet Function Analyzer-100 system, aspirin resistance was evaluated in aspirin-treated patients from the outpatient department. The associations between aspirin resistance and their concomitant common cardiovascular medication were analyzed. Aspirin resistance was prevalent in 147 (17.7%) of 831 patients. Concomitant angiotensin receptor blocker (ARB) treatment and low platelet count were associated with aspirin response (P = .04, .02, respectively). Multivariate logistic regression analysis results showed an association between aspirin response and ARB therapy (adjusted odds ratio [OR] 1.48; 95% confidence interval, CI: 1.08-2.18). And the association was blunted when platelet count was considered (adjusted OR 1.43, 95% CI: 0.92-2.23). In ARB-treated patients, increased creatinine and decreased hematocrit laboratory data increased the risk of aspirin resistance (P = .02, .04, respectively), and the effect of platelet count on aspirin resistance was diminished by ARB therapy. Concomitant ARB treatment in aspirin-treated patients decreased the risk of aspirin resistance, and the effect was dependent on low platelet count. In ARB-treated patients, increased creatinine and decreased hematocrit data increased the risk of aspirin resistance. In addition, the effect of platelet count on aspirin resistance was diminished by ARB treatment.
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Affiliation(s)
- Hung Yi Chen
- Division of Cardiology, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan.,Institute of Public Health and Community Medicine Research Center, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Pesus Chou
- Institute of Public Health and Community Medicine Research Center, National Yang-Ming University School of Medicine, Taipei, Taiwan
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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
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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.
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Puentes JC, Quintero ST, Uriza LF, Rueda MA, Piedrahita A, Contreras V. Complicaciones trombóticas y hemorrágicas en pacientes con aneurismas cerebrales tratados por vía endovascular y su relación con el uso de antiagregantes plaquetarios: evaluación descriptiva. Neurocirugia (Astur) 2018; 29:18-24. [DOI: 10.1016/j.neucir.2017.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 08/08/2017] [Accepted: 08/16/2017] [Indexed: 11/28/2022]
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Chen HY, Chou P. PFA-100-measured aspirin resistance is the predominant risk factor for hospitalized cardiovascular events in aspirin-treated patients: A 5-year cohort study. J Clin Pharm Ther 2017; 43:249-255. [PMID: 29055181 DOI: 10.1111/jcpt.12643] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 10/02/2017] [Indexed: 12/13/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Aspirin therapy is the clinical gold standard for the prevention of cardiovascular events. However, cardiovascular events still develop in some patients undergoing aspirin therapy. Many laboratory methods exist for measuring aspirin resistance. Using the platelet Function Analyzer (PFA)-100 system, we aimed to determine the effect of aspirin resistance on hospitalized cardiovascular events (hCVE) in a 5-year follow-up cohort. We also sought to determine the impact of aspirin resistance on the relationship between common cardiovascular risk factors and cardiovascular hospitalization. METHOD Aspirin resistance was evaluated in aspirin-treated patients from the outpatient department. A total of 465 patients during a 5-year follow-up period were included in this study. The primary endpoint of the study was hospitalization for any acute cardiovascular event. The prevalence and associated risk factors of acute cardiovascular events were evaluated. RESULTS AND DISCUSSION Aspirin resistance was prevalent in 91 (20.0%) of 465 patients. Prior hospitalization history of cardiovascular events was highly associated with aspirin resistance (P = .001). At the 5-year follow-up, cardiovascular events were found to have developed in 11 patients (8 stroke and 3 myocardial infarction) who exhibited aspirin resistance (12.1%) and in 9 (4 stroke and 5 myocardial infarction) patients who did not exhibit aspirin resistance (2.4%) (P < .001). At the 5-year follow-up, multivariate logistic regression analysis results showed a strong association between aspirin resistance and cardiovascular events (adjusted odds ratio 4.28; 95% CI: 1.64-11.20; P = .03). WHAT IS NEW AND CONCLUSION PFA-100 measurements of aspirin resistance correlate with hCVE, as evidenced by both the past medical history and the 5-year follow-up. The logistic regression analysis results showed that aspirin resistance plays a larger role in hospitalized cardiovascular disease than do other cardiovascular risk factors.
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Affiliation(s)
- H Y Chen
- Division of Cardiology, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan.,Institute of Public Health and Community Medicine Research Center, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - P Chou
- Institute of Public Health and Community Medicine Research Center, National Yang-Ming University School of Medicine, Taipei, Taiwan
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Tsujimoto M, Enomoto Y, Kokuzawa J, Iwama T. Diabetes mellitus and carotid artery plaques exhibiting high-intensity signals on MR angiography are related to increased platelet reactivity after carotid artery stenting. J Neurointerv Surg 2016; 9:106-110. [PMID: 27370776 PMCID: PMC5264231 DOI: 10.1136/neurintsurg-2016-012419] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 06/07/2016] [Accepted: 06/15/2016] [Indexed: 11/25/2022]
Abstract
Background Increased platelet reactivity after carotid artery stenting (CAS) may cause thromboembolic complications. Objective This study aimed to investigate the incidence of increased platelet reactivity after CAS and to determine the factors related to it. Methods Patients who underwent CAS were recruited prospectively. They received pre-procedural antiplatelet therapy comprising some combination of aspirin (100 mg/day), clopidogrel (75 mg/day), and/or cilostazol (200 mg/day) for a minimum of 7 days. ADP- and collagen-induced platelet aggregation were measured before and 4 days after CAS. Changes in platelet reactivity were reported as changes in the categorized platelet reactivity grade based on the effective dose 50%. Clinical characteristics of patients with and without increased platelet reactivity were compared. Results Among 38 consecutive patients who underwent CAS, 18 (47%) exhibited increased platelet reactivity. Diabetes mellitus (OR 15.0; 95% CI 2.1 to 106.5; p=0.007) and carotid artery plaques exhibiting high-intensity signals (HIS) on time-of-flight MR angiography (TOF-MRA) (OR 25.2; 95% CI 2.0 to 316.2; p=0.013) were independently associated with increased platelet reactivity in a multivariate analysis. Conclusions Increased platelet reactivity occurred in nearly half of the studied patients subjected to CAS and was independently associated with diabetes mellitus and carotid artery plaques exhibiting HIS on TOF-MRA.
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Affiliation(s)
- Masanori Tsujimoto
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yukiko Enomoto
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Jouji Kokuzawa
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Toru Iwama
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
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Kim BJ, Kwon JY, Jung JM, Lee DH, Kang DW, Kim JS, Kwon SU. Association between silent embolic cerebral infarction and continuous increase of P2Y12 reaction units after neurovascular stenting. J Neurosurg 2014; 121:891-8. [PMID: 25036195 DOI: 10.3171/2014.6.jns132448] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Endovascular procedures are one of the important treatment options for steno-occlusive arteries in ischemic stroke patients. However, embolic complications after such procedures are always a concern. The authors investigated the association between serial change of residual platelet reactivity and silent embolic cerebral infarction (SECI) after endovascular treatment. METHODS Ischemic stroke patients undergoing stenting of intra- or extracranial arteries were recruited prospectively. Residual platelet reactivity, represented by aspirin reaction units (ARUs) and P2Y12 reaction units (PRUs), was measured serially (6 hours before, immediately after, and 24 hours after the procedure). A loading dosage of aspirin (500 mg) and/or clopidogrel (300 mg) was given 24 hours before the procedure to patients naïve to antiplatelet agents, whereas the usual dosage (aspirin 100 mg and clopidogrel 75 mg) was continued for patients who had previously been taking these agents for more than a week. Diffusion-weighted MRI was performed before and 24 hours after the procedure to detect new SECIs. Clinical characteristics, baseline ARU and PRU values, and the change in ARU and PRU values after stenting were compared between patients with and without SECIs. RESULTS Among 69 consecutive patients who underwent neurovascular stent insertion, 41 patients (59.4%) had poststenting SECIs. The lesion was located only at the vascular territory of the stented vessel in 21 patients (51.2%), outside the stented vessel territory in 8 patients (19.5%), and both inside and outside in 12 patients (29.3%). The occurrence of SECIs was not associated with the baseline ARU or PRU value, but was associated with PRU increase after stenting (36 ± 73 vs -12 ± 59, p = 0.007), deployment of a longer stent (31.1 ± 16.5 mm vs 21.8 ± 9.9 mm, p = 0.01), and stent insertion in extracranial arteries (78.1% vs 45.2%, p = 0.008). Stent length (OR 1.066, p = 0.01) and PRU change (OR 1.009, p = 0.04) were independently associated with the occurrence of SECI. CONCLUSIONS Residual platelet reactivity after dual antiplatelet treatment measured before stenting did not predict poststenting SECI. However, the longer stent and the serial increase of PRU values after stenting were related to SECI. Continuous increase of platelet activation after endovascular procedure may be important in poststent cerebral infarction.
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Spiliopoulos S, Kassimis G, Hatzidakis A, Krokidis M. High on-treatment platelet reactivity in peripheral endovascular procedures. Cardiovasc Intervent Radiol 2014; 37:559-71. [PMID: 23897511 DOI: 10.1007/s00270-013-0707-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Accepted: 07/10/2013] [Indexed: 02/05/2023]
Abstract
The use of aspirin is considered the "gold standard" for the decrease of major adverse cardiovascular events in patients with atherosclerosis, including peripheral arterial disease (PAD), whereas a dual-antiplatelet regimen with aspirin and clopidogrel is usually indicated for such patients after angioplasty and stent deployment. However, a substantial number of subsequent adverse events still occur, even in patients who receive double-antiplatelet therapy. The "high on-treatment platelet reactivity" (HTPR) phenomenon has been lately recognized and plays a major role in the management of patients with PAD. Greater and more rapid inhibition of platelet aggregation has become the goal for new antiplatelet agents with the expectation of further improving outcomes for percutaneous intervention for PAD. The purpose of this review article is to highlight current evidence regarding the prevalence, aetiology, and clinical implications of HTPR in PAD as well as to discuss the possibilities of novel alternative antiplatelet regiments.
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Dual antiplatelet therapy plus postoperative heparin and dextran is safe and effective for reducing risk of embolic stroke during aneurysm coiling. Acta Neurochir (Wien) 2014; 156:855-9. [PMID: 24595538 DOI: 10.1007/s00701-014-2031-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 02/10/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Thromboembolic events represent a clinically significant cause of neurological morbidity during the endovascular management of cerebral aneurysms. We have implemented an anti-thromboembolic regimen consisting of pre- and postoperative dual antiplatelet therapy, as well as postoperative anticoagulation using heparin and dextran. The aims of our study were to examine the effect of this regimen on thromboembolic rates during elective aneurysm coiling, and to elucidate risk factors associated with the development of thromboembolic events in this setting. METHODS We conducted a retrospective review of patients who underwent elective intracranial aneurysm coiling between January 2005 and February 2012. The primary outcome of interest was the occurrence of a clinically significant peri-procedural thromboembolic event. Secondary outcomes included the occurrence of a central nervous system (CNS) or systemic hemorrhage. RESULTS During the study period, 312 patients underwent elective aneurysm coiling and six (2 %) thromboembolic events occurred; three (1 %) occurred in the group that received the anti-thromboembolic regimen (261 patients) and three (6 %) occurred in the group that did not receive the regimen (51 patients), resulting in a statistically significant difference (P = 0.024). Both the presence of a hypercoagulable state (P = 0.014) and the lack of the anti-thromboembolic regimen (P = 0.043) were significantly associated with the occurrence of a thromboembolic event. CONCLUSIONS This study provides evidence that the regimen described here is safe and reduces thromboembolic complications during elective aneurysm coiling. Ours is likely the most aggressive regimen in the published literature and significantly reduced the rate of thromboembolism without any significant increase hemorrhagic complications.
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Hong Y, Wang YJ, Deng Z, Wu Q, Zhang JM. Stent-assisted coiling versus coiling in treatment of intracranial aneurysm: a systematic review and meta-analysis. PLoS One 2014; 9:e82311. [PMID: 24454690 PMCID: PMC3893071 DOI: 10.1371/journal.pone.0082311] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Accepted: 10/22/2013] [Indexed: 12/04/2022] Open
Abstract
Background and Purpose Stent-assisted coiling was initially invented for wide-neck aneurysms, but is now used for smaller berry aneurysms. The aim of this study was to compare the safety and efficiency of stent-assisted coiling with conventional coiling in treatment of intracranial aneurysms. Methods A meta-analysis of studies that compared stent-assisted coiling with coiling only was conducted by searching English literatures via Pubmed, Medline and Cochrane Library databases without restricting the publication year. The primary outcomes in this study were immediate occlusion, progressive thrombosis rate, all-complication rate and angiographic recurrence. The secondary outcomes examined were packing density, mortality, permanent complication and thromboembolic complication rate. Results Ten retrospective cohort studies were included. There is currently only one unfinished randomized study. Although the stent-assisted coiling group tended to show a lower initial occlusion rate than that of the coiling-only group (57.6% versus 68.7%; OR, 0.66; 95% CI, 0.30–1.44; P = 0.30), it achieved a significantly higher progressive thrombosis rate during follow up compared to that of the coiling only group (37.5% versus 19.4%; OR, 2.75; 95% CI, 1.95–3.86; P<0.00001) and a significantly lower recurrence rate (16.2% versus 34.4%; OR, 0.35; 95% CI, 0.25–0.49; P<0.00001). With respect to safety concerns, the all-complication rate (17.6% versus 15.9%; OR, 1.12; 95% CI, 0.77–1.62; P = 0.56), mortality rate (9.1% versus 2.6%; OR, 2.31; 95% CI, 0.68–7.82; P = 0.18), permanent complication rate (5.6% versus 3.9%; OR, 1.52; 95% CI, 0.96–2.41; P = 0.08) and thromboembolic complication rate (4.2% versus 4.9%; OR, 0.99; 95% CI, 0.41–2.38; P = 0.97) did not show significant difference between the two groups. Conclusions Stent-assisted coiling has a lower recurrence rate than conventional coiling. Analysis of complication events did not show any significant difference between the two methods. Despite the findings reported herein, further validation by well-designed prospective studies is needed.
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Affiliation(s)
- Yuan Hong
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Yong-Jie Wang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Zheng Deng
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Qun Wu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- * E-mail: (QW); (JMZ)
| | - Jian-Min Zhang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- * E-mail: (QW); (JMZ)
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Levitt MR, Ghodke BV, Hallam DK, Sekhar LN, Kim LJ. Incidence of microemboli and correlation with platelet inhibition in aneurysmal flow diversion. AJNR Am J Neuroradiol 2013; 34:2321-5. [PMID: 23811975 DOI: 10.3174/ajnr.a3627] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Flow-diverting stents have been associated with embolic and hemorrhagic complications, but the rate of procedure-related microemboli is unknown. Using transcranial Doppler sonography, we measured the rate of microemboli in 23 patients treated with flow-diverting stents. Patients received preprocedural dual antiplatelet medications and intraprocedural heparinization. Point-of-care platelet reactivity testing was performed before the procedure, and nonresponders (>213 P2Y12/ADP receptor reactivity units) received additional thienopyridine. Transcranial Doppler sonography was performed within 12-24 hours. Microemboli were detected in 3 patients (13%), 2 of whom were initially nonresponders. There was no association between the presence of microemboli and procedural or neurologic complications, aneurysm size, number of stents, or procedure time. Eight procedures (34.8%) required additional thienopyridine for inadequate platelet inhibition, and 3 required further treatment for persistent nonresponse to point-of-care platelet reactivity testing. There were 6 technical and 2 postoperative complications; none were associated with inadequate platelet inhibition or microemboli. The combination of routine point-of-care platelet reactivity testing and postprocedural microembolic monitoring may help identify patients at risk for thromboembolic complications after flow-diverting stents.
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Song TJ, Suh SH, Min PK, Kim DJ, Kim BM, Heo JH, Kim YD, Lee KY. The influence of anti-platelet resistance on the development of cerebral ischemic lesion after carotid artery stenting. Yonsei Med J 2013; 54:288-94. [PMID: 23364958 PMCID: PMC3575994 DOI: 10.3349/ymj.2013.54.2.288] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Cerebral ischemic lesions are frequently observed after carotid artery stenting (CAS), and anti-platelet agents are used to prevent stent thrombosis and peri-procedural complications. However, despite the premedication, cerebral ischemic lesions are observed, suggesting that they may rather be related to anti-platelet resistance. We, therefore, investigated the effects of anti-platelet resistance on the development of cerebral ischemic lesions after CAS. MATERIALS AND METHODS We retrospectively reviewed patients who received CAS and selected patients for whom brain MRI was performed within 24 hours after CAS and for whom anti-platelet resistance was checked. Anti-platelet resistance was examined by the VerifyNow system. We analyzed the correlation between anti-platelet resistance and cerebral ischemic lesions detected on follow-up MRI. RESULTS Among 76 patients, 45 (59.2%) developed new ischemic lesions after CAS. Twelve (15.8%) patients showed aspirin resistance and 50 (65.8%) patients showed clopidogrel resistance. Patients with a new ischemic lesion demonstrated a significantly greater frequency of clopidogrel resistance than those who had no new ischemic lesion (82.2% versus 41.9%, p=0.001). The frequency of aspirin resistance was not significantly different between the groups of patients with and without new ischemic lesions (20.0% versus 9.7%, p=0.340). In multivariate analysis, clopidogrel resistance was a significant risk factor for post-procedural cerebral ischemia. CONCLUSION Anti-platelet resistance can be used to predict new ischemic lesions after CAS. Anti-platelet resistance should be evaluated in all patients prior to CAS to prevent ischemic complications related to CAS.
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Affiliation(s)
- Tae-Jin Song
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Hyun Suh
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
- Severance Institute for Vascular and Metabolic Research, Yonsei University, Seoul, Korea
| | - Pil-Ki Min
- Department of Cardiology, Yonsei University College of Medicine, Seoul, Korea
- Severance Institute for Vascular and Metabolic Research, Yonsei University, Seoul, Korea
| | - Dong Joon Kim
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Moon Kim
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Young-Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung-Yul Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
- Severance Institute for Vascular and Metabolic Research, Yonsei University, Seoul, Korea
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Lawson MF, Fautheree GL, Waters MF, Decker DA, Mocco JD, Hoh BL. Acute intraprocedural thrombus formation during wingspan intracranial stent placement for intracranial atherosclerotic disease. Neurosurgery 2010; 67:ons166-70; discussion ons170. [PMID: 20679932 DOI: 10.1227/01.neu.0000380948.85926.3c] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Treatment of intracranial atherosclerotic disease with the Wingspan-Gateway intracranial stent and balloon angioplasty system has been reported in several multicenter registries. To date, the incidence of acute intraprocedural thrombus formation during Wingspan stent placement has not been reported. OBJECTIVE We reviewed the incidence of acute thrombus formation, treatment, and outcome for patients who underwent Wingspan stent placement by the senior author (B.L.H.) between June 2006 and April 2009. METHODS We routinely perform angiograms every 10 minutes for at least 30 minutes after placement of a Wingspan stent to check for acute thrombus formation. Acute thrombus was graded: (1) visible thrombus but not flow limiting, (2) visible and flow-limiting thrombosis, and (3) complete stent occlusion. Recanalization was graded according to Thrombosis In Myocardial Infarction score. RESULTS Forty-one patients underwent Wingspan stent placement for intracranial stenosis. Acute intraprocedural thrombus formation developed in 6 (14.6%) within 20 minutes after stent placement: 3 grade 1, 1 grade 2, and 2 grade 3. All 6 were successfully recanalized with Thrombosis In Myocardial Infarction score 3 after intravenous abciximab with or without intra-arterial tissue plasminogen activator and/or balloon angioplasty. There was no morbidity, and all 6 patients were discharged home at their neurological baseline. CONCLUSION We recommend serial angiography every 10 minutes for at least 30 minutes after placement of Wingspan stents. Once detected, acute thrombosis can be successfully treated with intravenous abciximab with or without intra-arterial tissue plasminogen activator and/or balloon angioplasty.
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Affiliation(s)
- Matthew F Lawson
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
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Kung DK, Policeni BA, Capuano AW, Rossen JD, Jabbour PM, Torner JC, Howard MA, Hasan D. Risk of ventriculostomy-related hemorrhage in patients with acutely ruptured aneurysms treated using stent-assisted coiling. J Neurosurg 2010; 114:1021-7. [PMID: 20950080 DOI: 10.3171/2010.9.jns10445] [Citation(s) in RCA: 123] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECT Intracranial stenting has improved the ability to treat wide-neck aneurysms via endovascular techniques. However, stent placement necessitates the use of antiplatelet agents, and the latter may complicate the treatment of patients with acutely ruptured aneurysms who demonstrate hydrocephalus and require ventriculostomy. Antiplatelet agents in this setting could increase the incidence of ventriculostomy-related hemorrhagic complications, but there are insufficient data in the medical literature to quantify this potential risk. The aim of this study was to directly quantify the risk of ventriculostomy-related hemorrhage in patients with acute aneurysmal subarachnoid hemorrhage treated with stent-assisted coiling. METHODS The authors retrospectively identified 131 patients who underwent endovascular treatment for an acutely ruptured aneurysm as well as ventriculostomy or ventriculoperitoneal (VP) shunt placement. The rate of hemorrhagic complications associated with ventriculostomy or VP shunt insertion was compared between patients who underwent coiling without a stent (Group 1) and those who underwent stent-assisted coiling and dual antiplatelet therapy (Group 2). RESULTS One hundred nine ventriculostomies or VP shunt placement procedures were performed in 91 patients in Group 1, and 50 procedures were undertaken in 40 patients in Group 2. The rates of radiographic hemorrhage and symptomatic hemorrhage were significantly higher in Group 2 (32% vs 14.7%, p = 0.02; and 8% vs 0.9%, p = 0.03, respectively). On multivariate analyses, Group 2 had 3.42 times the odds of a radiographic hemorrhage (95% CI 1.46-8.04, p = 0.0048) after adjusting for antiplatelet use prior to admission. CONCLUSIONS The application of dual antiplatelet therapy in stent-assisted coiling of acutely ruptured aneurysms is associated with an increase in the risk of hemorrhagic complications following ventriculostomy or VP shunt placement, as compared with its use in a coiling procedure without a stent.
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Affiliation(s)
- David K Kung
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242, USA.
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