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Kuhn AL, Singh J, Puri AS. Dual Antiplatelet Non-Responder: Resistance to Clopidogrel and Ticagrelor. Neurohospitalist 2024; 14:312-315. [PMID: 38894997 PMCID: PMC11181978 DOI: 10.1177/19418744241228630] [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: 06/21/2024] Open
Abstract
Background Dual antiplatelet therapy is often required for neurointerventional procedures, especially when a stent or flow diverter is placed in the cervical and intracranial vessels. Patients are usually started on aspirin and clopidogrel given the simplicity of the once daily regimen with reasonable cost. Unfortunately, about a third of patients do not show the desired antiplatelet response to clopidogrel and another agent needs to be introduced. Ticagrelor is a potent antiplatelet medication that has a favorable pharmacological profile and has emerged as a reliable alternative to clopidogrel in recent years. Despite ticagrelor non-responders being rare, they do exist, and identification of these patients is important. Results A 74-year-old female was incidentally found to harbor a right posterior communicating aneurysm which was successfully treated electively with stent-assisted coiling. Platelet inhibition testing revealed non-responsiveness to Clopidogrel. Ticagrelor was initiated but the patient's platelet reactivity unit remained in the normal range. Management algorithms to maximize a patient's ticagrelor response by facilitating enteral absorption were applied but no platelet inhibition was achieved. The patient was eventually identified as a true ticagrelor non-responder. Conclusion Resistance to antiplatelet medication can result in devastating complications with permanent neurological deficits. Ticagrelor non-responders are rare but do exist. Platelet inhibition testing should be part of the preprocedural workup for neurointerventions.
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Affiliation(s)
- Anna Luisa Kuhn
- Department of Radiology, Division of Neurointerventional Radiology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Jasmeet Singh
- Department of Radiology, Division of Neurointerventional Radiology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Ajit S. Puri
- Department of Radiology, Division of Neurointerventional Radiology, University of Massachusetts Chan Medical School, Worcester, MA, USA
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2
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Jebrin R, El Nekidy WS, Abidi E, John TLS, Kesav P, Hussain SI, Abdelsalam M, Khaled L, Raj D, John S. Racial differences in P2Y12 inhibitor responsiveness in patients undergoing neuro-endovascular procedures: A cohort from the Middle East. Clin Neurol Neurosurg 2024; 239:108167. [PMID: 38402103 DOI: 10.1016/j.clineuro.2024.108167] [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: 10/21/2023] [Revised: 02/04/2024] [Accepted: 02/05/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND Data on P2Y12 inhibitors responsiveness from the middle east is scarce. We sought to investigate patient responsiveness to P2Y12 inhibitors within a cohort of major races that characterize the UAE population. The secondary objective was to assess risk factors for hyper and hypo-responsiveness in this population. METHODS We conducted a cross-sectional study on adults who received either clopidogrel or ticagrelor treatments and had platelet responsiveness testing before undergoing neuro-endovascular interventions at our quaternary care hospital between March 2015 and April 2019. RESULTS During the study period, 249 subjects met the inclusion criteria. Overall, 17.3 % were hyper-responsive and 25.7 % were hypo-responsive to P2Y12 inhibitors. When comparing between the P2Y12 inhibitors, rates of hyper-responsiveness were significantly higher to ticagrelor when compared to clopidogrel (11 versus 6 %, p = 0.02 respectively). Contrarily, hypo-responsiveness rates were significantly higher in clopidogrel treated patients compared to their ticagrelor treated counterparts (23 versus 2 %, p < .001 respectively). Patients of Middle-Eastern origin showed a significantly higher rate of hypo-responsiveness to both clopidogrel and ticagrelor when compared to other races (41.1 % and 26.7 %, P < 0.001 respectively). Asians showed the highest rates of hyper-responsiveness for both agents. Multivariate logistic regression analysis showed that proton pump inhibitors and statin combination, (OR: 6.39, 95 %CI [1.60, 25.392]), and Middle East vs. Indian subcontinent patients (OR: 4.67, 95 %CI [1.79-12.14]) were independent predictors of hypo-responsiveness to both P2Y12 inhibitors. CONCLUSION This study demonstrated a high rate of hypo-responsiveness to P2Y12 inhibitors in a UAE cohort of patients undergoing neuro-endovascular procedures. In addition, therapeutic responsiveness to P2Y12 inhibitors varied markedly based on the racial background. Future larger studies are needed to evaluate genetic variations that may contribute to this rate of hypo-responsiveness in our population.
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Affiliation(s)
- Rita Jebrin
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates
| | - Wasim S El Nekidy
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States
| | - Emna Abidi
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates
| | | | - Praveen Kesav
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States
| | - Syed I Hussain
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates
| | | | - Luna Khaled
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates
| | - Divya Raj
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates
| | - Seby John
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States.
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May CC, Holden D, Robbins BT, Cook AM, Jung S, Smetana KS, Roels C, Harlan SS, Keegan S, Brophy G, Al Mohaish S, Sandler M, Spetz S, Wohlfarth K, Owusu-Guha J, Buschur P, Hetrick E, Dombrowski K, Glover J, Levesque M, Dingman S, Hussain M. Multicenter Comparison of the Safety and Efficacy of Clopidogrel Versus Ticagrelor for Neuroendovascular Stents. Neurocrit Care 2024; 40:262-271. [PMID: 37322326 DOI: 10.1007/s12028-023-01749-7] [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: 01/18/2023] [Accepted: 05/05/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) is commonly employed for neuroendovascular stenting due to the significant risk of thromboembolism. Clopidogrel and aspirin are most often selected as initial DAPTs; however, there is limited literature available to support guidance of DAPT in this setting. The objective of this study was to evaluate safety and efficacy in patients whose final regimen included either DAPT with aspirin and clopidogrel (DAPT-C) or DAPT with aspirin and ticagrelor (DAPT-T). METHODS This was a multicenter, retrospective cohort of patients who underwent neuroendovascular stenting and received DAPT between July 1, 2017, and October 31, 2020. Study participants were allocated into groups based on discharge DAPT regimen. The primary outcome was incidence of stent thrombosis at 3-6 months on DAPT-C versus DAPT-T, as defined by the presence of thrombus on imaging or new onset stroke. Secondary outcomes included major and minor bleeding and death within 3-6 months after the procedure. RESULTS Five hundred and seventy patients were screened across 12 sites. Of those, 486 were included (DAPT-C n = 360, DAPT-T n = 126). There was no difference in the primary outcome of stent thrombosis between the DAPT-C and DAPT-T groups (8% vs. 8%, p = 0.97) and no difference in any of the secondary safety outcomes. CONCLUSIONS Using DAPT-C or DAPT-T regimens in a broad population of neuroendovascular stenting procedures appears to have similar safety and efficacy profiles. Further prospective evaluation is warranted to streamline the practice of DAPT selection and monitoring to determine the impact on clinical outcomes.
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Affiliation(s)
- Casey C May
- Department of Pharmacy Practice and Science, The Ohio State University College of Pharmacy, 214A Parks Hall, 500 12th Ave, Columbus, OH, 4321, USA.
| | - Devin Holden
- Department of Pharmacy, Albany Medical Center, Albany, NY, USA
| | - Blake T Robbins
- Department of Pharmacy, University of Kentucky Healthcare, Lexington, KY, USA
| | - Aaron M Cook
- Department of Pharmacy, University of Kentucky Healthcare, Lexington, KY, USA
| | - Sara Jung
- Wellstar Kennestone Hospital, Marietta, GA, USA
| | | | - Christina Roels
- Novant Health Forsyth Medical Center, Winston-Salem, NC, USA
| | | | - Shaun Keegan
- University of Cincinnati Medical Center, Cincinnati, OH, USA
| | | | | | | | | | | | | | - Pamela Buschur
- OhioHealth Riverside Methodist Hospital, Columbus, OH, USA
| | | | - Keith Dombrowski
- University of South Florida/Tampa General Hospital, Tampa, FL, USA
| | - Jennifer Glover
- University of South Florida/Tampa General Hospital, Tampa, FL, USA
| | - Melissa Levesque
- University of South Florida/Tampa General Hospital, Tampa, FL, USA
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4
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Jung YS, Jin BH, Park MS, Kim CO, Chae D. Population pharmacokinetic-pharmacodynamic modeling of clopidogrel for dose regimen optimization based on CYP2C19 phenotypes: A proof of concept study. CPT Pharmacometrics Syst Pharmacol 2024; 13:29-40. [PMID: 37775990 PMCID: PMC10787215 DOI: 10.1002/psp4.13053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 08/21/2023] [Accepted: 08/23/2023] [Indexed: 10/01/2023] Open
Abstract
Clopidogrel is an antiplatelet drug used to reduce the risk of acute coronary syndrome and stroke. It is converted by CYP2C19 to its active metabolite; therefore, poor metabolizers (PMs) of CYP2C19 exhibit diminished antiplatelet effects. Herein, we conducted a proof-of-concept study for using population pharmacokinetic-pharmacodynamic (PK-PD) modeling to recommend a personalized clopidogrel dosing regimen for individuals with varying CYP2C19 phenotypes and baseline P2Y12 reaction unit (PRU) levels. Data from a prospective phase I clinical trial involving 36 healthy male participants were used to develop the population PK-PD model predicting the concentrations of clopidogrel, clopidogrel H4, and clopidogrel carboxylic acid, and linking clopidogrel H4 concentrations to changes in PRU levels. A two-compartment model effectively described the PKs of both clopidogrel and clopidogrel carboxylic acid, and a one-compartment model of those of clopidogrel H4. The CYP2C19 phenotype was identified as a significant covariate influencing the metabolic conversion of the parent drug to its metabolites. A PD submodel of clopidogrel H4 that stimulated the fractional turnover rate of PRU levels showed the best performance. Monte Carlo simulations suggested that PMs require three to four times higher doses than extensive metabolizers to reach the target PRU level. Individuals within the top 20th percentile of baseline PRU levels were shown to require 2.5-3 times higher doses than those in the bottom 20th percentile. We successfully developed a population PK-PD model for clopidogrel considering the impact of CYP2C19 phenotypes and baseline PRU levels. Further studies are necessary to confirm actual dosing recommendations for clopidogrel.
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Affiliation(s)
- Yun Seob Jung
- Department of Convergence MedicineYonsei University Wonju College of MedicineWonjuKorea
| | - Byung Hak Jin
- Department of Clinical PharmacologySeverance Hospital, Yonsei University Health SystemSeoulKorea
| | - Min Soo Park
- Department of Clinical PharmacologySeverance Hospital, Yonsei University Health SystemSeoulKorea
- Department of PediatricsYonsei University College of MedicineSeoulKorea
| | - Choon Ok Kim
- Department of Clinical PharmacologySeverance Hospital, Yonsei University Health SystemSeoulKorea
| | - Dongwoo Chae
- Department of PharmacologyYonsei University College of MedicineSeoulKorea
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5
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Flynn LM, Mohamed E, Dobbs N, Nania A, Du Plessis J, Keston PM, Downer JJ. Safety of dual antiplatelet therapy using aspirin and low-dose Prasugrel with platelet reactivity testing in flow diverter treatment of intracranial aneurysms. Interv Neuroradiol 2023:15910199231217142. [PMID: 38031444 DOI: 10.1177/15910199231217142] [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: 12/01/2023] Open
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) is standard care for intracranial stenting to prevent thrombotic complications. Clopidogrel resistance has resulted in patients receiving newer P2Y12 inhibitors like Prasugrel, which may reduce thrombotic complications but could increase haemorrhagic complications. This study, utilising platelet reactivity testing, compared thrombotic and haemorrhagic complications associated with Clopidogrel or 20 mg Prasugrel loading in patients treated with flow diverters (FD) for intracranial aneurysms. METHODS We retrospectively analysed prospectively collected data from 225 consecutive FD procedures. All patients received aspirin. 147 cases received Clopidogrel and 82 received Prasugrel. All patients had VerifyNow testing before the procedure. RESULTS P2Y12 non-responders were significantly more likely to have thrombotic complications than responders and hyper-responders (7% vs. 2%, p = 0.01). Low-dose Prasugrel resulted in a significantly lower rate of non-responders when compared with Clopidogrel (7% vs. 25%, p < 0.01). We found no statistically significant difference in rates of haemorrhage between the Clopidogrel and Prasugrel groups (2.4% vs. 3.9%, p = 0.47). There were 12 complications (≤7 days) in the Clopidogrel group versus 6 in the Prasugrel group (9% vs. 7.8%, respectively, p = 0.91) and a non-significant reduction in thrombotic complications in the Prasugrel group (5.2% vs. 3.9%, p = 0.88). No significant difference was shown in long-term complications between the groups (p = 0.33). CONCLUSION These results support the use of platelet reactivity testing and the safety of low-dose Prasugrel for FD treatment of intracranial aneurysms.
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Affiliation(s)
- Liam M Flynn
- Department of Clinical Neurosciences, Edinburgh, UK
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6
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Krishnakumar H, Mascitelli J, Hassan A, Leary J, Son C. Treatment of cerebral aneurysms with flow diversion or stent assisted coiling in patients on concurrent oral anticoagulation. Neuroradiol J 2023; 36:464-469. [PMID: 36409963 PMCID: PMC10588601 DOI: 10.1177/19714009221114443] [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] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Flow diversion and stent assisted coiling are increasingly utilized strategies in the endovascular treatment of cerebral aneurysms. Ischemic and hemorrhagic complications play an important role in the outcome following such embolizations. Little is published regarding patients on concurrent oral anticoagulation and undergoing such embolizations and the rates of complications and patient outcomes. MATERIALS AND METHODS Retrospective data for consecutive patients on concurrent oral anticoagulation undergoing flow diversion or stent assisted coiling for cerebral aneurysms was accessed from databases at the participating sites. Patient demographics, comorbidities, antiplatelet regimens, aneurysm characteristics, complications, and radiographic results were recorded and descriptive statistics reported. RESULTS Eleven patients were identified undergoing embolization in the setting of preoperative anticoagulant use and included seven patients undergoing flow diversion and four patients undergoing stent assisted coiling. There was a wide range of antiplatelet and anticoagulant management strategies. There were four major complications in three patients (27.2%) to include two serious bleeding events in addition to ischemic strokes. Both serious bleeding events occurred in patients continued on oral anticoagulation with the addition of antiplatelets. At a mean follow-up of 9.6 months, three aneurysms had continued filling for a good radiographic outcome of 72.7%. CONCLUSIONS Anticoagulant and antiplatelet use in the setting of flow diversion or stent assisted coiling may carry increased risks as compared to historical norms and, for flow diversion, offer decreased efficacy.
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Affiliation(s)
- Hari Krishnakumar
- Long School of Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Justin Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center, San Antonio, TX, USA
| | - Ameer Hassan
- Department of Neurology, University of Texas Rio Grande Valley Medical School, Harlingen, TX, USA
- Valley Baptist Medical Center, Harlingen, TX, USA
| | - Jonathan Leary
- Department of Neurosurgery, University of Texas Health Science Center, San Antonio, TX, USA
| | - Colin Son
- Neurosurgical Associates of San Antonio, San Antonio, TX, USA
- School of Osteopathic Medicine, University of the Incarnate Word, San Antonio, TX, USA
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7
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Young CC, Bass DI, Cruz MJ, Carroll K, Vanent KN, Lee C, Sen RD, Feroze AH, Williams JR, Levy S, McCray D, Kelly CM, Barber J, Kim LJ, Levitt MR. Clopidogrel hyper-response increases peripheral hemorrhagic complications without increasing intracranial complications in endovascular aneurysm treatments requiring dual antiplatelet therapy. J Clin Neurosci 2022; 105:66-72. [PMID: 36113244 DOI: 10.1016/j.jocn.2022.09.005] [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: 04/19/2022] [Revised: 08/09/2022] [Accepted: 09/03/2022] [Indexed: 10/31/2022]
Abstract
Clinical significance of increased clopidogrel response measured by VerifyNow P2Y12 assay is unclear; management guidelines are lacking in the context of neuroendovascular intervention. Our objective was to assess whether increased clopidogrel response predicts complications from endovascular aneurysm treatment requiring dual antiplatelet therapy. A single-institution, 9-year retrospective study of patients undergoing endovascular treatments for ruptured and unruptured aneurysms requiring aspirin and clopidogrel was conducted. Patients were grouped according to preoperative platelet inhibition in response to clopidogrel measured by the VerifyNow P2Y12 assay (VNP; P2Y12 reactivity units, PRU). Demographic and clinical features were compared across groups. Hemorrhagic complication rates (intracranial, major extracranial, minor extracranial) and thromboembolic complications (in-stent stenosis, stroke/transient ischemic attack) were compared, controlling for potential confounders and multiple comparisons. Data were collected from 284 patients across 317 procedures. Pre-operative VNP assays identified 9 % Extreme Responders (PRU ≤ 15), 13 % Hyper-Responders (PRU 16-60), 62 % Therapeutic Responders (PRU 61-214), 16 % Hypo-Responders (PRU ≥ 215). Increased response to clopidogrel was associated with increased risk of any hemorrhagic complication (≤60 PRU vs > 60 PRU; 39 % vs 24 %, P = 0.050); all intracranial hemorrhages occurred in patients with PRU > 60. Thromboembolic complications were similar between therapeutic and subtherapeutic patients (<215 PRU vs ≥ 215 PRU; 15 % vs 16 %, P = 0.835). Increased preoperative clopidogrel response is associated with increased rate of extracranial hemorrhagic complications in endovascular aneurysm treatments. Hyper-responders (16-60 PRU) and Extreme Responders (≤15 PRU) were not associated with intracranial hemorrhagic or thrombotic complications. Hypo-responders who underwent adjustment of antiplatelet therapy and neurointerventions did not experience higher rates of complications.
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Affiliation(s)
- Christopher C Young
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA
| | - David I Bass
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA
| | - Michael J Cruz
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA
| | - Kate Carroll
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA
| | - Kevin N Vanent
- School of Medicine, University of Washington, Seattle, WA 98104, USA
| | - Chungeun Lee
- School of Medicine, Washington State University, Spokane, WA 99202, USA
| | - Rajeev D Sen
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA
| | - Abdullah H Feroze
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA
| | - John R Williams
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA
| | - Samuel Levy
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA; Stroke & Applied Neurosciences Center, University of Washington, Seattle, WA 98104, USA
| | - Denzel McCray
- Stroke & Applied Neurosciences Center, University of Washington, Seattle, WA 98104, USA
| | - Cory M Kelly
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA; Stroke & Applied Neurosciences Center, University of Washington, Seattle, WA 98104, USA
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA
| | - Louis J Kim
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA; Stroke & Applied Neurosciences Center, University of Washington, Seattle, WA 98104, USA; Department of Radiology, University of Washington, Seattle, WA 98104, USA
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA; Stroke & Applied Neurosciences Center, University of Washington, Seattle, WA 98104, USA; Department of Radiology, University of Washington, Seattle, WA 98104, USA; Department of Mechanical Engineering, University of Washington, Seattle, WA 98104, USA.
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8
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Fujita K, Fujii S, Hirai S, Yamaoka H, Ishikawa M, Karakama J, Miki K, Yoshimura M, Nemoto S, Sumita K. P2Y12 reaction units and ischemic and bleeding events after neuro-endovascular treatment. J Stroke Cerebrovasc Dis 2022; 31:106631. [PMID: 35849918 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106631] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/20/2022] [Accepted: 06/30/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND PURPOSE To investigate the associations of perioperative P2Y12 reaction units (PRU) measured using VerifyNow with ischemic and bleeding events, and to determine the PRU threshold in the setting of elective neuro-endovascular treatment (EVT) for intracranial/extracranial vascular disease in patients taking aspirin and clopidogrel. METHODS Of the patients undergoing elective neuro-EVT while taking aspirin and clopidogrel, those taking both antiplatelet agents for 7 days or more and whose PRU and aspirin reaction units (ARU) were measured were included. The primary and safety outcomes were defined as symptomatic ischemic and major bleeding events within 30 days after EVT. RESULTS A total of 197 patients were available for the analyses. Higher PRU was associated with symptomatic ischemic events on multivariable logistic analysis (odds ratio per 10 increase 1.14 [95% confidence interval 1.03-1.27], p=0.011). Receiver operating characteristic curve analysis showed that PRU ≥212 was the threshold to predict symptomatic ischemic events (area under the curve=0.73; sensitivity, 62.5%; specificity, 82.0%). Lower PRU was also associated with major bleeding events (odds ratio per 10 increase 0.87 [0.78-0.96], p=0.004), and the threshold to predict major bleeding events was PRU ≤46 (area under the curve=0.76; sensitivity, 70.0%; specificity, 87.2%) CONCLUSIONS: The PRU value was associated with symptomatic ischemic and major bleeding events after elective neuro-EVT in patients taking aspirin and clopidogrel. PRU ≥212 and PRU ≤46 appeared to be the threshold values to predict symptomatic ischemic and major bleeding events, respectively.
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Affiliation(s)
- Kyohei Fujita
- Department of Endovascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan; Department of Neurology and Neurological Science, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shoko Fujii
- Department of Endovascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Sakyo Hirai
- Department of Endovascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Hiroto Yamaoka
- Department of Endovascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Mariko Ishikawa
- Department of Endovascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Jun Karakama
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Kazunori Miki
- Department of Endovascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan; Department of Endovascular Surgery, Tokyo Metropolitan Police Hospital, Tokyo, Japan
| | - Masataka Yoshimura
- Department of Neurosurgery, Tsuchiura Kyodo General Hospital, Ibaraki, Japan.
| | - Shigeru Nemoto
- Department of Endovascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan; Department of Neurosurgery, Kanto Rosai Hospital, Kanagawa, Japan.
| | - Kazutaka Sumita
- Department of Endovascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan.
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9
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Thromboembolic Events during Endovascular Coiling for Unruptured Intracranial Aneurysms: Clinical Significance of Platelet Reactivity Unit and Adjunctive Cilostazol. Clin Neurol Neurosurg 2022; 213:107133. [DOI: 10.1016/j.clineuro.2022.107133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 01/03/2022] [Accepted: 01/14/2022] [Indexed: 11/21/2022]
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10
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Camargo LM, Lima PCTM, Janot K, Maldonado IL. Safety of Oral P2Y12 Inhibitors in Interventional Neuroradiology: Current Status and Perspectives. AJNR Am J Neuroradiol 2021; 42:2119-2126. [PMID: 34674995 DOI: 10.3174/ajnr.a7303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 07/22/2021] [Indexed: 11/07/2022]
Abstract
In the field of interventional neuroradiology, antiplatelet agents are commonly used to prepare patients before the implantation of permanent endovascular materials. Among the available drugs, clopidogrel is the most frequently used one, but resistance phenomena are considered to be relatively common. Prasugrel and ticagrelor were recently added to the pharmacologic arsenal, but the safety of these agents in patients undergoing neurointerventional procedures is still a subject of discussion. The cumulative experience with both drugs is less extensive than that with clopidogrel, and the experience with patients in the neurology field is less extensive than in the cardiology domain. In the present article, we provide a narrative review of studies that investigated safety issues of oral P2Y12 inhibitors in interventional neuroradiology and discuss potential routes for future research.
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Affiliation(s)
- L M Camargo
- From the Faculdade de Medicina (L.M.C.), Universidade Salvador, Salvador, Brazil
| | - P C T M Lima
- Serviço de Clínica Médica (P.C.T.M.L.), Hospital Santo Antônio, Associação Obras Sociais Irmã Dulce, Salvador, Brazil
| | - K Janot
- Service de Neuroradiologie (K.J.), Centre Hospitalier Régional Universitaire de Tours, Tours, France
| | - I L Maldonado
- U1253, iBrain (I.L.M.), Université de Tours, Institut National de la Santé et de la Recherche Médicale, Tours, France
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11
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Hosoo H, Ishikawa E, Tsuruta W, Sato M, Ito Y, Hayakawa M, Takigawa T, Marushima A, Suzuki K, Hyodo A, Matsumaru Y. Antiplatelet Therapy and Periprocedural Risk Factor Analysis for Pipeline Embolization Device Treatment of Unruptured Internal Carotid Artery Aneurysms: A Retrospective, Multicenter Analysis. World Neurosurg 2021; 157:e102-e110. [PMID: 34610445 DOI: 10.1016/j.wneu.2021.09.109] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/24/2021] [Accepted: 09/25/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Aneurysm treatment using the Pipeline Embolization Device has been established but appropriate maintenance of dual antiplatelet therapy (APT) is essential. This multicenter retrospective study assessed whether APT was properly adjusted for clopidogrel resistance and identified risk factors associated with periprocedural complications. METHODS Consecutive cases of use of the Pipeline Embolization Device for internal carotid artery aneurysms (>10 mm) between November 2015 and April 2020 were analyzed. Dual APT (aspirin + clopidogrel) was prescribed before treatment. If preprocedural P2Y12 reaction unit (PRU) values were >240, APT was adjusted. Periprocedural complications were compared between APT nonadjustment and adjustment groups and periprocedural risk factors were also analyzed. RESULTS A total of 162 procedures were assessed. The mean maximum aneurysm size was 15.35 mm. APT adjustment was required in 47 cases (29.0%), primarily by switching to prasugrel. There were no significant differences in complication incidence between the 2 groups even after propensity score matching. The risk factor independently associated with ischemic complications was a neck size of 8 mm or larger (odds ratio [OR], 5.25; P = 0.018) and restricting analysis to the APT nonadjustment group showed PRU values of 190 or higher (OR, 5.84; P = 0.047) and neck sizes of 8 mm or larger (OR, 7.05; P = 0.029) as significant factors. The risk factor independently associated with hemorrhagic complications was a neck size of 7 mm or larger (OR, 11.57; P = 0.023). CONCLUSIONS APT adjustment for clopidogrel resistance was safe and effective. Neck width was a risk factor for both ischemic and hemorrhagic complications. PRU values of 190 or higher were also associated with ischemic complications.
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Affiliation(s)
- Hisayuki Hosoo
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Eiichi Ishikawa
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan.
| | - Wataro Tsuruta
- Department of Endovascular Neurosurgery, Toranomon Hospital, Tokyo, Japan
| | - Masayuki Sato
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Yoshiro Ito
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Mikito Hayakawa
- Division of Stroke Prevention and Treatment, Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Tomoji Takigawa
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Aiki Marushima
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Kensuke Suzuki
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Akio Hyodo
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Yuji Matsumaru
- Division of Stroke Prevention and Treatment, Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
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12
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Dowlati E, Pasko KBD, Liu J, Miller CA, Felbaum DR, Sur S, Chang JJ, Liu AH, Armonda RA, Mai JC. Treatment of In-Stent Stenosis Following Flow Diversion of Intracranial Aneurysms with Cilostazol and Clopidogrel. Neurointervention 2021; 16:285-292. [PMID: 34503310 PMCID: PMC8561031 DOI: 10.5469/neuroint.2021.00290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 07/26/2021] [Indexed: 12/01/2022] Open
Abstract
In-stent stenosis is a feared complication of flow diversion treatment for cerebral aneurysms. We present 2 cases of patients treated with pipeline flow diversion for unruptured cerebral aneurysms. Initial perioperative dual antiplatelet therapy (DAPT) consisted of standard aspirin plus clopidogrel. At 6-month follow-up cerebral angiography, the patients were noted to have developed significant in-stent stenosis (63% and 53%). The patients were treated with cilostazol and clopidogrel for at least 6 months. Subsequent angiography at 1-year post-treatment showed significant improvement of the in-stent stenosis from 63% to 34% and 53% to 21%. The role of cilostazol as treatment of intracranial in-stent stenosis has not been previously described. Cilostazol’s vasodilatory effect and suppression of vascular smooth muscle proliferation provides ideal benefits in this setting. Cilostazol plus clopidogrel may be a safe and effective alternative to standard DAPT for treatment of in-stent stenosis following flow diversion and warrants further consideration and investigation.
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Affiliation(s)
- Ehsan Dowlati
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | | | - Jiaqi Liu
- Georgetown University School of Medicine, Washington, DC, USA
| | - Charles A Miller
- Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Daniel R Felbaum
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA.,Department of Neurosurgery, MedStar Washington Hospital Center, Washington, DC, USA
| | - Samir Sur
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA.,Department of Neurosurgery, MedStar Washington Hospital Center, Washington, DC, USA
| | - Jason J Chang
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Ai-Hsi Liu
- Department of Radiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Rocco A Armonda
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA.,Department of Neurosurgery, MedStar Washington Hospital Center, Washington, DC, USA
| | - Jeffrey C Mai
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA.,Department of Neurosurgery, MedStar Washington Hospital Center, Washington, DC, USA
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13
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Liang F, Ma C, Zhu H, Liu L, Liang S, Jiang P, Zhang Y, Jiang C. Using angiographic parametric imaging-derived radiomics features to predict complications and embolization outcomes of intracranial aneurysms treated by pipeline embolization devices. J Neurointerv Surg 2021; 14:826-831. [PMID: 34413243 DOI: 10.1136/neurintsurg-2021-017832] [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: 05/27/2021] [Accepted: 08/09/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Pipeline embolization devices (PEDs) have gained widespread popularity in the treatment of intracranial aneurysms (IAs). However, precise predictors of treatment outcomes are still lacking. This study aimed to use angiographic parametric imaging (API)-derived radiomics features to explore whether biomarkers extracted from immediate postprocedural digital subtraction angiography (DSA) were associated with complications and embolization outcomes of IAs treated with PED without adjunctive coils. METHODS Radiomic features were extracted from postprocedural DSA by API, and radiomics feature selection and radiomics score calculation were performed by the least absolute shrinkage and selection operator (LASSO) logistic regression. Angiographic findings and clinical characteristics were screened using stepwise multivariable logistic regression analysis to identify significant variables for predicting the complication endpoint. Radiomics feature selection and radiomics risk score (RadRS) calculations were performed by LASSO Cox regression. Univariate and multivariate Cox regression analyses were used to identify significant predictors for the occlusion endpoint. RESULTS We screened 281 observations for complications and 235 observations for embolization outcomes from IAs treated in our center using PED between June 2015 and July 2020. Multivariate regression analysis showed association of the radiomics score (p<0.01) and hypertension (p=0.04) with complications. RadRS (p<0.01), symptoms (p<0.01), and age (p=0.03) were predictors of embolization outcomes. Kaplan-Meier analysis revealed that symptomatic patients (p<0.01) and those with off-label IAs (p=0.03) had shorter intervals to complete occlusion. CONCLUSIONS Biomarkers extracted from immediate postprocedural DSA by API could be potential indicators for assessing treatment outcomes of IAs treated by PED without adjunctive coils.
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Affiliation(s)
- Fei Liang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chao Ma
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Haoyu Zhu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Lian Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shikai Liang
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Peng Jiang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yupeng Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chuhan Jiang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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14
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Shoda K, Enomoto Y, Egashira Y, Kinoshita T, Mizutani D, Iwama T. Long-term complications after stent assist coiling dependent on clopidogrel response. BMC Neurol 2021; 21:247. [PMID: 34182941 PMCID: PMC8237461 DOI: 10.1186/s12883-021-02270-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 06/07/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) is necessary for stent assisted coiling. However, long term use of DAPT has a potential risk of hemorrhagic events. We aimed to examine the relationship between clopidogrel reactivity and complications. METHODS Patients who underwent stent assisted coiling for unruptured aneurysms or previously treated aneurysms and received periprocedural DAPT in our institution between August 2011 to March 2020 were included. Platelet reactivity for clopidogrel was measured by VerifyNow assay system, and we defined the cut off value of P2Y12 Reaction Units (PRU) at 208 and classified patients as hypo-responders (PRU≧208) or responders (PRU<208). The rates of hemorrhagic and thrombotic events within 30 days (acute phase) and 30 days after the procedure (delayed phase) were compared between the two groups. Furthermore, changes in hemoglobin levels were measured before and after the procedure and at chronic stages (1 to 6 months thereafter). RESULTS From 61 patients included in this study, 36 patients were hypo-responders and 25 patients were responders. Hemorrhagic events occurred 8.0% only in responders in the acute phase (p = 0.16), and 2.78% in hypo-responders and 20.0% in responders in the delayed phase (p = 0.037). Changes in hemoglobin levels before and after the procedure were 1.22 g/dl in hypo-responders and 1.74 g/dl in responders (p = 0.032) while before the procedure and chronic stages they were 0.39 g/dl in hypo-responders and 1.39 g/dl in responders (p < 0.01). Thrombotic events were not significantly different between the two groups. CONCLUSION Long term use of DAPT after stent assisted coiling is related to hemorrhagic events in the delayed phase. Preventing for hemorrhagic events, the duration of DAPT should be carefully considered in clopidogrel responders.
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Affiliation(s)
- Kenji Shoda
- Department of Neurosurgery, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, Gifu, 501-1194, Japan.
| | - Yukiko Enomoto
- Department of Neurosurgery, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, Gifu, 501-1194, Japan
| | - Yusuke Egashira
- Department of Neurosurgery, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, Gifu, 501-1194, Japan
| | - Takamasa Kinoshita
- Department of Neurosurgery, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, Gifu, 501-1194, Japan
| | - Daisuke Mizutani
- Department of Neurosurgery, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, Gifu, 501-1194, Japan
| | - Toru Iwama
- Department of Neurosurgery, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, Gifu, 501-1194, Japan
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15
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Miller TR, Wessell A, Jindal G, Malhotra A, Simard JM, Gandhi D. The utility of platelet inhibition testing in patients undergoing Pipeline embolization of intracranial aneurysms. J Neurointerv Surg 2021; 14:neurintsurg-2021-017681. [PMID: 34078649 DOI: 10.1136/neurintsurg-2021-017681] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 05/20/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND The utility of using the VerifyNow P2Y12 platelet inhibition assay in patients undergoing Pipeline embolization of intracranial aneurysms remains controversial. As we have routinely employed the assay for patients undergoing flow diversion, we elected to explore the relationship between P2Y12 hyporesponse as indicated by a P2Y12 Reaction Units (PRU) value >200 and treatment outcomes, including intraprocedural platelet aggregation and ischemic complications. METHODS All successful intracranial aneurysm Pipeline treatments performed at our institution from November 2011 to May 2019 were included. The rate of P2Y12 hyporesponse and treatment outcomes were evaluated. Multivariable logistic regression was utilized to determine independent predictors of treatment outcomes. RESULTS 333 qualifying treatments were performed in 297 patients. Clopidogrel hyporesponse was initially noted in 24%, falling to 17% by day-of-procedure by dose titration. A glycoprotein (GP) IIb/IIIa inhibitor was administered prophylactically in 3% of cases for persistent, profound hyporesponse. 27 (8.1%) patients developed acute platelet aggregation; only 6 demonstrated day-of-procedure P2Y12 hyporesponse. Day-of-procedure hyporesponse was not associated with intraprocedural platelet aggregation or ischemic complications. Greater Pipeline embolization device (PED) diameter was associated with a reduced odds of platelet aggregation (OR 0.38, 95% CI 0.17 to 0.85; p=0.019). Antiplatelet non-compliance (OR 25.20, 95% CI 3.86 to 164.61; p=0.001) and treatment of posterior circulation aneurysms (OR 5.23, 95% CI 1.22 to 22.33; p=0.026) were the only independent predictors of ischemic complications. CONCLUSIONS P2Y12 hyporesponse was not associated with acute platelet aggregation or ischemic complications in our patients undergoing Pipeline embolization of intracranial aneurysms, possibly due to aggressive management of the hyporesponse using clopidogrel dose titration and/or GP IIb/IIIa inhibitor administration.
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Affiliation(s)
- Timothy R Miller
- Diagnostic Radiology, Neuroradiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Aaron Wessell
- Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Gaurav Jindal
- Diagnostic Radiology, Neuroradiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - J Marc Simard
- Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Dheeraj Gandhi
- Diagnostic Radiology, Neuroradiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
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16
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Borchert RJ, Simonato D, R Hickman C, Fuschi M, Thibault L, Henkes H, Fiorella D, Tan BY, Yeo LL, D Makalanda HL, Wong K, Bhogal P. P2Y12 inhibitors for the neurointerventionalist. Interv Neuroradiol 2021; 28:92-103. [PMID: 33947251 PMCID: PMC8905084 DOI: 10.1177/15910199211015042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The use of antiplatelets is widespread in clinical practice. However, for neurointerventional procedures, protocols for antiplatelet use are scarce and practice varies between individuals and institutions. This is further complicated by the quantity of antiplatelet agents which differ in route of administration, dosage, onset of action, efficacy and ischemic and hemorrhagic complications. Clarifying the individual characteristics for each antiplatelet agent, and their associated risks, will increasingly become relevant as the practice of mechanical thrombectomy, stenting, coiling and flow diversion procedures grows. The aim of this review is to summarize the existing literature for the use of P2Y12 inhibitors in neurointerventional procedures, examine the quality of the evidence, and highlight areas in need of further research.
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Affiliation(s)
- Robin J Borchert
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Davide Simonato
- Department of Neuroradiology, Oxford University Hospital NHS Foundation Trust, Oxford, UK.,Institute of Radiology, University of Padova, Padova, Italy
| | - Charlotte R Hickman
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Maurizio Fuschi
- Department of Neuroradiology, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | | | - Hans Henkes
- Clinic for Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | - David Fiorella
- Clinic for Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | - Benjamin Yq Tan
- Clinic for Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | - Leonard Ll Yeo
- Clinic for Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | | | - Ken Wong
- Royal London Hospital, London, UK
| | - Pervinder Bhogal
- Clinic for Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
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17
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Rosengart A, Collins MK, Hendrix P, Uber R, Sartori M, Jain A, Mao J, Goren O, Schirmer CM, Griessenauer CJ. P 2Y 12 inhibitors in neuroendovascular surgery: An opportunity for precision medicine. Interv Neuroradiol 2021; 27:682-694. [PMID: 33541183 DOI: 10.1177/1591019921991394] [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: 11/16/2022] Open
Abstract
INTRODUCTION Dual antiplatelet therapy (DAPT), primarily the combination of aspirin with a P2Y12 inhibitor, in patients undergoing intravascular stent or flow diverter placement remains the primary strategy to reduce device-related thromboembolic complications. However, selection, timing, and dosing of DAPT is critical and can be challenging given the existing significant inter- and intraindividual response variations to P2Y12 inhibitors. METHODS Assessment of indexed, peer-reviewed literature from 2000 to 2020 in interventional cardiology and neuroendovascular therapeutics with critical, peer-reviewed appraisal and extraction of evidence and strategies to utilize DAPT in cardio- and neurovascular patients with endoluminal devices. RESULTS Both geno- and phenotyping for DAPT are rapidly and conveniently available as point-of-care testing at a favorable cost-benefit ratio. Furthermore, systematic inclusion of a quantifying clinical risk score combined with an operator-linked, technical risk assessment for potential adverse events allows a more precise and individualized approach to new P2Y12 inhibitor therapy. CONCLUSIONS The latest evidence, primarily obtained from cardiovascular intervention trials, supports that combining patient pharmacogenetics with drug response monitoring, as part of an individually tailored, precision medicine approach, is both predictive and cost-effective in achieving and maintaining individual target platelet inhibition levels. Indirect evidence supports that this gain in optimizing drug responses translates to reducing main adverse events and overall treatment costs in patients undergoing DAPT after intracranial stent or flow diverting treatment.
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Affiliation(s)
- Axel Rosengart
- Department of Neurosurgery, Geisinger Health System, Danville, PA, USA
| | - Malie K Collins
- Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Philipp Hendrix
- Department of Neurosurgery, Saarland University Medical Center and Saarland University, Faculty of Medicine, Homburg/Saar, Germany
| | | | | | - Abhi Jain
- Department of Radiology, Einstein Medical Center, Philadelphia, PA, USA
| | - Jennifer Mao
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Oded Goren
- Department of Neurosurgery, Geisinger Health System, Danville, PA, USA
| | - Clemens M Schirmer
- Department of Neurosurgery, Geisinger Health System, Danville, PA, USA.,Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Christoph J Griessenauer
- Department of Neurosurgery, Geisinger Health System, Danville, PA, USA.,Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
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18
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Daou BJ, Palmateer G, Linzey JR, Thompson BG, Chaudhary N, Gemmete JJ, Pandey AS. Stent-assisted coiling of cerebral aneurysms: Head to head comparison between the Neuroform Atlas and EZ stents. Interv Neuroradiol 2021; 27:353-361. [PMID: 33509014 DOI: 10.1177/1591019921989476] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The Neuroform Atlas stent is thought to have features allowing for an improved stent delivery system. We aimed to provide a comparison of the Atlas and Neuroform EZ stents in patients treated with stent-assisted coiling. METHODS Seventy-seven aneurysms treated with the Atlas stent and 77 aneurysms with similar characteristics treated with the EZ stent were retrospectively compared. Outcomes included angiographic occlusion per the Raymond-Roy (RR) scale, recanalization, retreatment and procedural complications. RESULTS With the Atlas stent, technical success was 100% and immediate RR1 occlusion was 81.8%. Follow-up RR1 was achieved in 83.7%. The recanalization rate was 7% and the retreatment rate was 4.6%. The complication rate was 6.5% (new neurological deficit in 1.3%). With the EZ stent, technical success was 96%, immediate RR1 occlusion was 67.6% and follow-up RR1 was 67.6%. The recanalization rate was 12.7% and the retreatment rate was 14.1%. The complication rate was 10.4% (new neurological deficit in 2.6%). The rate of immediate RR1 occlusion was significantly higher with the Atlas stent (p = 0.03), and the rate of follow-up RR1 was nonsignificantly higher with the Atlas stent (p = 0.08). The retreatment rate was significantly lower with the Atlas stent (p = 0.009). There were no significant differences in the rates of recanalization (p = 0.5) and complications (p = 0.6). CONCLUSIONS Stent-assisted coiling with the Atlas stent is safe and effective and shows better immediate results as compared to the EZ stent, with improved overall follow-up outcomes.
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Affiliation(s)
- Badih J Daou
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Gregory Palmateer
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Joseph R Linzey
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Neeraj Chaudhary
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA.,Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Joseph J Gemmete
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA.,Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
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19
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Yoshimura M, Sumita K, Fujii S, Miki K, Aizawa Y, Fujita K, Yamamoto S, Nemoto S, Maehara T. Periprocedural Variability of Platelet Functions in Carotid Artery Stenting: An Analysis Using VerifyNow. JOURNAL OF NEUROENDOVASCULAR THERAPY 2021; 15:505-516. [PMID: 37502767 PMCID: PMC10370580 DOI: 10.5797/jnet.oa.2020-0170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 10/31/2020] [Indexed: 07/29/2023]
Abstract
Objective The assessment of platelet functions is necessary to prevent both thromboembolic and hemorrhagic complications under dual antiplatelet therapy (DAPT). Using the VerifyNow (Accumetrics, Inc., San Diego, CA, USA) assay, this study aimed to reveal time-dependent changes in platelet functions after carotid artery stenting (CAS). Methods We enrolled retrospectively 43 patients who underwent CAS under DAPT. Aspirin reaction unit (ARU) and P2Y12 reaction unit (PRU) values were determined on the day before and on days 1, 3, and 7 after the procedure. Multiple comparison tests (MCTs) were performed among ARU and PRU measurement points, and the proportions of hypo- and hyper-responses were compared. Results The median ARU values were 408 (interquartile range: 392-497) before CAS and 418 (405-470) on day 1, 405 (393.0-460.5) on day 3, and 402 (388.5-477.5) on day 7 (not significant in MCTs). The percentages of hypo-responses were 16.3%, 7.0%, 2.3%, and 7.0%, respectively (p = 0.11). The significantly different median PRU values were 173 (116.5-209.5), 233 (166.5-273.5), 139 (70.5-205.5), and 51 (9.0-79.5), respectively. The median PRU was before the procedure within the therapeutic range but exceeded the upper cutoff on day 1 and was below the lower cutoff on day 7. The percentages of hypo-responses were 14.0%, 51.2%, 18.6%, and 11.6%, respectively (p <0.001) and the percentages of hyper-responses were 9.3%, 2.3%, 23.3%, and 62.8%, respectively (p <0.001). Conclusion In the periprocedural CAS period, ARU values were stable, but PRU values showed time-dependent changes. PRU values were above the therapeutic range the day after CAS but decreased below this range on day 7.
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Affiliation(s)
- Masataka Yoshimura
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
- Department of Neurosurgery, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Kazutaka Sumita
- Department of Endovascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shoko Fujii
- Department of Endovascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazunori Miki
- Department of Endovascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yuki Aizawa
- Department of Endovascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kyohei Fujita
- Department of Endovascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shinji Yamamoto
- Department of Neurosurgery, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Shigeru Nemoto
- Department of Endovascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Taketoshi Maehara
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
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20
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Pressman E, De la Garza CA, Chin F, Fishbein J, Waqas M, Siddiqui A, Snyder K, Davies JM, Levy E, Kan P, Ren Z, Mokin M. Nuisance bleeding complications in patients with cerebral aneurysm treated with Pipeline embolization device. J Neurointerv Surg 2020; 13:247-250. [PMID: 32620576 DOI: 10.1136/neurintsurg-2020-016245] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/03/2020] [Accepted: 06/15/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Patients with cerebral aneurysms treated with the Pipeline embolization device (PED) are maintained on dual antiplatelet therapy (DAPT) to prevent thromboembolic complications. Rates of minor, "nuisance" bleeding in these patients remain unknown. We sought to evaluate the frequency and factors associated with this bleeding and its effect on DAPT compliance. METHODS We performed a multicenter retrospective cohort study on consecutive cases of intracranial aneurysms treated with PED. Patient characteristics, aneurysm characteristics, and bleeding complications were analyzed. Severity of bleeding was defined according to a previously published classification defining nuisance bleeding as easy bruising, bleeding from small cuts, petechia, and ecchymosis. RESULTS 245 PED aneurysm procedures on 243 patients were retrospectively collected from three academic centers over a 4.25-year period. Sixty-seven patients (27%) had nuisance bleeds. Patients with a higher risk of nuisance bleeding were older (59.1±3.4 vs . 54.7±2.2, P=0.032). Patients with nuisance bleeds were more likely to have their DAPT regimen changed or dose lowered (29% vs 8.3%, P<0.001), were on DAPT for less time (10.0 months±2.60 vs. 14.6 months±1.95, P=0.005) and were more likely to have aneurysm occlusion at 6 months (P<0.001). Stepwise logistic regression found age predictive of a nuisance bleed (OR=1.033) CONCLUSIONS: Nuisance bleeding was a common complaint of PED-treated aneurysm patients maintained on DAPT. Increasing age and aneurysmal occlusion at 6 months were the only factors predictive of nuisance bleeds. Clinicians were more likely to adjust antiplatelet regimens or stop DAPT early given a nuisance bleed.
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Affiliation(s)
- Elliot Pressman
- University of South Florida Department of Neurosurgery and Brain Repair, Tampa, Florida, USA
| | - Carlos A De la Garza
- Neurology, Baylor College of Medicine Department of Neurology, Houston, Texas, USA
| | - Felix Chin
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Jacob Fishbein
- University of South Florida Department of Neurosurgery and Brain Repair, Tampa, Florida, USA
| | - Muhammad Waqas
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Adnan Siddiqui
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Kenneth Snyder
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Jason M Davies
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Elad Levy
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Zeguang Ren
- University of South Florida Department of Neurosurgery and Brain Repair, Tampa, Florida, USA.,Neurosciences Group, Tampa General Hospital, Tampa, FL, USA
| | - Maxim Mokin
- University of South Florida Department of Neurosurgery and Brain Repair, Tampa, Florida, USA .,Neurosciences Group, Tampa General Hospital, Tampa, FL, USA
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21
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Entezami P, Holden DN, Boulos AS, Paul AR, Field NC, Nourollahzadeh E, Yamamoto J, Dalfino JC. Cangrelor dose titration using platelet function testing during cerebrovascular stent placement. Interv Neuroradiol 2020; 27:88-98. [PMID: 32611215 DOI: 10.1177/1591019920936923] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Optimal antiplatelet inhibition is vital during cerebrovascular stenting procedures, yet no standardized recommendation exists for antithrombotic therapy in these scenarios. Cangrelor is an intravenous P2Y12 inhibitor with a favorable pharmacokinetic profile for use during neuroendovascular stenting. METHODS A retrospective review of all neuroendovascular patients who underwent stenting between 1 January 2019 and 22 March 2020 and were treated with cangrelor was conducted. Thirty-seven patients met inclusion criteria. RESULTS All patients were administered a bolus of 5 mcg/kg of cangrelor followed by a maintenance infusion. Antiplatelet effects of cangrelor were monitored using platelet reactivity units (PRU). Based on the initial PRU, seven patients' doses were adjusted with subsequent PRUs in or near the goal range of 50-150. One patient experienced an acute intraprocedural occlusion likely related to a subtherapeutic PRU which subsequently resolved with cangrelor dose adjustment and intra-arterial tirofiban administration, and one patient experienced a post-procedure stent occlusion which required a thrombectomy and intra-arterial tirofiban administration. No hemorrhagic complications occurred. DISCUSSION Cangrelor utilization during neuroendovascular stenting with maintenance doses of <2 mcg/kg/min with dose adjustments based on platelet function testing has not been previously described. Cangrelor presents many advantages compared to standard therapy in patients undergoing stent placement related to its pharmacokinetic profile, rapid onset of action, ease of transition to oral P2Y12 antiplatelet agents, and measurability. CONCLUSION Cangrelor is a promising alternative to currently available therapies, especially in patients with a high hemorrhagic risk.
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Affiliation(s)
- Pouya Entezami
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
| | - Devin N Holden
- Department of Pharmacy, Albany Medical Center, Albany, NY, USA
| | - Alan S Boulos
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
| | - Alexandra R Paul
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
| | - Nicholas C Field
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
| | - Emad Nourollahzadeh
- Department of Neurosurgery, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - Junichi Yamamoto
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
| | - John C Dalfino
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
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22
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King RM, Langan ET, Ughi GJ, Raskett CM, Puri AS, Henkes H, Gounis MJ. Acute Thrombus Burden on Coated Flow Diverters Assessed by High Frequency Optical Coherence Tomography. Cardiovasc Intervent Radiol 2020; 43:1218-1223. [PMID: 32385610 DOI: 10.1007/s00270-020-02482-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 04/04/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE The implantation of flow diverters requires administration of dual anti-platelet therapy, posing the potential for complications. The p48MW HPC (phenox, Bochüm, Germany) hydrophilic-coated flow diverting stent is designed to be anti-thrombotic, thus opening the potential for single anti-platelet therapy. We deploy a novel intravascular high-resolution imaging technique, high-frequency optical coherence tomography (HF-OCT), to study in an animal model the acute thrombus formation on coated p48MW devices versus uncoated control devices. METHODS Three pigs were implanted with 4 flow diverters each, two test hydrophilic-coated devices, and two control uncoated devices (p48MW). Each pig was treated with a different anti-platelet regime: no anti-platelet therapy, aspirin only, aspirin and clopidogrel. Twenty minutes after the flow diverter was implanted, an HF-OCT data set was acquired. Acute clot formed on the flow diverter at each covered side branch was measured from the HF-OCT slices. Factors considered to be important were the device type (pHPC versus bare metal), aspirin, clopidogrel, and vessel location. A linear model was constructed from the significant factors. RESULTS Both coating (p < 0.001) and aspirin (p = 0.003) were significantly related to reduction in clot burden, leading to an approximate 100-fold and 50-fold reduction in clot, respectively. CONCLUSIONS This study shows the power of HF-OCT not only in the detection of clot but also the quantification of clot burden. In an animal model, the pHPC-coated p48MW significantly reduced acute thrombus formation over jailed side branches as compared to the bare metal p48MW that was nearly eliminated when combined with aspirin administration.
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Affiliation(s)
- Robert M King
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, 55 Lake Ave N, SA-107R, Worcester, MA, 01655, USA
- Department of Biomedical Engineering, Worcester Polytechnic Institute, Worcester, MA, USA
| | - Erin T Langan
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, 55 Lake Ave N, SA-107R, Worcester, MA, 01655, USA
| | - Giovanni J Ughi
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, 55 Lake Ave N, SA-107R, Worcester, MA, 01655, USA
| | - Christopher M Raskett
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, 55 Lake Ave N, SA-107R, Worcester, MA, 01655, USA
| | - Ajit S Puri
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, 55 Lake Ave N, SA-107R, Worcester, MA, 01655, USA
| | - Hans Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - Matthew J Gounis
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, 55 Lake Ave N, SA-107R, Worcester, MA, 01655, USA.
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23
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Corliss BM, Freedman R, Brennan MM, Smith J, Nerva JD, Harris NS, Polifka AJ, Hoh BL, Fox WC. Laboratory assessments of therapeutic platelet inhibition in endovascular neurosurgery: complication prediction using the VerifyNow P2Y12 assay and thromboelastography with platelet mapping. J Neurosurg 2020; 134:884-892. [PMID: 32084635 DOI: 10.3171/2019.12.jns192396] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 12/02/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Inhibition of platelet aggregation is universally used to prevent thromboembolic complications related to stent placement in endovascular neurosurgery, but excessive inhibition potentiates hemorrhagic complications. Previously, the authors demonstrated that two different commercially available measures of adenosine diphosphate (ADP)-dependent platelet inhibition-the VerifyNow P2Y12 clopidogrel assay (measured in platelet reactivity units [PRU]) and maximal amplitude (MA) attributable to ADP activity (MA-ADP) derived from thromboelastography (TEG) with platelet mapping (PM)-yielded wildly different results. This study sought to analyze observed complications to quantify the ideal therapeutic windows for both tests. METHODS Ninety-one patients with simultaneous or near-simultaneous PRU and TEG-PM results who underwent craniocervical endovascular stenting at the authors' institution between September 2015 and November 2017 were identified and retrospectively enrolled. From November 2017 until June 2019, 109 additional patients were prospectively enrolled. For this study, in-hospital thrombotic and hemorrhagic complications (both CNS and non-CNS) were tabulated, and receiver operating characteristic (ROC) curve analysis was used to identify threshold values of the PRU and MA-ADP for predicting each type of complication. RESULTS Of the 200 patients enrolled, 7 were excluded because of anemia or thrombocytopenia outside of the test manufacturer's specified ranges and 1 was excluded because they did not have a TEG-PM result. Including complications of all severities, there were a total of 15 CNS thrombotic complications, 1 access-site thrombotic complication, 3 CNS hemorrhages, 8 access-site hemorrhagic complications, and 3 hemorrhagic complications not affecting either the CNS or the access site. ROC curve analysis yielded therapeutic threshold values of 118-144 PRU. The results demonstrated PRU has a significant dose-dependent effect on the rates of thrombosis and hemorrhage. Logistic regression models did not demonstrate statistically significant relationships between the MA-ADP and either thrombosis or hemorrhage. ROC analysis based on these models is of little value and did not identify significant threshold values for MA-ADP. CONCLUSIONS There continues to be poor correlation between the results of TEG-PM and PRU. PRU accurately predicted complications, with a relatively narrow ideal value range of 118-144. The MA-ADP alone does not appear able to accurately predict either hemorrhagic or thrombotic complications in this group.
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Affiliation(s)
| | - Rachel Freedman
- 2University of Florida College of Medicine, Gainesville, Florida; and
| | | | | | - John D Nerva
- 4Department of Neurological Surgery, Tulane University, Metairie, Louisiana
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24
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Wipplinger C, Griessenauer CJ. Commentary: Antiplatelet Therapy in Flow Diversion. Neurosurgery 2020; 86:E231-E233. [PMID: 31844900 DOI: 10.1093/neuros/nyz462] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 08/23/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Christoph J Griessenauer
- Department of Neurosurgery and Neuroscience Institute, Geisinger, Danville, Pennsylvania.,Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
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25
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Kim HJ, Oh JS, Park SQ, Yoon SM, Ahn HS, Kim BT. The Efficacy of P2Y12 Reactive Unit to Predict the Periprocedural Thromboembolic and Hemorrhagic Complications According to Clopidogrel Responsiveness and Safety of Modification of Dual Antiplatelet Therapy : A Meta-Analysis. J Korean Neurosurg Soc 2019; 63:539-549. [PMID: 31661948 PMCID: PMC7477146 DOI: 10.3340/jkns.2019.0082] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 08/07/2019] [Indexed: 01/16/2023] Open
Abstract
The efficacy of P2Y12 reaction unit (PRU) of VerifyNow still remains as a controversial issue in neurointervention. So we investigated the usefulness of PRU of VerifyNow to predict the peri-procedural thromboembolic events (TE) and hemorrhagic events (HE). And we evaluated the safety of modified dual antiplatelet therapy (DAPT) or triple antiplatelet therapy (TAPT) for clopidogrel hyporesponders. We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, Web of Science and Scopus on August 19 2018. Data was collected the 1) incidence of TE between clopidogrel responder and clopidogrel hypo-responder, 2) incidence of HE between clopidogrel hyper-responder and clopidogrel responder and hypo-responder, and 3) incidence of TE and HE between modified DAPT or TAPT and standard DAPT in clopidogrel hypo-responder. High cut-off value of PRU was defined as PRU >40% or <220. Fifteen studies were enrolled. Clopidogrel responder showed lower incidence of TE than hypo-responder (risk ratio [RR], 0.32; 95% confidence interval [CI], 0.17-0.61; p<0.001). With the high cut-off value of PRU, clopidogrel responder showed more lower incidence of TE than hypo-responder (RR, 0.11; 95% CI, 0.02-0.45; p=0.002). The incidence of periprocedural HE have higher on clopidogrel hyper-responder than clopidogrel responder and hypo-responder (RR, 4.26; 95% CI, 1.10-16.44; p=0.04; I2=66%). The incidence of periprocedural TE after changing regimen of DAPT for clopidogrel hypo-responder have a tendency to reduce, but there was no significant difference between modified DAPT or TAPT group and standard DAPT group (p>0.05). The incidence of periprocedural HE after changing regimen of DAPT for clopidogrel hypo-responder was no significant difference between modified DAPT or TAPT group and standard DAPT group (p>0.05). PRU is a useful tool as a predictor of peri-procedural TE or HE on neurointervention. PRU has a threshold effect of cut-off value to predict the peri-procedural TE. Modified DAPT or TAPT to prevent TE in clopidogrel hypo-responders could not reduce the incidence of TE. We should investigate the further research about modification of regiment on neurointervention.
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Affiliation(s)
- Hyun Jung Kim
- Department of Public Health, Graduate School of Korea University, Seoul, Korea
| | - Jae Sang Oh
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Sukh Que Park
- Department of Neurosurgery, Soonchunhyang University Seoul, Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Seok Mann Yoon
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Hyeong Sik Ahn
- Department of Public Health, Graduate School of Korea University, Seoul, Korea
| | - Bum Tae Kim
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
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26
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González A, Ortega-Quintanilla J, Zapata-Arriaza E, de Albóniga-Chindurza A, García-Lozano JR, Luque Vega MI, Cayuela A. Dose adjustment of clopidogrel in hyper-responder patients with unruptured intracranial aneurysms treated with stents. J Neurointerv Surg 2019; 12:499-504. [DOI: 10.1136/neurintsurg-2019-015288] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 10/01/2019] [Accepted: 10/08/2019] [Indexed: 12/29/2022]
Abstract
BackgroundThe management of clopidogrel in hyper-responders has not been well described. We report the treatment and dose adjustment individualization with clopidogrel oral solution (COS) in hyper-responder patients with an unruptured intracranial aneurysm treated with a stent.MethodsA prospective study (2015–2018) in patients receiving clopidogrel prior to endovascular treatment was performed. Platelet reactivity after clopidogrel therapy was evaluated with the VerifyNow PRU test. Initial values ≤80 PRU (P2Y12 reactivity units) were classified as a hyper-response according to prior evidence. Patients were treated with clopidogrel for 7–10 days before stent treatment. Seven days post-procedure the dose of COS was gradually reduced (30 mg–20 mg–10 mg–5 mg) every 5 days to 5 mg (1 mL)/day.ResultsTwenty patients with 24 aneurysms were classified as having a hyper-response to clopidogrel. Mean age was 55.2 years (range 42–64) and 80% were women. Mean baseline PRU value and the percentage of platelet inhibition were 16.4±11.5 PRU and 92.05±7.5%, respectively. The mean time used to decrease the dose of clopidogrel to 5 mg/day was 27±4.3 days. Modified dosing strategies were shown to increase the final PRU values and to decrease the percentage of platelet inhibition (137.42±27.4 and 41.5±14.8%, respectively). Two of the 20 patients with dose adjustment of oral solution of clopidogrel (5 mg/day) in our cohort exhibited a delayed conversion to hypo-response. No patients suffered thromboembolic events related to the dose adjustment of clopidogrel with 5 mg/day during the follow-up.ConclusionReduction of the daily maintenance dose of clopidogrel in hyper-responder patients could provide a similar antiplatelet effect to the standard dose of clopidogrel, allowing a PRU value in the optimal range.
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27
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Corliss BM, Polifka AJ, Harris NS, Hoh BL, Fox WC. Laboratory assessments of therapeutic platelet inhibition in endovascular neurosurgery: comparing results of the VerifyNow P2Y12 assay to thromboelastography with platelet mapping. J Neurosurg 2019; 129:1160-1165. [PMID: 29271717 DOI: 10.3171/2017.6.jns17535] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 06/05/2017] [Indexed: 12/24/2022]
Abstract
OBJECTIVEInhibition of platelet aggregation is vital to preventing thromboembolic complications related to stent placement in endovascular neurosurgery, but excessive inhibition potentiates hemorrhagic complications. Recent evidence suggests an ideal inhibition range of 70-150 P2Y12 response units (PRU) as measured on the VerifyNow assay, which relies on photometric measurements of platelet aggregation. Thromboelastography (TEG) with platelet mapping (PM) is an alternative assay that directly measures clot formation and mechanical strength. This study compares the results of PRU to TEG-PM.METHODSPatients with simultaneous or near-simultaneous PRU and TEG-PM results who underwent cervical carotid artery stenting, intracranial stent-assisted aneurysm coiling, or flow diversion at the authors' institution between August 2015 and November 2016 were identified. PRU results were compared with the TEG maximal amplitude (MA) attributable to adenosine diphosphate (ADP) activity (MA-ADP) as measured by TEG-PM. Platelet inhibition was considered therapeutic for MA-ADP values < 50 mm or PRU < 194. The Pearson correlation coefficient was calculated, and the sensitivity and specificity of PRU were calculated assuming that the results of TEG-PM reflected the true degree of platelet inhibition.RESULTSTwenty-three patients were identified with a total of 37 matched sets of TEG-PM and PRU. Three of these pairs were excluded due to anemia outside of the PRU manufacturer's recommended range. The Pearson correlation coefficient for these values was 0.50 (p = 0.0026). The prevalence of clopidogrel nonresponders determined by TEG-PM (9%) matched reported rates (5%-12%); PRU demonstrated much higher prevalence (39%). For detecting a therapeutic level of platelet inhibition, PRU demonstrated a sensitivity of 0.59, specificity of 0.50, positive predictive value of 0.95, and negative predictive value of 0.07. Ideal inhibition was concordant in only 25% of observations in which at least one of the results was ideal.CONCLUSIONSAgreement between TEG-PM and PRU regarding the degree of platelet inhibition is poor. PRU likely overestimates clopidogrel resistance, as 93% of patients with PRU > 194 demonstrate a therapeutic level of platelet inhibition on TEG.
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Affiliation(s)
| | | | - Neil S Harris
- 2Pathology, University of Florida, Gainesville, Florida
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28
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Pikis S, Mantziaris G, Mamalis V, Barkas K, Tsanis A, Lyra S, Karkoulias K, Petrosyan T, Archontakis E. Diffusion weighted image documented cerebral ischemia in the postprocedural period following pipeline embolization device with shield technology treatment of unruptured intracranial aneurysms: a prospective, single center study. J Neurointerv Surg 2019; 12:407-411. [DOI: 10.1136/neurintsurg-2019-015363] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 09/04/2019] [Accepted: 09/08/2019] [Indexed: 01/12/2023]
Abstract
ObjectiveAcute ischemic stroke and silent cerebral infarctions following pipeline embolization device (PED) treatment of intracranial aneurysms have been estimated to occur in 3–6% and in 50.9–90% of patients respectively. The PED with Shield technology (PED-Shield) incorporates a surface phosphorylcholine polymer to reduce the thrombogenicity of the implant. We sought to determine the incidence of diffusion weighted image (DWI) documented cerebral ischemia after PED-Shield treatment of unruptured intracranial aneurysms.MethodsThis prospective study involved a single center series of consecutive patients treated for an unruptured intracranial aneurysm with the PED-Shield. All participants underwent clinical evaluation on admission, after the procedure, at discharge, and 30 days following treatment. Brain MRI was obtained within 72 hours of the procedure. Ischemic lesions identified on DWI sequences where examined as to their number, size, and location in relation to the procedure.ResultsOver 12 months, 33 patients harboring 38 intracranial aneurysms were treated with the PED-Shield in 36 procedures. Neither mortality nor clinically evident ischemic events were noted in the 30 day postprocedural period. DWI documented, silent cerebral ischemia occurred in six patients (18.18%) after six procedures (16.66%). No statistically significant risk factors for postprocedural silent cerebral ischemia were identified.ConclusionWe demonstrated a reduced rate of silent cerebral infarcts following PED-Shield treatment of intracranial aneurysms than previously reported with other endovascular treatment modalities and with the previous device generations. Further research is necessary to evaluate our results and to identify methods to reduce the incidence of postprocedural cerebral ischemic events.
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29
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Podlasek A, Al Sultan AA, Assis Z, Kashani N, Goyal M, Almekhlafi MA. Outcome of intracranial flow diversion according to the antiplatelet regimen used: a systematic review and meta-analysis. J Neurointerv Surg 2019; 12:148-155. [DOI: 10.1136/neurintsurg-2019-014996] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 05/30/2019] [Accepted: 06/02/2019] [Indexed: 01/15/2023]
Abstract
BackgroundThromboembolic 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.ObjectiveTo explore contemporary evidence on the safety of emerging dual antiplatelet regimens in flow diverting stenting procedures.MethodsWe 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.ResultsOf 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).ConclusionsEvidence 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.
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30
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Ajadi E, Kabir S, Cook A, Grupke S, Alhajeri A, Fraser JF. Predictive value of platelet reactivity unit (PRU) value for thrombotic and hemorrhagic events during flow diversion procedures: a meta-analysis. J Neurointerv Surg 2019; 11:1123-1128. [PMID: 31005859 DOI: 10.1136/neurintsurg-2019-014765] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 03/26/2019] [Accepted: 03/28/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE Platelet function testing prior to flow diversion procedures, although initially heavily debated, has seen a substantial increase in its adoption to assess the risk of operative and perioperative thrombotic and hemorrhagic events. This meta-analysis was conducted to assess platelet function testing, particularly the VerifyNow Platelet Reactivity Unit (PRU) assay, for a relationship between the reported assay PRU value and thrombotic and hemorrhagic events. MATERIALS AND METHODS The currently available literature (2013-2018) was surveyed with PubMed and Google Scholar searches. Included studies were those for which there were at least 30 cases during the study period, for which VerifyNow platelet reactivity unit values were obtained prior to the procedures and for which intraoperative and perioperative adverse events were noted. PRU value cut-offs ranging from >200 to >240 comprised the hyporesponse group while values ranging from <60 to <70 comprised the hyper-response group. The data were subject to statistical analysis to assess the relationship between PRU values and thrombotic and hemorrhagic events. The collected data were subsequently statistically analyzed to assess for publication bias. RESULTS The searches yielded 27 studies, of which 12 met the inclusion criteria for the meta-analysis. The meta-analysis included data from 1464 reported Pipeline cases. The study included 273 men and 1177 women with a mean age across the analyzed procedures of 58 years (range 25-85). After loading with antiplatelet medications, preprocedural platelet hyper-responsiveness was associated with a greater incidence of hemorrhagic events with an increased absolute risk of 12%, but showed no relationship with thrombotic events. Preprocedural platelet hyporesponsiveness was associated with a greater incidence of thrombotic events with an absolute risk of 15%, but showed no relationship with hemorrhagic events. CONCLUSIONS VerifyNow PRU values that correspond to platelet hyporesponse or hyper-response to dual antiplatelet therapy are associated with a higher risk of thrombotic and hemorrhagic events, respectively. Thus, the PRU value may offer some predictive value for these events.
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Affiliation(s)
- Ebunoluwa Ajadi
- University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Shaowli Kabir
- Department of Statistics, College of Arts and Sciences, University of Kentucky, Lexington, Kentucky, USA
| | - Aaron Cook
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Stephen Grupke
- Department of Radiology, University of Kentucky, Lexington, KY, USA
| | - Abdulnasser Alhajeri
- Department of Neurology, University of Kentucky, Lexington, KY, USA.,Department of Radiology, University of Kentucky, Lexington, KY, USA
| | - Justin F Fraser
- Department of Neurology, University of Kentucky, Lexington, KY, USA.,Department of Neurological Surgery, University of Kentucky, Lexington, Kentucky, USA.,Department of Radiology, University of Kentucky, Lexington, KY, USA.,Department of Neuroscience, University of Kentucky, Lexington, KY, USA
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31
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Atallah E, Saad H, Li J, Kumar A, Tjoumakaris S, Chalouhi N, Hasan D, Zarzour H, Herial N, Gooch MR, Rosenwasser RH, Jabbour P. The Experience With Flow Diverters in the Treatment of Posterior Inferior Cerebellar Artery Aneurysms. Oper Neurosurg (Hagerstown) 2019; 17:8-13. [DOI: 10.1093/ons/opy301] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 09/12/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Elias Atallah
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Hassan Saad
- Department of Neurological Surgery, Arkansas Neuroscience Institute, CHI St. Vincent, Little Rock, Arkansas
| | - Jonathan Li
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Ayan Kumar
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Nohra Chalouhi
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - David Hasan
- Department of Neurological Surgery, Iowa University Hospital and Clinics, Iowa City, Iowa
| | - Hekmat Zarzour
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Nabeel Herial
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Michael Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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32
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Yi HJ, Hwang G, Lee BH. Variability of Platelet Reactivity on Antiplatelet Therapy in Neurointervention Procedure. J Korean Neurosurg Soc 2018; 62:3-9. [PMID: 30630291 PMCID: PMC6328804 DOI: 10.3340/jkns.2018.0151] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 08/01/2018] [Indexed: 12/11/2022] Open
Abstract
As more intracranial aneurysms and other cerebrovascular pathologies are treated with neurointervention procedure, thromboembolic events that frequently lead to serious neurological deficit or fatal outcomes are increasing. In order to prevent the thromboembolic events, antiplatelet therapy is used in most procedures including coil embolization, stenting, and flow diversion. However, because of variable individual pharmacodynamics responses to antiplatelet drugs, especially clopidogrel, it is difficult for clinicians to select the adequate antiplatelet regimen and its optimal dose. This article reviews the neurointervention literature related to antiplatelet therapy and suggests a strategy for tailoring antiplatelet therapy in individual patients undergoing neurointervention based on the results of platelet function testing.
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Affiliation(s)
- Ho Jun Yi
- Department of Neurosurgery, Hangang Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Gyojun Hwang
- Department of Neurosurgery, Hangang Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Byoung Hun Lee
- Department of Neurosurgery, Hangang Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
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33
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Foreman PM, Enriquez-Marulanda A, Mooney JH, Schmalz PGR, Griessenauer CJ, Deveikis JP, Harrigan MR. Whole blood aggregometry prior to Pipeline embolization device treatment of intracranial aneurysms: defining an optimal platelet inhibition cutoff value for clopidogrel. J Neurosurg 2018; 131:1437-1444. [PMID: 30497139 DOI: 10.3171/2018.6.jns181044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 06/11/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Dual antiplatelet therapy is required for the treatment of intracranial aneurysms with the Pipeline embolization device (PED). Platelet function testing (PFT) is often used to assess the efficacy of the antiplatelet regimen prior to PED placement. The optimal impedance values for whole blood aggregometry in this setting have not been defined. METHODS A retrospective review of a prospectively maintained database was performed for the years 2011-2015 to identify patients with intracranial aneurysms treated with the PED who underwent pretreatment PFT using whole blood aggregometry. Antiplatelet therapy was not altered based on PFT results; all patients remained on standard doses of aspirin and clopidogrel. Clinical, radiographic, and laboratory data were analyzed to identify the optimal cutoff impedance value for clopidogrel responsiveness using the receiver operating characteristic curve and Youden's index. RESULTS Forty-nine patients underwent 53 endovascular procedures for the treatment of 76 aneurysms using the PED. The majority of these aneurysms were located in the anterior circulation (90.8%) and affected the internal carotid artery (89.5%). Patients in 30 procedures (56.6%) were identified as clopidogrel responders based on the manufacturer cutoff value (< 6 Ω). Thromboembolic complications occurred in 13 (24.5%) procedures; patients in 6 (11.3%) cases were symptomatic and those in 3 (5.7%) cases had ischemic strokes. Eleven of the 13 (84.6%) thromboembolic complications occurred in clopidogrel nonresponders. An impedance value of ≥ 6 Ω was independently associated with thromboembolic complications. The optimal electrical impedance value was identified as ≥ 6 Ω (sensitivity 84.6%, specificity 70.0%, area under the curve 0.77) for identifying clopidogrel nonresponders. CONCLUSIONS Thromboembolic complications are more common following PED placement in patients who do not respond adequately to clopidogrel. Clopidogrel nonresponders can be identified using pretreatment whole blood aggregometry. The optimal cutoff value to categorize a patient as a clopidogrel nonresponder when using whole blood aggregometry is ≥ 6 Ω.
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Affiliation(s)
- Paul M Foreman
- 1Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | | | - James H Mooney
- 1Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Philip G R Schmalz
- 1Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Christoph J Griessenauer
- 3Department of Neurosurgery, Geisinger, Danville, Pennsylvania; and
- 4Department of Neurosurgery and
- 5Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - John P Deveikis
- 2Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Mark R Harrigan
- 2Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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34
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Abstract
Antiplatelet agents used to treat neurovascular disease include aspirin; P2Y12 receptor antagonists clopidogrel, prasugrel, and ticagrelor; ADP antagonist ticlopidine; phosphodiesterase inhibitor dipyridamole; and glycoprotein IIb/IIIa inhibitors abciximab, eptifibatide, and tirofiban. Numerous studies have been performed evaluating their efficacy in stroke, extracranial carotid artery disease and dissection, intracranial atherosclerotic disease, and moyamoya disease. The rapid technological advancements in endovascular neurosurgical devices have also made antiplatelet therapy a necessary part of treating intracranial aneurysms. This article presents the relevant data supporting the use of antiplatelet agents in vascular neurosurgery and recommendations based on the described studies.
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Affiliation(s)
- Amanda S Zakeri
- Department of Neurological Surgery, Ohio State University Medical Center, N-1014 Doan Hall, 410 West 10th Avenue, Columbus, OH 43210, USA
| | - Shahid M Nimjee
- Department of Neurological Surgery, Ohio State University Medical Center, N-1014 Doan Hall, 410 West 10th Avenue, Columbus, OH 43210, USA.
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35
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Kolumam Parameswaran P, Dai D, Ding YH, Urban MW, Manlove L, Sathish V, Cebral JR, Kallmes DF, Kadirvel R. Downstream vascular changes after flow-diverting device deployment in a rabbit model. J Neurointerv Surg 2018; 11:523-527. [PMID: 30415228 DOI: 10.1136/neurintsurg-2018-014123] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 10/05/2018] [Accepted: 10/20/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND Flow diverters (FDs) are increasingly used in the treatment of intracranial aneurysms, and carry the risk of thromboembolic complications, even in patients treated with dual antiplatelet therapy. The effect of FDs on the downstream vascular is unknown. The aim of the study was to investigate vascular wall pulse wave velocity (PWV) and contractility changes following FD treatment in a rabbit model. METHODS FDs (Pipeline Embolic Device, Medtronic Inc., Irvine, California, USA) were implanted in the aorta of normal rabbits and sham-operated aorta were used as controls (n=6 per group). Pulse wave imaging with ultra-fast ultrasound at 1600 frames per second (Vantage, Verasonics, Inc., Kirkland, WA) was performed in the vessel wall distal to FD prior to device implantation and at 8- week follow-up to measure the PWV. Force contraction vascular reactivity studies were conducted in the aortic rings using an organ bath. RESULTS The difference in mean PWV in the follow-up compared with pre-implantation was significantly higher in the distal vessels compared with sham controls (1.18 m/s [SD=0.54] vs. 0.37 m/s [SD=1.09], P=0.03). Conversely, the aortic segments distal to the FD exhibited a 55% increase in vascular contractility compared with proximal segments (P=0.002). We observed a significant positive correlation between mean PWV and mean vascular contractility. CONCLUSION Implantation of FD was associated with increased PWV and vascular contractility, suggesting that FD implantation causes changes to the vascular wall. Further studies are needed to understand the clinical implication of changes in vascular PWV and contractility.
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Affiliation(s)
| | - Daying Dai
- Applied Neuroradiology Research Laboratory, Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Yong-Hong Ding
- Applied Neuroradiology Research Laboratory, Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew W Urban
- Division of Radiology Research, Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Logan Manlove
- Pulmonary Cell Biology Laboratory, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Venkatachalem Sathish
- Department of Pharmaceutical Sciences, North Dakota State University, Fargo, North Dakota, USA
| | - Juan R Cebral
- Department of Bioengineering, George Mason University, Fairfax, Virginia, USA
| | - David F Kallmes
- Applied Neuroradiology Research Laboratory, Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ramanathan Kadirvel
- Applied Neuroradiology Research Laboratory, Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
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36
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DeGrote JR, Olafson EM, Drofa A, Kouznetzov E, Manchak M, Leedahl ND, Leedahl DD. Ticagrelor and Acetylsalicylic Acid after Placement of Pipeline Embolization Device for Cerebral Aneurysm: A Case Series. Can J Hosp Pharm 2018; 71:349-355. [PMID: 30626980 PMCID: PMC6306182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Dual antiplatelet therapy with acetylsalicylic acid (ASA) and a P2Y12-receptor antagonist is often used to prevent thrombotic complications after placement of a Pipeline embolization device (PED) for cerebral aneurysm. Although clopidogrel is common in this setting, high rates of nonresponse to this drug have made ticagrelor a potentially attractive alternative. OBJECTIVE To describe safety and efficacy outcomes for ticagrelor following PED placement, including measurement of platelet function. METHODS A retrospective analysis of data was completed for patients who underwent PED placement for cerebral aneurysm at a single centre between November 2015 and March 2017, with subsequent prescription of ticagrelor and ASA as dual antiplatelet therapy. The primary end point was any ischemic stroke or death within 1 year after the procedure. Intracranial hemorrhage was a secondary end point. Additionally, measurement of and values for platelet reactivity units (PRUs) during receipt of ticagrelor and ASA were evaluated. RESULTS A total of 29 patients were included in this retrospective study. One patient experienced ischemic stroke 226 days after placement of the PED. In addition, 3 patients died during the 1-year follow-up period for causes unrelated to stroke or bleeding complications. No cases of intracranial hemorrhage were observed. Samples for measurement of P2Y12 levels were drawn at the discretion of the neurointerventionalists, and the PRU value was measured at least once for 28 (97%) of the 29 patients. The mean number of PRU measurements per patient after initiation of ticagrelor was 2.1 (standard deviation [SD] 1). Mean PRU value after initiation of ticagrelor was 65 (SD 57). CONCLUSIONS In this case series describing the use of ticagrelor and ASA as dual antiplatelet therapy after PED placement for cerebral aneurysm, there was just one ischemic stroke, which occurred after the dual antiplatelet therapy had been discontinued. Further prospective trials are needed to describe the utility of ticagrelor use after PED placement, as well as its dosing and monitoring.
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Affiliation(s)
- Jodi R DeGrote
- , PharmD, BCCCP, is with Pharmacy Services, Sanford Medical Center, Fargo, North Dakota
| | - Elizabeth M Olafson
- , PharmD, is with Pharmacy Services, Sanford Medical Center, Fargo, North Dakota
| | - Alexander Drofa
- , MD, is with the Department of Surgery, University of North Dakota, Grand Forks, North Dakota, and the Department of Neurosurgery, Sanford Brain and Spine Institute, Fargo, North Dakota
| | - Evgueni Kouznetzov
- , MD, is with the Department of Neurosurgery, Sanford Brain and Spine Institute, Fargo, North Dakota
| | - Michael Manchak
- , MD, is with the Department of Neurosurgery, Sanford Brain and Spine Institute, Fargo, North Dakota
| | - Nathan D Leedahl
- , PharmD, BCPS, is with Pharmacy Services, Sanford Medical Center, Fargo, North Dakota
| | - David D Leedahl
- , PharmD, BCPS-AQ ID, BCCCP, is with Pharmacy Services, Sanford Medical Center, Fargo, North Dakota
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37
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Kim KS, Fraser JF, Grupke S, Cook AM. Management of antiplatelet therapy in patients undergoing neuroendovascular procedures. J Neurosurg 2018; 129:890-905. [DOI: 10.3171/2017.5.jns162307] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Neuroendovascular techniques for treating cerebral aneurysms and other cerebrovascular pathology are increasingly becoming the standard of care. Intraluminal stents, aneurysm coils, and other flow diversion devices typically require concomitant antiplatelet therapy to reduce thromboembolic complications. The variability inherent with the pharmacodynamic response to common antiplatelet agents such as aspirin and clopidogrel complicates optimal selection of antiplatelet agents by clinicians. This review serves to discuss the literature related to antiplatelet use in neuroendovascular procedures and provides recommendations for clinicians on how to approach patients with variable response to antiplatelet agents, particularly clopidogrel.
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Affiliation(s)
- Keri S. Kim
- 1Department of Pharmacy Practice, University of Illinois Medical Center at Chicago, Illinois
| | - Justin F. Fraser
- 2Departments of Neurological Surgery, Neurology, Radiology, and Anatomy and Neurobiology, Center for Advanced Translational Stroke Science
| | | | - Aaron M. Cook
- 4UK HealthCare; and
- 5University of Kentucky College of Pharmacy, Lexington, Kentucky
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38
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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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39
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Saber H, Kherallah RY, Hadied MO, Kazemlou S, Chamiraju P, Narayanan S. Antiplatelet therapy and the risk of ischemic and hemorrhagic complications associated with Pipeline embolization of cerebral aneurysms: a systematic review and pooled analysis. J Neurointerv Surg 2018; 11:362-366. [PMID: 30201813 DOI: 10.1136/neurintsurg-2018-014082] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 08/01/2018] [Accepted: 08/03/2018] [Indexed: 11/04/2022]
Abstract
BACKGROUND Pipeline embolization devices (PEDs) are increasingly used in the treatment of cerebral aneurysms. Yet, major ischemic or hemorrhagic complications after PED treatment associated with antiplatelet regimens are not well-established. OBJECTIVE To investigate the risk of ischemic and hemorrhagic complications associated with common antiplatelet regimens following PED treatment, and to examine whether platelet function testing (PFT) is associated with a lower risk of these complications. METHODS We searched Medline, Embase, and Cochrane from 2009 to 2017. Twenty-nine studies were included that had reported a uniform antiplatelet regimen protocol and had provided data on major ischemic and hemorrhagic complications following PED treatment. Random-effect meta-analysis was used to pool overall ischemic and hemorrhagic event rates across studies. The rate of these complications with respect to the antithrombotic regimen and PFT was assessed by χ2 proportional tests. RESULTS Overall, 2002 patients (age 55.9 years, 76% female) were included. A low-dose acetylsalicylic acid (ASA) regimen before and after PED treatment was associated with a higher rate of late ischemic complications than with high-dose ASA therapy (2.62 (95% CI 1.46 to 4.69) and 2.56 (1.41 to 4.64), respectively). Duration of post-procedure clopidogrel therapy <6 months was associated with greater rates of ischemic complications (1.56, 95% CI 1.11 to 2.20) than a clopidogrel regimen of ≥6 months. Performing PFT before PED treatment was not associated with the risk of ischemic complications (1.27, 95% CI 0.77 to 2.10). CONCLUSION High-dose ASA therapy and clopidogrel treatment for at least 6 months were associated with a reduced incidence of ischemic events, without affecting the risk of hemorrhagic events.
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Affiliation(s)
- Hamidreza Saber
- Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Riyad Y Kherallah
- Department of Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Mohamad O Hadied
- Department of Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | | | - Parthasarathi Chamiraju
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Sandra Narayanan
- Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan, USA.,Department of Neurosurgery, Wayne State University School of Medicine, Detroit, Michigan, USA
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Bender MT, Zarrin DA, Campos JK, Jiang B, Chandra A, Vo CD, Caplan JM, Huang J, Tamargo RJ, Lin LM, Colby GP, Coon AL. Precision of VerifyNow P2Y12 Assessment of Clopidogrel Response in Patients Undergoing Cerebral Aneurysm Flow Diversion. Neurosurgery 2018; 85:543-549. [DOI: 10.1093/neuros/nyy395] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 07/30/2018] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Dual antiplatelet therapy (DAT), most commonly with aspirin and Clopidogrel, is the standard of care for intracranial stenting, including flow diversion. Clopidogrel response varies by individual.
Objective
To investigate the real-world precision of VerifyNow P2Y12 assessment (Accumetrics, San Diego, California) of Clopidogrel response.
Methods
Using a prospectively-collected, IRB-approved cerebral aneurysm database 643 patients were identified who were treated with the Pipeline embolization device from 2011 to 2017. Patients with multiple P2Y12 assays drawn within a 24-h window were identified. A single patient could contribute multiple, independent sets. Levels drawn before a 5-d course of DAT and patients who received alternative antiplatelet agents were excluded. Therapeutic range was defined as platelet reaction units (PRU) 60–200.
Results
A total of 1586 P2Y12 measurements were recorded; 293 (46%) patients had more than one assay. One hundred forty (22%) patients had multiple P2Y12 measurements within 24 h. These patients accounted for 230 independent 24-h sets. The average P2Y12 fluctuation across all sets was 35 points; the 25th, 50th, and 75th percentiles were 12, 26, and 48 points, respectively. Of the 230 24-h sets of P2Y12 assays, 76% remained within their original therapeutic category: 100 (43%) all therapeutic, 54 (23%) all hypo-responsive, and 21 (9%) all hyper-responsive. Twenty-four percent of patients fluctuated between therapeutic categories when multiple P2Y12 assessments were drawn within a 24-h period: 29 (13%) between hypo-response and therapeutic, 23 (10%) between hyper-response and therapeutic, and 3 (1%) between hypo-response and hyper-response.
CONCLUSION
Our experience suggests P2Y12 is an often-imprecise measure, and this should be considered when utilizing P2Y12 levels for clinical decisions.
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Affiliation(s)
- Matthew T Bender
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - David A Zarrin
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jessica K Campos
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bowen Jiang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Arun Chandra
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Chau D Vo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Justin M Caplan
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Li-Mei Lin
- Department of Neurosurgery, University of California Irvine, Orange, California
| | - Geoffrey P Colby
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California
| | - Alexander L Coon
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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41
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Hydrophilic Stent Coating Inhibits Platelet Adhesion on Stent Surfaces: Initial Results In Vitro. Cardiovasc Intervent Radiol 2018; 41:1779-1785. [PMID: 30039502 PMCID: PMC6182755 DOI: 10.1007/s00270-018-2036-7] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 05/20/2018] [Indexed: 11/30/2022]
Abstract
Background Endovascular stents and flow diverter stents (FDS) have revolutionized the treatment of intradural aneurysms; however, the need for dual anti-platelet treatment (DAPT) limits their use and can cause additional issues. Therefore, there is a need to develop stent coatings that negate the need for DAPT. Methods Two different hydrophilic polymer coatings (HPC-I and HPC-II) were used to coat small nickel titanium plates to initially test the hydrophilic properties of these coatings when applied to nickel titanium. The plates were subsequently incubated with non-medicated whole blood from healthy volunteers for 10 min and stained with a CD61 immunofluorescent antibody that allows detection of adherent platelets. The coatings were applied to FDS wires and were again incubated with non-medicated whole blood from the same volunteers. Scanning electron microscopy was used to detect adherent platelets on the wire surface. Results The HPC-II coating (1.12 ± 0.4%) showed a significantly lower CD61 +ve cell count (p ≤ 0.001) compared to both uncoated NiTi plates (48.61 ± 7.3%) and those with the HPC-I coating (mean 40.19 ± 8.9%). Minimal adherent platelets were seen on the FDS nickel titanium wires coated with the HPC-II compared to uncoated FDS under electron microscopy. Conclusion There is a significant decrease in the number of adherent CD61 +ve platelets on nickel titanium surfaces coated with the HPC-II coating compared to uncoated surfaces. The coating can be successfully applied to the wires of flow diverters. The results of this study are promising with regard to the development of new anti-thrombogenic endovascular devices.
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Beydoun HA, Azarbaijani Y, Cheng H, Anderson-Smits C, Marinac-Dabic D. Predicting Successful Treatment of Intracranial Aneurysms with the Pipeline Embolization Device Through Meta-Regression. World Neurosurg 2018; 114:e938-e958. [DOI: 10.1016/j.wneu.2018.03.120] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 03/17/2018] [Accepted: 03/17/2018] [Indexed: 10/17/2022]
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43
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Jiang B, Bender MT, Westbroek EM, Campos JK, Lin LM, Xu R, Tamargo RJ, Huang J, Colby GP, Coon AL. Procedural complexity independent of P2Y12 reaction unit (PRU) values is associated with acute in situ thrombosis in Pipeline flow diversion of cerebral aneurysms. Stroke Vasc Neurol 2018; 3:169-175. [PMID: 30294473 PMCID: PMC6169609 DOI: 10.1136/svn-2018-000150] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 02/24/2018] [Indexed: 12/03/2022] Open
Abstract
Background Acute in situ thrombosis is an ischaemic phenomenon during Pipeline embolisation device (PED) procedures with potentially high morbidity and mortality. There is controversy regarding the role of platelet function testing with P2Y12 assay as a predictor of intraprocedural thromboembolic events. There is limited knowledge on whether procedural complexity influences these events. Methods Data were collected retrospectively on 742 consecutive PED cases at a single institution. Patients with intraprocedural acute thrombosis were compared with patients without these events. Results A cohort of 37 PED cases with acute in situ thrombosis (mean age 53.8 years, mean aneurysm size 8.4 mm) was matched with a cohort of 705 PED cases without intraprocedural thromboembolic events (mean age 56.4 years, mean aneurysm size 6.9 mm). All patients with in situ thrombosis received intra-arterial and/or intravenous abciximab. The two groups were evenly matched in patient demographics, previous treatment/subarachnoid hemorrhage (SAH) and aneurysm location. There was no statistical difference in postprocedural P2Y12 reaction unit (PRU) values between the two groups, with a mean of 156 in the in situ thrombosis group vs 148 in the control group (p=0.5894). Presence of cervical carotid tortuosity, high cavernous internal carotid artery grade, need for multiple PED and vasospasm were not significantly different between the two groups. The in situ thrombosis group had statistically significant longer fluoroscopy time (60.4 vs 38.4 min, p<0.0001), higher radiation exposure (3476 vs 2160 mGy, p<0.0001), higher rates of adjunctive coiling (24.3% vs 8.37%, p=0.0010) and higher utilisation of balloon angioplasty (37.8% vs 12.2%, p<0.0001). Clinically, the in situ thrombosis cohort had higher incidence of major and minor stroke, intracerebral haemorrhage and length of stay. Conclusions Predictors of procedural complexity (higher radiation exposure, longer fluoroscopy time, adjunctive coiling and need for balloon angioplasty) are associated with acute thrombotic events during PED placement, independent of PRU values.
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Affiliation(s)
- Bowen Jiang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Matthew T Bender
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Erick M Westbroek
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jessica K Campos
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Li-Mei Lin
- Department of Neurosurgery, University of California, Irvine School of Medicine, Orange, California, USA
| | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Geoffrey P Colby
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA
| | - Alexander L Coon
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Griessenauer CJ, Jain A, Enriquez-Marulanda A, Gupta R, Adeeb N, Moore JM, Grassi SA, Dalal SS, Ogilvy CS, Thomas AJ, Schirmer CM. Pharmacy-Mediated Antiplatelet Management Protocol Compared to One-time Platelet Function Testing Prior to Pipeline Embolization of Cerebral Aneurysms: A Propensity Score-Matched Cohort Study. Neurosurgery 2018; 84:673-679. [DOI: 10.1093/neuros/nyy091] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 02/22/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- Christoph J Griessenauer
- Department of Neurosurgery, Geisinger Health, Danville, Pennsylvania
- Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
- Department of Neurosurgery, Paracelsus Medical University, Salzburg, Austria
| | - Abhi Jain
- Department of Neurosurgery, Geisinger Health, Danville, Pennsylvania
- Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | | | - Raghav Gupta
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Nimer Adeeb
- Department of Neurosurgery, Louisiana State University, Shreveport, Louisiana
| | - Justin M Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Stacey A Grassi
- Department of Pharmacy, Geisinger Health, Danville, Pennsylvania
| | - Shamsher S Dalal
- Department of Radiology, Geisinger Health, Danville, Pennsylvania
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ajith J Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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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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Delgado Almandoz JE, Kayan Y, Tenreiro A, Wallace AN, Scholz JM, Fease JL, Milner AM, Mulder M, Uittenbogaard KM, Tenreiro-Picón O. Clinical and angiographic outcomes in patients with intracranial aneurysms treated with the pipeline embolization device: intra-procedural technical difficulties, major morbidity, and neurological mortality decrease significantly with increased operator experience in device deployment and patient management. Neuroradiology 2017; 59:1291-1299. [PMID: 28986614 DOI: 10.1007/s00234-017-1930-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 09/19/2017] [Indexed: 12/31/2022]
Abstract
PURPOSE Flow diversion constitutes a pivotal advancement in endovascular intracranial aneurysm treatment, but requires development of a new skill set. The aim of this study is to determine whether outcomes after treatment with the Pipeline Embolization Device improve with experience. METHODS We retrospectively reviewed all patients with intracranial aneurysms treated with Pipeline at two centers over a 4.5-year period. Baseline patient and aneurysm characteristics, complications, and angiographic outcomes were analyzed. RESULTS One hundred forty patients underwent 150 Pipeline procedures to treat 167 intracranial aneurysms during the study period, 109 women, mean age 55.4 years. One hundred twenty-six aneurysms were ICA, mean size 10.2 mm and mean neck 6.4 mm. Intra-procedural technical difficulties were higher during the first 75 procedures compared with the subsequent 75 (13.3 vs 2.7%; p = 0.03), as combined major morbidity and neurological mortality (14.7 vs 4%; p = 0.046). In multivariate regression analysis, increased operator experience with Pipeline remained an independent predictor of intra-procedural technical difficulties (p = 0.02, odds ratio (OR) 0.015, 95% CI 0.0004-0.55) and combined major morbidity and neurological mortality (p = 0.03, OR 0.16, 95% CI 0.03-0.84). At last follow-up, 123 aneurysms were completely occluded (81.5%, mean 24 months). In our cohort, age ≤ 53 years was an independent predictor of complete aneurysm occlusion at last follow-up (p = 0.001, OR 0.92, 95% CI 0.88-0.97). Five aneurysms were retreated (3.3%). CONCLUSION The Pipeline embolization device is an effective treatment for intracranial aneurysms. The risk of intra-procedural technical difficulties and combined major morbidity and neurological mortality decreases significantly with increased operator experience in Pipeline deployment and patient management.
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Affiliation(s)
- Josser E Delgado Almandoz
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, 800 E. 28th Street, Minneapolis, MN, 55407, USA.
| | - Yasha Kayan
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, 800 E. 28th Street, Minneapolis, MN, 55407, USA
| | - Andrea Tenreiro
- Division of Interventional Neuroradiology, Clínica El Ávila, Caracas, Venezuela
| | - Adam N Wallace
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, 800 E. 28th Street, Minneapolis, MN, 55407, USA
| | - Jill M Scholz
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, 800 E. 28th Street, Minneapolis, MN, 55407, USA
| | - Jennifer L Fease
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, 800 E. 28th Street, Minneapolis, MN, 55407, USA
| | - Anna M Milner
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, 800 E. 28th Street, Minneapolis, MN, 55407, USA
| | - Maximilian Mulder
- Division of Critical Care Medicine, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Kyle M Uittenbogaard
- Division of Neurological Surgery, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
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Olafson EM, DeGrote JR, Drofa A, Kouznetsov E, Manchak M, Leedahl ND, Leedahl DD. A Case Series of 18 Patients Receiving Ticagrelor After Carotid Stenting. J Pharm Pract 2017; 31:519-521. [DOI: 10.1177/0897190017729524] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Purpose: Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor antagonist is often used to prevent thrombotic complications after endovascular stent placement. Most of the published experience surrounding DAPT after carotid stenting is with clopidogrel. Ticagrelor may be a promising alternative, especially in patients who may be considered nonresponders to clopidogrel. However, clinical outcomes utilizing DAPT with ticagrelor in a cohort with carotid stenting is lacking. In this case series, we describe our experience with systematic prescribing of ticagrelor after carotid stent placement in 18 patients. Methods: A retrospective review of 18 patients prescribed ticagrelor who underwent carotid stenting between November 2015 and January 2017 was performed. All eligible patients were included in the review. The primary end point of interest was any ischemic stroke or death within 30 days following the procedure. Intracranial hemorrhage was a secondary end point. Results and Conclusions: No patients experienced the primary end point of ischemic stroke or death within 30 days. No intracranial hemorrhages were observed. The use of ticagrelor after carotid stenting may be a reasonable alternative to clopidogrel after carotid stent placement. Randomized trials to support our findings are needed.
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Affiliation(s)
| | | | - Alexander Drofa
- Department of Surgery, University of North Dakota, Grand Forks, ND, USA
- Department of Neurosurgery, Sanford Brain and Spine Institute, Fargo, ND, USA
| | - Evgueni Kouznetsov
- Department of Neurosurgery, Sanford Brain and Spine Institute, Fargo, ND, USA
| | - Michael Manchak
- Department of Neurosurgery, Sanford Brain and Spine Institute, Fargo, ND, USA
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Texakalidis P, Bekelis K, Atallah E, Tjoumakaris S, Rosenwasser RH, Jabbour P. Flow diversion with the pipeline embolization device for patients with intracranial aneurysms and antiplatelet therapy: A systematic literature review. Clin Neurol Neurosurg 2017; 161:78-87. [PMID: 28863286 DOI: 10.1016/j.clineuro.2017.08.003] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 08/01/2017] [Accepted: 08/07/2017] [Indexed: 11/17/2022]
Abstract
Flow diversion with the Pipeline Embolization Device (PED) is reported as a safe and efficient treatment for patients with intracranial aneurysms; however, literature discussing the antiplatelet (APT) regimen used before and after the PED is limited. Our aim was to systematically review and summarize available data regarding the APT regimen and the platelet function test (PFT) that was used. We also sought to provide an overview of the aneurysm morphologies and adverse event rates associated with the PED use. This systematic review was conducted according to the PRISMA statement and eligible studies were identified through search of the PubMed and Cochrane databases. We reviewed 28 studies, involving 1556 patients that underwent aneurysm treatment with the PED. The preprocedural aspirin (ASA) 300- 325mg (2-14days) combined with clopidogrel 75mg (3 to >10days) were used as a treatment strategy in 61.7% of patients and ASA 81mg with clopidogrel 75mg for 5-10days for 27%. Patients who received low versus high dose pre-PED ASA, were at less risk for a hemorrhagic event (0.7% versus 3.3%, p=0.053); however no statistical significance was reached. There was also lack of relationship between patients that received low versus high preprocedural ASA in terms of thromboembolic events. Regarding postprocedural APT, ASA (>6months) and clopidogrel (3- 12 months) was the regimen of choice for 93% of patients. Most studies conducted at least one PFT, most common being the VerifyNow. The most frequently reported target P2Y12 Reaction unit (PRU) and Aspirin Reaction Unit (ARU) values were <230 and <550 respectively. There was no statistically demonstrable difference in regards to thrombotic events between centers that conducted at least one PFT and centers that did not test their patients with a PFT. The overall rates of symptomatic thrombotic episodes were 6.6% and hemorrhagic were 3%. The pre- and post-PED APT dose and duration varies across different institutions. More prospective studies are needed to compare the efficacy of different APT agents and reach conclusions regarding use of PFT and platelet reaction values in order to decrease hemorrhagic and thromboembolic complications associated with the PED.
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Affiliation(s)
- Pavlos Texakalidis
- School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Kimon Bekelis
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Elias Atallah
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Stavropoula Tjoumakaris
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA.
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Marosfoi M, Clarencon F, Langan ET, King RM, Brooks OW, Tamura T, Wainwright JM, Gounis MJ, Vedantham S, Puri AS. Acute thrombus formation on phosphorilcholine surface modified flow diverters. J Neurointerv Surg 2017; 10:406-411. [PMID: 28689183 PMCID: PMC5869458 DOI: 10.1136/neurintsurg-2017-013175] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 05/25/2017] [Accepted: 05/26/2017] [Indexed: 12/22/2022]
Abstract
Purpose Thromboembolic complications remain a limitation of flow diverting stents. We hypothesize that phosphorilcholine surface modified flow diverters (Pipeline Flex with Shield Technology, sPED) would have less acute thrombus formation on the device surface compared with the classic Pipeline Embolization device (cPED). Methods Elastase-induced aneurysms were created in 40 rabbits and randomly assigned to receive cPED or sPED devices with and without dual antiplatelet therapy (DAPT) (four groups, n=10/group). Angioplasty was performed to enhance apposition and create intimal injury for a pro-thrombotic environment. Both before and after angioplasty, the flow diverter was imaged with intravascular optical coherence tomography. The outcome measure was the number of predefined segments along the implant relative to the location of the aneurysm with a minimum of 0 (no clot formation) and maximum of 3 (all segments with thrombus). Clot formation over the device at ostia of branch arteries was assessed as either present or absent. Results Following angioplasty, the number of flow diverter segments with clots was significantly associated with the flow diverter (p<0.0001), but not with DAPT (p=0.3872) or aneurysm neck size (p=0.8555). The incidence rate for clots with cPED was 1.72 times more than with sPED. The clots on the flow diverter at the location corresponding to side branch ostia was significantly lower with sPED than with cPED (OR 0.180; 95% CI 0.044 to 0.734; p=0.0168), but was not associated with DAPT (p=0.3198). Conclusion In the rabbit model, phosphorilcholine surface modified flow diverters are associated with less thrombus formation on the surface of the device.
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Affiliation(s)
- Miklos Marosfoi
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Frederic Clarencon
- Department of Interventional Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Erin T Langan
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Robert M King
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Olivia W Brooks
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Takamisu Tamura
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - John M Wainwright
- Research and Development, Medtronic Neurovascular, Irvine, California, USA
| | - Matthew J Gounis
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Srinivasan Vedantham
- Department of Medical Imaging, The University of Arizona - Banner University Medical Center, Tucson, Arizona, USA
| | - Ajit S Puri
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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Adeeb N, Griessenauer CJ, Foreman PM, Moore JM, Shallwani H, Motiei-Langroudi R, Alturki A, Siddiqui AH, Levy EI, Harrigan MR, Ogilvy CS, Thomas AJ. Use of Platelet Function Testing Before Pipeline Embolization Device Placement. Stroke 2017; 48:1322-1330. [DOI: 10.1161/strokeaha.116.015308] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 02/10/2017] [Accepted: 02/20/2017] [Indexed: 12/24/2022]
Abstract
Background and Purpose—
Thromboembolic complications constitute a significant source of morbidity after neurointerventional procedures. Flow diversion using the pipeline embolization device for the treatment of intracranial aneurysms necessitates the use of dual antiplatelet therapy to reduce this risk. The use of platelet function testing before pipeline embolization device placement remains controversial.
Methods—
A retrospective review of prospectively maintained databases at 3 academic institutions was performed from the years 2009 to 2016 to identify patients with intracranial aneurysms treated with pipeline embolization device placement. Clinical and radiographic data were analyzed with emphasis on thromboembolic complications and clopidogrel responsiveness.
Results—
A total of 402 patients underwent 414 pipeline embolization device procedures for the treatment of 465 intracranial aneurysms. Thromboembolic complications were encountered in 9.2% of procedures and were symptomatic in 5.6%. Clopidogrel nonresponders experienced a significantly higher rate of thromboembolic complications compared with clopidogrel responders (17.4% versus 5.6%). This risk was significantly lower in nonresponders who were switched to ticagrelor when compared with patients who remained on clopidogrel (2.7% versus 24.4%). In patients who remained on clopidogrel, the rate of thromboembolic complications was significantly lower in those who received a clopidogrel boost within 24 hours pre-procedure when compared with those who did not (9.8% versus 51.9%). There was no significant difference in the rate of hemorrhagic complications between groups.
Conclusions—
Clopidogrel nonresponders experienced a significantly higher rate of thromboembolic complications when compared with clopidogrel responders. However, this risk seems to be mitigated in nonresponders who were switched to ticagrelor or received a clopidogrel boost within 24 hours pre-procedure.
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Affiliation(s)
- Nimer Adeeb
- From the Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (N.A., C.J.G., J.M.M., R.M.-L., A.A., C.S.O., A.J.T.); Department of Neurosurgery, University of Alabama at Birmingham (P.M.F., M.R.H.); and Department of Neurosurgery, State University of New York at Buffalo (H.S., A.H.S., E.I.L.)
| | - Christoph J. Griessenauer
- From the Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (N.A., C.J.G., J.M.M., R.M.-L., A.A., C.S.O., A.J.T.); Department of Neurosurgery, University of Alabama at Birmingham (P.M.F., M.R.H.); and Department of Neurosurgery, State University of New York at Buffalo (H.S., A.H.S., E.I.L.)
| | - Paul M. Foreman
- From the Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (N.A., C.J.G., J.M.M., R.M.-L., A.A., C.S.O., A.J.T.); Department of Neurosurgery, University of Alabama at Birmingham (P.M.F., M.R.H.); and Department of Neurosurgery, State University of New York at Buffalo (H.S., A.H.S., E.I.L.)
| | - Justin M. Moore
- From the Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (N.A., C.J.G., J.M.M., R.M.-L., A.A., C.S.O., A.J.T.); Department of Neurosurgery, University of Alabama at Birmingham (P.M.F., M.R.H.); and Department of Neurosurgery, State University of New York at Buffalo (H.S., A.H.S., E.I.L.)
| | - Hussain Shallwani
- From the Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (N.A., C.J.G., J.M.M., R.M.-L., A.A., C.S.O., A.J.T.); Department of Neurosurgery, University of Alabama at Birmingham (P.M.F., M.R.H.); and Department of Neurosurgery, State University of New York at Buffalo (H.S., A.H.S., E.I.L.)
| | - Rouzbeh Motiei-Langroudi
- From the Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (N.A., C.J.G., J.M.M., R.M.-L., A.A., C.S.O., A.J.T.); Department of Neurosurgery, University of Alabama at Birmingham (P.M.F., M.R.H.); and Department of Neurosurgery, State University of New York at Buffalo (H.S., A.H.S., E.I.L.)
| | - Abdulrahman Alturki
- From the Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (N.A., C.J.G., J.M.M., R.M.-L., A.A., C.S.O., A.J.T.); Department of Neurosurgery, University of Alabama at Birmingham (P.M.F., M.R.H.); and Department of Neurosurgery, State University of New York at Buffalo (H.S., A.H.S., E.I.L.)
| | - Adnan H. Siddiqui
- From the Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (N.A., C.J.G., J.M.M., R.M.-L., A.A., C.S.O., A.J.T.); Department of Neurosurgery, University of Alabama at Birmingham (P.M.F., M.R.H.); and Department of Neurosurgery, State University of New York at Buffalo (H.S., A.H.S., E.I.L.)
| | - Elad I. Levy
- From the Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (N.A., C.J.G., J.M.M., R.M.-L., A.A., C.S.O., A.J.T.); Department of Neurosurgery, University of Alabama at Birmingham (P.M.F., M.R.H.); and Department of Neurosurgery, State University of New York at Buffalo (H.S., A.H.S., E.I.L.)
| | - Mark R. Harrigan
- From the Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (N.A., C.J.G., J.M.M., R.M.-L., A.A., C.S.O., A.J.T.); Department of Neurosurgery, University of Alabama at Birmingham (P.M.F., M.R.H.); and Department of Neurosurgery, State University of New York at Buffalo (H.S., A.H.S., E.I.L.)
| | - Christopher S. Ogilvy
- From the Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (N.A., C.J.G., J.M.M., R.M.-L., A.A., C.S.O., A.J.T.); Department of Neurosurgery, University of Alabama at Birmingham (P.M.F., M.R.H.); and Department of Neurosurgery, State University of New York at Buffalo (H.S., A.H.S., E.I.L.)
| | - Ajith J. Thomas
- From the Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (N.A., C.J.G., J.M.M., R.M.-L., A.A., C.S.O., A.J.T.); Department of Neurosurgery, University of Alabama at Birmingham (P.M.F., M.R.H.); and Department of Neurosurgery, State University of New York at Buffalo (H.S., A.H.S., E.I.L.)
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