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Murali Krishnam Raju P, Shyamala P, Venkata Narayana B, Kondra S, Mantena BPV. Assay of tirofiban and identification of oxidative impurity in aqueous injection by using UPLC-PDA/QDa detectors. ANNALES PHARMACEUTIQUES FRANÇAISES 2021; 80:35-47. [PMID: 34153240 DOI: 10.1016/j.pharma.2021.06.002] [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: 12/23/2020] [Revised: 06/08/2021] [Accepted: 06/14/2021] [Indexed: 11/19/2022]
Abstract
The basic objective of this study is to propose a short, reliable, mass compatible ultra-performance liquid chromatography (UPLC) method to confirm the identity of impurities and to estimate the assay and purity of Tirofiban simultaneously in aqueous injection (5mg/100mL bag). Aqueous formulations are susceptible to oxidation, hence the possible oxidative degradation impurities of Tirofiban were studied in this experiment by using UPLC coupled with photodiode array/Quadrupole Dalton Analyzer (PDA/QDa) detectors. The required separations were achieved in the column: ACQUITY HSS T3 (100×2.1) mm, 1.7μm, operated at 30°C by using 0.02% Triethyl amine (TEA) in water, pH 2.8 with formic acid as solution-A and 0.1% formic acid in 9:1 acetonitrile, water as solution-B. Binary gradient flow is delivered at the rate of 0.5mL/min and the detection of impurities specifically carried out at 227nm using empower3 software. RP-UPLC/PDA with QDa detector was used for the experiment. The method was linear and accurate from the concentrations: 0.04 to 0.38μg/mL for impurity-A and 0.04 to 75μg/mL for Tirofiban. The major unknown degradation impurity generated during the oxidative degradation has been identified as N-oxide derivative (Impurity-B) [(M+H)+ 455.1] by using QDa detector operated in an electro spray positive ion mode by applying a voltage of 0.8kV. This method was further validated as per ICH Q2 (R2) guidelines. Hence, the proposed method is said to be a fast, sensitive and comprehensive technique, which could give a clear idea about the assay and impurity profile of Tirofiban injection.
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Affiliation(s)
- P Murali Krishnam Raju
- Department of Physical, Nuclear Chemistry & Chemical Oceanography, School of Chemistry, Andhra University, Visakhapatnam, 530003 Andhra Pradesh, India; Aurobindo Pharma Limited, Bachupally, R.R District, Hyderabad, 500090 Telangana, India
| | - P Shyamala
- Department of Physical, Nuclear Chemistry & Chemical Oceanography, School of Chemistry, Andhra University, Visakhapatnam, 530003 Andhra Pradesh, India.
| | - B Venkata Narayana
- Aurobindo Pharma Limited, Bachupally, R.R District, Hyderabad, 500090 Telangana, India
| | - S Kondra
- Aurobindo Pharma Limited, Bachupally, R.R District, Hyderabad, 500090 Telangana, India
| | - B P V Mantena
- Aurobindo Pharma Limited, Bachupally, R.R District, Hyderabad, 500090 Telangana, India
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Albanna W, Merkelbach L, Schubert GA, Stoppe C, Heussen N, Riabikin A, Wiesmann M, Blume C, Jablawi F, Schiefer J, Clusmann H, Neuloh G. Risk of postprocedural intracerebral hemorrhage in patients with ruptured cerebral aneurysms after treatment with antiplatelet agents. J Neurol Sci 2020; 420:117219. [PMID: 33162063 DOI: 10.1016/j.jns.2020.117219] [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: 07/31/2020] [Revised: 10/29/2020] [Accepted: 11/02/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Endovascular treatment of ruptured cerebral aneurysms frequently requires antiplatelet medication to prevent thromboembolism. This might raise concern regarding the risk of postprocedural hemorrhage (pH), e.g. from placement of intracranial probes. We explored the risk of PH associated with standard antiplatelet therapy (sAP: acetylsalicylic acid, and/or clopidogrel) in the context of aneurysmal subarachnoid hemorrhage (aSAH). METHODS We retrospectively reviewed a total of 146 consecutive cases with cerebral aneurysms treated between 1/2011-12/2015, and distinguished between minor (0.5 cm3) - 4 cm3) or major (> 4 cm3) PH occurring within four weeks after intervention. A separate analysis included hemorrhages related to placement of intracranial probes and drainages in the subgroup of 99 cases with such surgical interventions (pPH). Clinical outcome was assessed via Glasgow Outcome Scale (GOS) twelve months after aSAH. RESULTS A total of 49 cases (33.6%) in the overall sample sustained PH, there were 19 cases of pPH. Multifactorial analyses yielded sAP as an independent predictor for minor, but not major PH (p < 0.001 vs. p = 0.829), with comparable results for pPH (p = 0.001 vs. p = 0.184). sAP did not influence the clinical outcome in either group. CONCLUSIONS sAP was associated with a higher rate of minor PH and, more specifically, of minor pPH. However, it was neither accompanied by the occurrence of major hemorrhages nor by unfavorable clinical outcome. Future prospective studies should confirm these observations and hemorrhage risks associated with extended anticoagulation regimes after complex interventions and intra-arterial vasospasm therapy should be explored in order to facilitate interdisciplinary decision-making in aSAH.
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Affiliation(s)
- Walid Albanna
- Department of Neurosurgery, RWTH Aachen University, Germany.
| | | | | | - Christian Stoppe
- Department of Intensive Care Medicine and Intermediate Care, RWTH Aachen University, Germany
| | - Nicole Heussen
- Department of Medical Statistics, RWTH Aachen University, Germany; Medical School, Sigmund Freud Private University, Vienna, Austria
| | - Alexander Riabikin
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Germany
| | - Martin Wiesmann
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Germany
| | | | - Fidaa Jablawi
- Department of Neurosurgery, Justus-Liebig-University, Giessen, Germany
| | | | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University, Germany
| | - Georg Neuloh
- Department of Neurosurgery, RWTH Aachen University, Germany
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Dornbos D, Katz JS, Youssef P, Powers CJ, Nimjee SM. Glycoprotein IIb/IIIa Inhibitors in Prevention and Rescue Treatment of Thromboembolic Complications During Endovascular Embolization of Intracranial Aneurysms. Neurosurgery 2019; 82:268-277. [PMID: 28472526 DOI: 10.1093/neuros/nyx170] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 03/10/2017] [Indexed: 11/13/2022] Open
Abstract
Thromboembolic complications remain a major risk of endovascular neurosurgery during the treatment of intracranial aneurysms, despite the use of therapeutic heparinization and oral antiplatelet therapy when indicated. Glycoprotein (GP) IIb/IIIa inhibitors target a nonredundant pathway of platelet aggregation following adhesion and activation. Initially established and implemented in the cardiovascular arena, this drug class has provided a new tool in the neurovascular armamentarium as well. Numerous case reports, case series, and retrospective reviews have evaluated the safety and efficacy of abciximab, eptifibatide, and tirofiban in the treatment of acute thromboembolic complications during the endovascular treatment of intracranial aneurysms. The use of this drug class has also been found to be beneficial as a prophylactic agent, providing ischemia protection during the placement of intracranial stents, flow diverters, and thrombogenic coils in the setting of subarachnoid hemorrhage and during elective aneurysmal embolization. While the current published literature clearly establishes efficacy and safety of GP IIb/IIIa inhibitors in the prevention of thromboembolic complications, there does not yet exist an established protocol for their administration in endovascular neurosurgery. This review provides a comprehensive evaluation of the current published literature pertaining to the use of all available GP IIb/IIIa inhibitors for thromboembolic complications, providing recommendations for dosing and administration of abciximab, eptifibatide, and tirofiban based on previously published rates of efficacy and intracranial hemorrhage.
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Affiliation(s)
- David Dornbos
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Joel S Katz
- Department of Neurological Surgery, OhioHealth Grant and Riverside Medical Center, Columbus, Ohio
| | - Patrick Youssef
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ciarán J Powers
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Shahid M Nimjee
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Yoon CH, Lee HW, Kim YS, Lee SW, Yeom JA, Roh J, Baik SK. Preliminary Study of Tirofiban Infusion in Coil Embolization of Ruptured Intracranial Aneurysms. Neurosurgery 2018; 82:76-84. [PMID: 28419294 DOI: 10.1093/neuros/nyx177] [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: 06/27/2016] [Accepted: 03/15/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND There have been some reports on the use of intra-arterial tirofiban in ruptured intracranial aneurysms, but few studies have reported on the use of 24 h of intravenous tirofiban infusion in patients with subarachnoid hemorrhage. OBJECTIVE To present our experience with intravenous tirofiban infusion, in the form of a monotherapy as well as in addition to intra-arterial tirofiban, as a prophylactic, and as a rescue management for thrombus in patients who have undergone embolization with coils for ruptured intracranial aneurysms. METHODS Between December 2008 and January 2015, we retrospectively reviewed 249 ruptured intracranial aneurysms that were treated with coiling at our institutions. A total of 28 patients harboring 28 ruptured and 3 unruptured intracranial aneurysms underwent intravenous tirofiban infusion during or after coil embolization of an aneurysm. Intra-arterial infusion of tirofiban via a microcatheter was also performed in 26 patients. RESULTS Thromboembolic formation during the procedure was detected in 25 cases. Intra-arterial tirofiban dissolved the thromboembolus under angiographic control after 10 or more minutes in 19 (76%) of 25 patients. Two intracranial hemorrhagic complications (increase in the extent of hematoma) occurred during the follow-up period. Two cases of other complications occurred: hematuria and perioral bleeding. CONCLUSION Intravenous tirofiban, as a monotherapy or in addition to intra-arterial tirofiban for thrombotic complications, seems to be useful as a treatment for acute aneurysm. However, alternatives to tirofiban should be considered if an associated hematoma is discovered before a patient receives a tirofiban infusion.
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Affiliation(s)
- Chang Hyo Yoon
- Department of Neurology, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Ho-Won Lee
- Department of Neurology, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Young Soo Kim
- Department of Neurosur-gery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Sang Won Lee
- Department of Neurosur-gery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Jeong A Yeom
- Department of Radiology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Jieun Roh
- Department of Radiology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Seung Kug Baik
- Department of Radiology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
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Kim SH, Kim TG, Kong MH. Intra-arterial and Intravenous Tirofiban Infusion for Thromboembolism during Endovascular Coil Embolization of Cerebral Aneurysm. J Korean Neurosurg Soc 2017; 60:518-526. [PMID: 28881114 PMCID: PMC5594625 DOI: 10.3340/jkns.2016.1212.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 02/22/2017] [Accepted: 04/11/2017] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Thromboembolism is the one of the most serious complications that can occur during endovascular coil embolization of cerebral aneurysm. We report on the effectiveness and safety of intra-arterial/intravenous (IA/IV) glycoprotein IIb/IIIa inhibitor (tirofiban) infusion for treating thromboembolism during endovascular coil embolization of cerebral aneurysm. METHODS We performed a retrospective analysis of 242 patients with ruptured or unruptured cerebral aneurysms (n=264) who underwent endovascular coil embolization from January 2011 to June 2014. Thromboembolism occurred in 20 patients (7.4%), including 14 cases of ruptured aneurysms and 6 cases of unruptured aneurysms. The most common site of aneurysms was the anterior communicating artery (n=8), followed by middle cerebral artery (n=6). When we found an enlarged thromboembolism during coil embolization, we tried to dissolve it using tirofiban administered via IA and IV loading (5 μg/kg, respectively) for 3-5 minutes followed by IV maintenance (0.08 μg/kg/min) for approximately 4-24 hours. RESULTS In 4 of 5 patients with total vessel occlusion, the vessel was recanalized to Thrombolysis in Cerebral Infarction Perfusion Scale (TICI) grade 3, and in 1 patient to TICI grade 2a. In 2 patients with partial vessel occlusion and 13 patients with minimal occlusion, the vessel recanalized to TICI grade 3. Irrelevant intracerebral hemorrhage was noted in 1 patient (5%), and thromboemboli-related cerebral infarction developed in 5 patients (25%), of which only 1 (5%) was symptomatic. CONCLUSION IA/IV infusion and IV maintenance with tirofiban appear to be an effective rescue treatment for thromboembolism during endovascular coil embolization in patients with ruptured or unruptured cerebral aneurysms.
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Affiliation(s)
- Sang Heum Kim
- Department of Neuroradiology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Tae Gon Kim
- Department of Neurosurgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Min Ho Kong
- Department of Neurosurgery, Seoul Medical Center, Seoul, Korea
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Kim MS, Jo KI, Yeon JY, Kim JS, Kim KH, Jeon P, Hong SC. Association between Postprocedural Infarction and Antiplatelet Drug Resistance after Coiling for Unruptured Intracranial Aneurysms. AJNR Am J Neuroradiol 2016; 37:1099-105. [PMID: 27056423 DOI: 10.3174/ajnr.a4777] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 11/19/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND PURPOSE Procedure-related thromboembolism is a major limitation of coil embolization, but the relationship between thromboembolic infarction and antiplatelet resistance is poorly understood. The purpose of this study was to verify the association between immediate postprocedural thromboembolic infarction and antiplatelet drug resistance after endovascular coil embolization for unruptured intracranial aneurysm. MATERIALS AND METHODS This study included 338 aneurysms between October 2012 and March 2015. All patients underwent postprocedural MR imaging within 48 hours after endovascular coil embolization. Antiplatelet drug resistance was checked a day before the procedure by using the VerifyNow system. Abnormal antiplatelet response was defined as >550 aspirin response units and >240 P2Y12 receptor reaction units. In addition, we explored the optimal cutoff values of aspirin response units and P2Y12 receptor reaction units. The primary outcome was radiologic infarction based on postprocedural MR imaging. RESULTS Among 338 unruptured intracranial aneurysms, 134 (39.6%) showed diffusion-positive lesions on postprocedural MR imaging, and 32 (9.5%) and 105 (31.1%) had abnormal aspirin response unit and P2Y12 receptor reaction unit values, respectively. Radiologic infarction was associated with advanced age (65 years and older, P = .024) only with defined abnormal antiplatelet response (aspirin response units ≥ 550, P2Y12 receptor reaction units ≥ 240). P2Y12 receptor reaction unit values in the top 10th percentile (>294) were associated with radiologic infarction (P = .003). With this cutoff value, age (adjusted odds ratio, 2.29; 95% confidence interval, 1.28-4.08), P2Y12 receptor reaction units (>294; OR, 3.43; 95% CI, 1.53-7.71), and hyperlipidemia (OR, 2.05; 95% CI, 1.04-4.02) were associated with radiologic infarction in multivariate analysis. CONCLUSIONS Radiologic infarction after coiling for unruptured aneurysm was closely associated with age. Only very high P2Y12 receptor reaction unit values (>294) predicted postprocedural infarction. Further controlled studies are needed to determine the precise cutoff values, which could provide information regarding the optimal antiplatelet regimen for aneurysm coiling.
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Affiliation(s)
- M S Kim
- From the Departments of Neurosurgery (M.S.K., J.Y.Y., J.S.K., S.C.H.)
| | - K I Jo
- Department of Neurosurgery (K.I.J.), Hana General Hospital, Cheongju, Korea
| | - J Y Yeon
- From the Departments of Neurosurgery (M.S.K., J.Y.Y., J.S.K., S.C.H.)
| | - J S Kim
- From the Departments of Neurosurgery (M.S.K., J.Y.Y., J.S.K., S.C.H.)
| | - K H Kim
- Radiology (K.H.K., P.J.), Division of Interventional Neuroradiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - P Jeon
- Radiology (K.H.K., P.J.), Division of Interventional Neuroradiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - S C Hong
- From the Departments of Neurosurgery (M.S.K., J.Y.Y., J.S.K., S.C.H.)
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Feng L, Liu J, Liu Y, Chen J, Su C, Lv C, Wei Y. Tirofiban combined with urokinase selective intra-arterial thrombolysis for the treatment of middle cerebral artery occlusion. Exp Ther Med 2016; 11:1011-1016. [PMID: 26998029 DOI: 10.3892/etm.2016.2995] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 06/24/2015] [Indexed: 01/18/2023] Open
Abstract
The aims of the present study were to establish a model of embolic stroke in rabbits and to evaluate the efficacy and safety of intra-arterially administered tirofiban combined with urokinase thrombolysis. The middle cerebral artery occlusion model (MCAO) of embolic stroke was established in New Zealand rabbits via an autologous clot. The model rabbits were allocated at random into four groups: Tirofiban group (T group), urokinase group (UK group), tirofiban and urokinase group (T + UK group) and the control group (C group). The recanalization rate, relative-apparent diffusion coefficient (rADC) and neurological function deficit score (NFDS) values were compared among the four groups. The recanalization rate, rADC and NFDS values were improved in the T + UK group compared with the other groups. In summary, the intra-arterial administration of tirofiban combined with urokinase thrombolysis was a more effective intervention in an MCAO model compared with intra-arterial urokinase alone, and may promote reperfusion and reduce infarct volume.
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Affiliation(s)
- Lei Feng
- Department of Neurovascular Surgery, Jining No. 1 People's Hospital, Jining, Shandong 272111, P.R. China
| | - Jun Liu
- Department of Neurovascular Surgery, Jining No. 1 People's Hospital, Jining, Shandong 272111, P.R. China
| | - Yunzhen Liu
- Department of Neurovascular Surgery, Jining No. 1 People's Hospital, Jining, Shandong 272111, P.R. China
| | - Jian Chen
- Department of Neurovascular Surgery, Jining No. 1 People's Hospital, Jining, Shandong 272111, P.R. China
| | - Chunhai Su
- Department of Neurovascular Surgery, Jining No. 1 People's Hospital, Jining, Shandong 272111, P.R. China
| | - Chuanfeng Lv
- Department of Clinical Pharmacy, Jining No. 1 People's Hospital, Jining, Shandong 272111, P.R. China
| | - Yuzhen Wei
- Department of Neurovascular Surgery, Jining No. 1 People's Hospital, Jining, Shandong 272111, P.R. China
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Gentric JC, Brisson J, Batista AL, Ghostine J, Raymond J, Roy D, Weill A. Safety of Abciximab injection during endovascular treatment of ruptured aneurysms. Interv Neuroradiol 2015; 21:332-6. [PMID: 25964436 DOI: 10.1177/1591019915582001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND AND PURPOSE We aimed to determine the safety of intra-arterial Abciximab injection in the management of thromboembolic complications during endovascular treatment of ruptured cerebral aneurysms. METHODS In a monocentric consecutive series of endovascular treatment of 783 ruptured aneurysms, 42 (5.3%) patients received Abciximab after the aneurysm was secured. Bleeding complications were registered and dichotomized as follows: new intracranial hemorrhage and peripheral bleeding. For each patient, World Federation of Neurosurgery (WFNS) subarachnoid hemorrhage (SAH) grade, shunting, and clinical outcomes in the post-operative period and at 3-6 months were recorded. RESULTS SAH WFNS grades were as follows: grade I n = 14, grade II n = 10, grade III n = 11, grade IV n = 4, grade V n = 3. Ten patients had intracranial hematoma additionally to the SAH prior to embolization. Four patients (9.5%) presented more blood on the post-embolization CT but only one suffered a new clinically relevant intracranial hemorrhage. Two patients (4.8%) experienced significant peripheral bleeding but none were associated with long-term disabilities. Fourteen patients had a shunt installed less than 24 h prior to Abciximab injection and one less than 48 h later. At 3-6-month follow-up, 31 patients (74%) achieved a modified Rankin Scale score (mRS) of 2 or less, six patients (14%) had a mRS of 3-5, three were dead (7%), and two were lost at follow-up. CONCLUSION When the aneurysm is secured, intra-arterial Abciximab injection is a low complication rate treatment modality for thromboembolic events during embolization of cerebral ruptured aneurysm.
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Affiliation(s)
| | | | | | | | - Jean Raymond
- CHUM Montréal, Neuroradiology, Montréal, Québec, Canada
| | - Daniel Roy
- CHUM Montréal, Neuroradiology, Montréal, Québec, Canada
| | - Alain Weill
- CHUM Montréal, Neuroradiology, Montréal, Québec, Canada
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Administration of eptifibatide during endovascular treatment of ruptured cerebral aneurysms reduces the rate of thromboembolic events. Neuroradiology 2014; 57:197-203. [PMID: 25326169 DOI: 10.1007/s00234-014-1452-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 10/06/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Thromboembolic complications are the most frequent complications of endovascular treatment of ruptured intracranial aneurysms. The optimal protocol to prevent thromboembolic complications during coil embolization does not yet exist. The aim of this study was to investigate the effectiveness and safety of eptifibatide for the prevention of thromboembolic complications during elective coil embolization of ruptured cerebral aneurysms. METHODS A consecutive series of 100 patients (group 1) with ruptured intracranial aneurysm were treated using endovascular coil embolization. At the beginning of the procedure, all patients received an intra-arterial bolus (0.2 mg/kg) of eptifibatide. The following data were collected: degree of aneurysmal occlusion after treatment, thromboembolic and hemorrhagic complications and other intraoperative adverse events. The results were compared with those from a control group (group 2) which were analyzed retrospectively. Group 2 consisted of 100 previous patients with ruptured aneurysm managed with coil embolization who had received heparin and/or aspirin at the beginning of the procedure. RESULTS (1) Patient populations in groups 1 and 2 were considered statistically comparable, except that group 1 (eptifibatide) included more wide-necked aneurysms (p = 0.011). (2) There were less thromboembolic complications in group 1 (p = 0.011): seven intraoperative complications in group 1 versus 20 in group 2. (3) Intraoperative hemorrhagic complications were statistically comparable in both groups (p = 1). CONCLUSION Eptifibatide was effective in lowering the intraoperative thromboembolic complication rate in ruptured aneurysms treated with coil embolization and did not increase the hemorrhagic risk.
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Brinjikji W, Morales-Valero SF, Murad MH, Cloft HJ, Kallmes DF. Rescue treatment of thromboembolic complications during endovascular treatment of cerebral aneurysms: a meta-analysis. AJNR Am J Neuroradiol 2014; 36:121-5. [PMID: 25082819 DOI: 10.3174/ajnr.a4066] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Intraprocedural thrombus formation during endovascular treatment of intracranial aneurysms is often treated with glycoprotein IIb/IIIa inhibitors and, in some instances, fibrinolytic therapy. We performed a meta-analysis evaluating the safety and efficacy of GP IIb/IIIa inhibitors compared with fibrinolysis. We also evaluated the safety and efficacy of abciximab, an irreversible inhibitor, compared with tirofiban and eptifibatide, reversible inhibitors of platelet function. MATERIALS AND METHODS We performed a comprehensive literature search for studies on rescue therapy for intraprocedural thromboembolic complications with glycoprotein IIb/IIIa inhibitors or fibrinolysis during endovascular treatment of intracranial aneurysms. We studied rates of periprocedural stroke/hemorrhage, procedure-related morbidity and mortality, immediate arterial recanalization, and long-term good clinical outcome. Event rates were pooled across studies by using random-effects meta-analysis. RESULTS Twenty-three studies with 516 patients were included. Patients receiving GP IIb/IIIa inhibitors had significantly lower perioperative morbidity from stroke/hemorrhage compared with those treated with fibrinolytics (11.0%; 95% CI, 7.0%-16.0% versus 29.0%; 95% CI, 13.0%-55.0%; P = .04) and were significantly less likely to have long-term morbidity (16.0%; 95% CI, 11.0%-21.0% versus 35.0%; 95% CI, 17.0%-58.0%; P = .04). There was a trend toward higher recanalization rates among patients treated with glycoprotein IIb/IIIa inhibitors compared with those treated with fibrinolytics (72.0%; 95% CI, 64.0%-78.0% versus 50.0%; 95% CI, 28.0%-73.0%; P = .08). Patients receiving tirofiban or eptifibatide had significantly higher recanalization rates compared with those treated with abciximab (83.0%; 95% CI, 68.0%-91.0% versus 66.0%; 95% CI, 58.0%-74.0%; P = .05). No difference in recanalization was seen in patients receiving intra-arterial (77.0%; 95% CI, 66.0%-85.0%) or intravenous GP IIb/IIIa inhibitors (70.0%; 95% CI, 57.0%-80.0%, P = .36). CONCLUSIONS Rescue therapy with thrombolytic agents resulted in significantly more morbidity than rescue therapy with glycoprotein IIb/IIIa inhibitors. Tirofiban/eptifibatide resulted in significantly higher recanalization rates compared with abciximab.
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Affiliation(s)
- W Brinjikji
- From the Departments of Radiology (W.B., H.J.C., D.F.K.)
| | | | - M H Murad
- Center for Science of Healthcare Delivery (M.H.M.), Mayo Clinic, Rochester, Minnesota
| | - H J Cloft
- From the Departments of Radiology (W.B., H.J.C., D.F.K.) Neurosurgery (S.F.M.-V., H.J.C., D.F.K.)
| | - D F Kallmes
- From the Departments of Radiology (W.B., H.J.C., D.F.K.) Neurosurgery (S.F.M.-V., H.J.C., D.F.K.)
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Sedat J, Chau Y, Mondot L, Chemla R, Lonjon M, Padovani B. Is eptifibatide a safe and effective rescue therapy in thromboembolic events complicating cerebral aneurysm coil embolization? Single-center experience in 42 cases and review of the literature. Neuroradiology 2013; 56:145-53. [PMID: 24281387 DOI: 10.1007/s00234-013-1301-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 11/02/2013] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Thromboembolic complications are the most frequent perioperative complications of endovascular treatment of intracranial aneurysms. Even if the effectiveness of glycoprotein IIb/IIIa inhibitors has been reported, the outcomes in published clinic data are contradictory. This study aims to assess the effectiveness and the safety of eptifibatide in thromboembolic complications during intracranial aneurysm embolization procedure. METHODS Between 2006 and 2012, 650 patients with intracranial aneurysm were treated using endovascular coil embolization, and in 62 cases (9.5 %), an intra-arterial thrombus developed. Glycoprotein IIb/IIIa inhibitor was administrated in 45 of them who required a rescue treatment. These 45 patients were treated with an intra-arterial bolus (0.2 mg/kg) of eptifibatide. We respectively reviewed the angiographic and clinical outcomes, and the periprocedural complications of the rescue treatment. RESULTS No intra- or early postoperative (48 h) bleeding was observed after treatment. A total recovery of the entire arterial tree (TICI 3) was established in 28 cases (62.2 %), a partial revascularization in 13 cases (28.8 %) (5 TICI 2A and 8 TICI 2B), and no revascularization or reperfusion (TICI 0 or TICI 1) in 4 cases (9 %). Eptifibatide was more effective on proximal obstructions and in-stent occlusions than on peripheral distal thrombus, which were completely disintegrated one time out of three. CONCLUSION Intra-operative intra-arterial use of eptifibatide does not imply an increase of hemorrhagic events. Even if eptifibatide allows for a high rate of arterial recanalization, its effectiveness seems to be less important in cases of distal occlusions.
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Affiliation(s)
- Jacques Sedat
- Unité de Neurointerventionnelle, Hôpital Saint-Roch, 5 rue Pierre Devoluy, Nice, 06000, France,
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