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Yeo JYP, Yau CE, Ong NY, Teo YH, Gopinathan A, Yang C, Jing M, Yang JJW, Sia CH, Tan BYQ, Yeo LLL. Comparing the Impact of Stenting vs. Medical Therapy for Intracranial Arterial Stenosis : A Systematic Review and One-stage and Two-stage Meta-Analysis of Randomized Clinical Trials. Clin Neuroradiol 2024; 34:379-390. [PMID: 38172262 DOI: 10.1007/s00062-023-01370-3] [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: 03/03/2023] [Accepted: 11/23/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE In the treatment of intracranial arterial stenosis (ICAS), controversies remain regarding the optimal treatment strategy. Our study aims to conduct an individual patient-level data meta-analysis of existing RCTs comparing PTAS versus best medical therapy and to identify differences in outcomes such as incidence of ischemic stroke or death. METHODS Randomised controlled trials comparing the outcomes of stenting versus best medical therapy for patients who had symptomatic ICAS of >50%. Excluded studies included case reports, case series, reviews, observational studies, letters or studies evaluating isolated angioplasty techniques without stenting. Data was extracted in accordance with PRISMA guidelines. RESULTS 7 studies involving 1425 participants were included. There was an increased risk in the incidence of stroke and death within the first 30 days post-procedure for patients treated with PTAS over best medical therapy (RR = 2.22 [1.28-3.86], I² = 0%). Patients who underwent stenting also had a significantly higher risk of intracranial haemorrhage (RR = 12.66 [2.41-66.45], I² = 0%) and death (RR = 5.41 [1.20-24.28], I² = 0%).Under the shared frailty model, stenting when compared to medical therapy has a HR of 1.81 (95% CI:1.25-2.6) of stroke or death across 1 year. Under the parametric Royston-Parmar model, stenting has a significant decrease in the RMST(-0.83 months; 95% CI: -1.30-0.37). Stenting continued to show worse outcomes up to the 3 year mark with a HR of 1.60 (95% CI: 1.11-2.32). CONCLUSIONS AND RELEVANCE There is an increased risk of peri- and post-procedural stroke and death over best medical therapy in patients with symptomatic ICAS who undergo PTAS. Further work is required to refine patient selection and mitigate peri-procedural risks.
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Affiliation(s)
- Joshua Y P Yeo
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Chun En Yau
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Natasha Yixuan Ong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yao Hao Teo
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Anil Gopinathan
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
- Department of Diagnostic Imaging, National University Health System, Singapore, Singapore
| | - Cunli Yang
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
- Department of Diagnostic Imaging, National University Health System, Singapore, Singapore
| | - Mingxue Jing
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Joanna J W Yang
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Benjamin Yong Qiang Tan
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Leonard Leong Litt Yeo
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore.
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
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Zhou Y, Li W, Wang C, Xie R, Zhu Y, Peng Q, Zhang L, Zhang H, Gu Y, Mu S, Liu J, Yang X. Roles of light transmission aggregometry and CYP2C19 genotype in predicting ischaemic complications during interventional therapy for intracranial aneurysms. Stroke Vasc Neurol 2023; 8:327-334. [PMID: 36746550 PMCID: PMC10512079 DOI: 10.1136/svn-2022-001720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 01/03/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND AND PURPOSE Light transmission aggregometry (LTA) and CYP2C19 genotype analysis are commonly used to evaluate the antiplatelet effects of clopidogrel during the interventional treatment of intracranial aneurysms. The aim of this study was to determine which test can predict ischaemic events during these treatments. METHODS Patient demographic information, imaging data, laboratory data and ischaemic complications were recorded. LTA and CYP2C19 genotype results were compared, and multiple linear regression was performed to examine factors related to platelet reactivity. Multivariate regression analysis was performed to determine whether LTA and CYP2C19 could predict ischaemic complications and to identify other clinical risk factors. Receiver operating characteristic curve analysis was conducted to calculate the cut-off value for predicting ischaemic complications. A subgroup analysis was also performed for different CYP2C19 genotype metabolisers, as well as for patients with flow diverters and traditional stents. RESULTS A total of 379 patients were included, of which 22 developed ischaemic events. Maximum platelet aggregation induced by ADP (ADP-MPA) could predict ischaemic events (p<0.001; area under the curve, 0.752 (95% CI 0.663 to 0.842)), and its cut-off value was 41.5%. ADP-MPA (p=0.001) and hypertension duration >10 years (p=0.022) were independent risk factors for ischaemic events, while the CYP2C19 genotype was not associated with ischaemic events. In the subgroup analysis, ADP-MPA could predict ischaemic events in fast metabolisers (p=0.004) and intermediate metabolisers (p=0.003). The cut-off value for ischaemic events was lower in patients with flow diverters (ADP-MPA=36.4%) than in patients with traditional stents (ADP-MPA=42.9%). CONCLUSIONS ADP-MPA can predict ischaemic complications during endovascular treatment of intracranial aneurysms. Patients with flow diverters require stronger antiplatelet medication than patients with traditional stents.
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Affiliation(s)
- Yangyang Zhou
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wenqiang Li
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Chao Wang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ruhang Xie
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yongnan Zhu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qichen Peng
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Limin Zhang
- Department of Clinical Diagnosis Laboratory, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yuxiang Gu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Shiqing Mu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jian Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Hong N, Kim SB, Yang HJ, Son YJ. Variability of response on prophylactic prasugrel for endovascular treatment of intracranial aneurysms: Clinical implications. PLoS One 2023; 18:e0287190. [PMID: 37352283 PMCID: PMC10289319 DOI: 10.1371/journal.pone.0287190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 05/31/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND AND PURPOSE Prophylactic prasugrel for endovascular treatment of intracranial aneurysms has been introduced and increased, but HTPR (high on-treatment platelet reactivity) or LTPR (low on-treatment platelet reactivity) of prasugrel is not uncommon in clinical circumstances. To investigate the predisposing factors of HTPR and LTPR on prasugrel premedication in the neurointerventional field and to determine its clinical implications. MATERIALS AND METHODS Between February 2016 and December 2020, 191 patients treated with coil embolization using prophylactic prasugrel in 234 intracranial aneurysms were the final candidates for this study. Patient and aneurysm characteristics, clinical status, and laboratory study values were carefully reviewed retrospectively. We performed risk factor analyses for HTPR and LTPR on prasugrel. RESULTS Ultimately, 20 patients (10.5%) had HTPR, and 74 patients (38.7%) were categorized as having LTPR. In multivariable analyses, the factors related to HTPR were BMI (adjusted OR 1.21, 95% CI 1.04-1.41, p = 0.01), history of antithrombotics (adjusted OR 3.79, 95% CI 1.39-10.34, p = 0.01), and hematocrit (adjusted OR 0.91, 95% CI 0.84-0.99, p = 0.03). Low BMI was the only risk factor for LTPR (adjusted OR 0.84, 95% CI 0.76-0.94, p = 0.001). CONCLUSION In the neurointerventional field, high BMI and prior use of antithrombotic agents were related to HTPR, and low BMI was associated with LTPR on prophylactic prasugrel. High hematocrit levels decreased the risk of HTPR. When preparing endovascular treatment for intracranial aneurysms, attention to patients with these clinical features is required to address the possibility of ischemic or bleeding complications.
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Affiliation(s)
- Noah Hong
- Department of Neurosurgery, Seoul National University-Seoul Metropolitan Government Boramae Medical Center, Seoul, Republic of Korea
| | - Seung Bin Kim
- Department of Critical Care Medicine, Seoul National University-Seoul Metropolitan Government Boramae Medical Center, Seoul, Republic of Korea
| | - Hee-Jin Yang
- Department of Neurosurgery, Seoul National University-Seoul Metropolitan Government Boramae Medical Center, Seoul, Republic of Korea
| | - Young-Je Son
- Department of Neurosurgery, Seoul National University-Seoul Metropolitan Government Boramae Medical Center, Seoul, Republic of Korea
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Wu Y, Yu J, Zhang T, Deng JP, Zhao Z. Endovascular treatment of distal internal carotid artery aneurysms and vertebral artery dissecting aneurysms with the Willis covered stent: A single-center, retrospective study. Interv Neuroradiol 2023; 29:63-78. [PMID: 35581717 PMCID: PMC9893231 DOI: 10.1177/15910199211070900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 12/09/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND More data is needed on the short- and medium-term efficacy and safety of the Willis covered stent in treating distal internal carotid artery (DICA) aneurysms and vertebral artery dissecting aneurysms (VADAs). METHODS Records of all 42 patients with DICA aneurysms or VADAs treated with the Willis covered stents at our institute between July 2014 and January 2019 were retrospectively examined. The patients' demographic information, symptoms, diagnosis, treatment procedure, immediate and follow-up clinical and angiographic outcomes were extracted. RESULTS 46 Willis covered stents were successfully implanted in all of the 42 patients (total 43 aneurysms). Immediate complete aneurysm occlusion was achieved in 37 patients (38 aneurysms) (88.4%), and endoleak occurred to 5 patients (5 aneurysms) (11.6%). 2 patients died post-operatively from procedure-related complications, another one died from reasons unrelated to the procedure. Among the remaining 39 patients, non-lethal complications occurred in 4 patients including ptosis and diplopia of the right eye, intra-operative hemorrhage and carotid cavernous fistulas (CCF). Angiographic and clinical follow-ups (means ± standard deviation: 8.8 ± 5.3 months) were done for 32 patients (33 aneurysms). Complete occlusion was maintained in all of the 33 aneurysms. 2 of the 32 patients had significant though asymptomatic parent artery (PA) occlusion. No ischemic or hemorrhagic event occurred during the follow-up period. The modified Rankin Scale (mRS) score was 0 in 31 patients and 1 in the remaining 1 patient. CONCLUSIONS The Willis covered stent could be a safe and effective treatment for complex DICA aneurysms with excellent durability. In addition, the Willis covered stent treated all of the 3 cases of VADAs in the study with complete success without any complications, however, as the number of the VADA cases was small, more cases are needed to further confirm the efficacy and safety of the Willis covered stent in treating VADAs.
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Affiliation(s)
| | | | - Tao Zhang
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University (The Fourth Military Medical
University), Xi’an, China
| | - Jian-Ping Deng
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University (The Fourth Military Medical
University), Xi’an, China
| | - Zhenwei Zhao
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University (The Fourth Military Medical
University), Xi’an, China
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Relationship between CYP2C19 Polymorphism and Clopidogrel Resistance in Patients with Coronary Heart Disease and Ischemic Stroke in China. Genet Res (Camb) 2022; 2022:1901256. [PMID: 36325266 PMCID: PMC9616677 DOI: 10.1155/2022/1901256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 10/15/2022] [Indexed: 11/25/2022] Open
Abstract
Objective Clopidogrel is widely used for preventing ischemic complications related to cardiovascular diseases. However, many patients experience clopidogrel resistance (CR). The polymorphisms of CYP2C19 have been implicated in CR, but CYP2C19 polymorphism considerably varies with both ethnic group and geographical location. This study aimed to investigate the association between CYP2C19 polymorphisms and clopidogrel resistance (CR) in patients with coronary heart disease and ischemic stroke among Han and Tibetan populations in Qinghai Province, China. Methods From June 2019 to January 2020, patients who were diagnosed with coronary heart disease or cerebral infarction in internal medicine of Qinghai Provincial People's Hospital and had taken dual antiplatelet drugs were included in this study. Blood was collected and routine items were completed. Whole exome sequencing was performed for CYP2C19 genetic polymorphisms of CYP2C19∗2 (rs4244285), CYP2C19∗3 (rs4986893), and CYP2C19∗17 (rs12248560). Results A total of 91 patients with coronary heart disease or cerebral infarction (67 Han people (65.99 ± 12.25 years old) and 24 Tibetan (63.6324 Tib years old)) including 52 cases with CR and 39 cases with non-CR were enrolled in this study. For the Han population, the differences in age, glycosylated hemoglobin, activated partial thromboplastin time (APTT), gender, aspirin resistance, and diabetes were significant between the CR and non-CR groups. For the Tibetan population, the two groups showed no significant difference in all indicators. There was no significant difference between CR and non-CR groups for all genotypes (CYP2C19 ∗2, ∗3, and ∗17) in either Han or Tibetan populations. For the Han populations, age, APTT, and aspirin resistance were significantly correlated with CR. Conclusion The present study indicated that CYP2C19∗2, CYP2C19∗3, and CYP2C19∗17 alleles were not correlated with CR for both Han and Tibetan populations in Qinghai Province, while age, APTT, and aspirin resistance were independent risk factors of CR in this region.
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Zhang Y, Fan D, Qiao S, Hu H. Verifynow P2Y 12 PRU-Guided Modification of Clopidogrel for Prevention of Recurrent Ischemic Stroke: A Real-World Prospective Cohort Study. Neurol Ther 2022; 11:1749-1766. [PMID: 36163415 DOI: 10.1007/s40120-022-00406-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 09/01/2022] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Clopidogrel resistance causes recurrent stroke. However, outcomes of modified antiplatelet medications to prevent recurrent ischemic stroke are not well known. METHODS Patients who received clopidogrel with and without modification as initial treatment for stroke were recruited and compared. The primary outcome was ischemic stroke and myocardial infarction at the 1-year follow-up. The secondary outcome was bleeding complications. RESULTS Overall, 206 patients treated with clopidogrel were enrolled and were divided into the modification (n = 39) and no modification (n = 167) groups. There was a significant difference in the incidence of severe cerebral arterial stenosis between the two groups (modification group, 16/39, 41.03%; no modification group, 36/167, 21.56%, P = 0.012) at baseline. The loss to follow-up rate was 12.14% (25/206). After adjustment for severe cerebral artery stenosis, antiplatelet modification based on the platelet reactivity unit (PRU) value significantly improved in the per protocol set (odds ratio 0.142, 95% confidential interval 0.022-0.898, P = 0.038). The area under the curve of the different PRU cutoff values were 0.630, 0.605, and 0.591 (P = 0.016, 0.051, and 0.092) for PRU 190, 208, and 235, respectively. CONCLUSION Verifynow P2Y12 PRU-guided modification of clopidogrel for ischemic stroke significantly improved or prevented recurrence at the 1-year follow-up. Our findings suggest that clopidogrel therapy based on the PRU cutoff value of 190 should be considered to improve outcomes. TRIAL REGISTRATION ClinicalTrials.gov NCT02618265 (December 1, 2015).
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Affiliation(s)
- Yuanjin Zhang
- Department of Neurology, Peking University Third Hospital, 49th North Garden Road, Haidian District, Beijing, 100191, China
| | - Dongsheng Fan
- Department of Neurology, Peking University Third Hospital, 49th North Garden Road, Haidian District, Beijing, 100191, China.
| | - Shudong Qiao
- Department of Neurology, Peking University Shougang Hospital, Beijing, China
| | - Hongtao Hu
- Department of Neurology, Beijing Jishuitan Hospital Hui Longguan Branch, Beijing, China
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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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Tan J, Song R, Luo S, Fu W, Su J, He Z. Willis covered stent treatment for blood blister-like aneurysm: A meta-analysis of efficacy and safety. Front Neurol 2022; 13:1101625. [PMID: 36895627 PMCID: PMC9990463 DOI: 10.3389/fneur.2022.1101625] [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: 11/18/2022] [Accepted: 12/20/2022] [Indexed: 02/23/2023] Open
Abstract
Background Blood blister-like aneurysm (BBA) is a rare and special type of intracranial aneurysm with extremely high rates of rupture, morbidity, mortality, and recurrence. Willis Covered Stent (WCS) is a new device that is specifically designed for the treatment of intracranial complex aneurysms. However, the efficacy and safety of WCS treatment for BBA remain controversial. Thus, a high level of evidence is required to prove the efficacy and safety of WCS treatment. Methods A systematic literature review was performed using a comprehensive literary search in Medline, Embase, and Web of Science databases to identify studies related to WCS treatment for BBA. A meta-analysis was then conducted to incorporate the efficacy and safety outcomes, including intraoperative situation, post-operative situation, and follow-up data. Results Eight non-comparative studies containing 104 patients with 106 BBAs met the inclusion criteria. In the intraoperative situation, the technical success rate was 99.5% [95% confidence interval (CI), 0.958, 1.000], the complete occlusion rate was 98.2% (95% CI, 0.925, 1.000), and the side branch occlusion rate was 4.1% (95% CI, 0.001, 0.114). Vasospasm and dissection occurred in 9.2% (95% CI, 0.000, 0.261) and 0.1% (95% CI, 0.000, 0.032) of the patients, respectively. In the post-operative situation, the rebleed and mortality rates were 2.2% (95% CI, 0.000, 0.074) and 1.5% (95% CI, 0.000, 0.062), respectively. In the follow-up data, recurrence and parent artery stenosis occurred in 0.3% (95% CI, 0.000, 0.042) and 9.1% (95% CI, 0.032, 0.168) of the patients, respectively. Ultimately, 95.7% (95% CI, 0.889, 0.997) of the patients had a good outcome. Conclusions Willis Covered Stent could be effectively and safely applied for BBA treatment. The results provide a reference for clinical trials in the future. Well-designed prospective cohort studies must be conducted for verification.
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Affiliation(s)
- Jiahe Tan
- Department of Neurosurgery, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Rui Song
- Key Laboratory of Molecular Biology for Infectious Diseases (Ministry of Education), Department of Infectious Diseases, Institute for Viral Hepatitis, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Siyue Luo
- Clinical Medicine, Second Clinical College of Chongqing Medical University, Chongqing, China
| | - Wenqiao Fu
- Department of Neurosurgery, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jun Su
- Department of Neurosurgery, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhaohui He
- Department of Neurosurgery, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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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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Kazimi AU, Weber CF, Keese M, Miesbach W. The Pre- and Postoperative Prevalence and Risk Factors of ASA Nonresponse in Vascular Surgery. Clin Appl Thromb Hemost 2021; 27:10760296211044723. [PMID: 34609920 PMCID: PMC8642110 DOI: 10.1177/10760296211044723] [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] [Indexed: 12/26/2022] Open
Abstract
Background An antiplatelet therapy with acetylsalicylic acid (ASA) is prescribed in the
prevention of cardiovascular events, but around 24% of ASA takers are
resistant to the treatment. Aim In this prospective, observational cohort study, we aimed to identify the
prevalence and risk factors of ASA nonresponse in patients who underwent
vascular surgery. Methods The study was conducted in the University hospital in Frankfurt am Main. In
total, 70 patients were pre-treated with 100 mg of ASA per day and underwent
either elective carotid thromboendarterectomy, femoral thromboendarterectomy
or endovascular aneurysm repair of the abdominal aorta. The platelet
function was measured on the first preoperative and the second or fourth
postoperative day with the multiple electrode aggregometry by in-vitro
stimulation with arachidonic acid (ASPItest) and thrombin receptor
activating peptide 6 (TRAPtest). The primary end point was the in-vitro
induced platelet aggregation in the ASPItest. If the ASPItest amounted ≥400
AU × min, the patients were categorized as ASA nonresponders. Results The total prevalence of ASA nonresponse in our study was 20% preoperatively
and 35.7% postoperatively (p = 0.005). As significant predictors for ASA
nonresponse, we demonstrated the area under the aggregation curve in the
TRAPtest preoperatively (p = 0.04) and postoperatively (p = 0.02), and the
two comorbidities arterial hypertension (P < .001; rho
0.44) and diabetes mellitus (p = 0.04; rho 0.39), which are already well
known to be associated with ASA nonresponse. Conclusion In conclusion, data of the study indicate a high incidence of perioperative,
laboratory ASA nonresponse in patients undergoing vascular surgery.
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Affiliation(s)
- Alia Uzra Kazimi
- Sana Klinikum Offenbach, Medical Clinic I, 9206Internal Intensive Care Medicine and General Medicine, Offenbach, Germany
| | | | | | - Wolfgang Miesbach
- Hemophilia Centre, 14984University Hospital Frankfurt, Medical Clinic II, Institute of Transfusion Medicine and Immunhematology, Frankfurt, Germany
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11
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Bass DI, Young CC, Park MS, Cruz MJ, Carroll KT, Vanent KN, Lee C, Sen RD, Angiolillo DJ, Cattaneo M, Kim LJ, Levitt MR. Severe, Intolerable Fatigue Associated with Hyperresponse to Clopidogrel. World Neurosurg 2021; 156:e374-e380. [PMID: 34563718 DOI: 10.1016/j.wneu.2021.09.075] [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: 06/10/2021] [Revised: 09/14/2021] [Accepted: 09/15/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Clopidogrel is a commonly used antiplatelet agent for the prevention of thromboembolic complications following neuroendovascular procedures, but anecdotal data have raised concern for the possibility that clopidogrel may induce severe, intolerable fatigue. The purpose of this study is to systematically investigate this phenomenon. METHODS We performed a dual-institution, 9-year, retrospective study of patients undergoing clopidogrel therapy for neuroendovascular procedures. Patients were included only if their response to clopidogrel was assessed by platelet function testing using the VerifyNow P2Y12 (VNP) assay. Hyperresponse to clopidogrel was defined as P2Y12 reaction units ≤60. Patients were considered to have had clopidogrel-induced severe fatigue if the onset of symptoms followed the initiation of clopidogrel therapy; symptoms improved following a reduction in the dose of clopidogrel; and symptoms could not be attributed to any other medical explanation. RESULTS Data were collected on 349 patients. Five patients (1.4%) met criteria for clopidogrel-induced severe fatigue. All 5 patients were female, ages 39-68. VNP assessments obtained while patients were symptomatic revealed hyperresponse to clopidogrel (0-22 P2Y12 reaction units). Symptoms improved in all 5 patients when the dose of clopidogrel was reduced by half. Notably, 30% of patients (n = 103) demonstrated a hyperresponse to clopidogrel on at least 1 VNP assessment, but 98 of these patients did not suffer from severe fatigue. CONCLUSIONS A syndrome of severe fatigue and other constitutional symptoms is a rare but clinically significant side effect of hyperresponse to clopidogrel in patients undergoing neuroendovasular intervention.
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Affiliation(s)
- David I Bass
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Christopher C Young
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Min S Park
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Michael J Cruz
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Kate T Carroll
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Kevin N Vanent
- School of Medicine, University of Washington, Seattle, Washington, USA
| | - Chungeun Lee
- School of Medicine, Washington State University, Spokane, Washington, USA
| | - Rajeev D Sen
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Dominick J Angiolillo
- Division of Cardiology, Department of Medicine, University of Florida, Jacksonville, Florida, USA
| | - Marco Cattaneo
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Louis J Kim
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA; Stroke & Applied Neurosciences Center, University of Washington, Seattle, Washington, USA; Department of Radiology, University of Washington, Seattle, Washington, USA
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA; Stroke & Applied Neurosciences Center, University of Washington, Seattle, Washington, USA; Department of Radiology, University of Washington, Seattle, Washington, USA; Department of Mechanical Engineering, University of Washington, Seattle, Washington, USA.
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12
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Laurent D, Dodd WS, Small C, Gooch MR, Ghosh R, Goutnik M, Blatt T, Porche K, Geh N, Adamczak S, Polifka AJ, Brzezicki G, Hoh B, Chalouhi N. Ticagrelor resistance: a case series and algorithm for management of non-responders. J Neurointerv Surg 2021; 14:179-183. [PMID: 34215660 DOI: 10.1136/neurintsurg-2021-017638] [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: 05/13/2021] [Accepted: 06/22/2021] [Indexed: 02/04/2023]
Abstract
The placement of cervical and intracranial stents requires the administration of antiplatelet drugs to prevent thromboembolic complications. Ticagrelor has emerged as the most widely used alternative in clopidogrel non-responders owing to its potent antiplatelet effects. Because ticagrelor does not require hepatic activation, many neurointerventionalists choose to forgo laboratory testing of platelet inhibition. In rare instances, patients may not achieve adequate platelet inhibition following ticagrelor administration. In this paper we review the mechanism of action of ticagrelor and its use in cerebrovascular procedures. We present two cases of ticagrelor non-responsiveness from two high-volume cerebrovascular centers, discuss their management, and propose an algorithm for managing ticagrelor non-responsiveness.
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Affiliation(s)
- Dimitri Laurent
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - William S Dodd
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Coulter Small
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - M Reid Gooch
- Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Ritam Ghosh
- Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Michael Goutnik
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | | | - Ken Porche
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Ndi Geh
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Stephanie Adamczak
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Adam J Polifka
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Grzegorz Brzezicki
- Department of Neurosurgery, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Brian Hoh
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Nohra Chalouhi
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
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13
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Sandler M, Hoang C, Mak HY, Levitt MR. Effect of bodyweight on VerifyNow Aspirin platelet function test: a retrospective review. J Neurointerv Surg 2020; 13:831-834. [PMID: 33257413 DOI: 10.1136/neurintsurg-2020-016842] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/12/2020] [Accepted: 11/16/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND Antiplatelet therapy is used to prevent stent thrombosis in intracranial stents, but the optimal dose of aspirin is unknown. This study sought to determine whether the degree of platelet inhibition with aspirin is affected by bodyweight as observed through a platelet reactivity assay. METHODS This is a retrospective review of patients who underwent neurovascular stent placement and had a VerifyNow Aspirin assay result. The primary outcome was the correlation between the VerifyNow Aspirin result, bodyweight, and the initial dose of aspirin. Secondary outcomes included the impact of the VerifyNow P2Y12 result and of weight on the incidence of bleeding or a thrombotic event. RESULTS Of the 142 included patients, 62.7% weighed ≥70 kg and 88.7% were initiated on aspirin 300-325 mg daily. 83.8% achieved a therapeutic VerifyNow Aspirin result. There was minimal correlation between the VerifyNow Aspirin result, bodyweight, and aspirin dose (R2=0.02). Between patients who weighed <70 kg versus ≥70 kg, there was no difference in the mean aspirin reaction units (ARU) (449 vs 435, p=0.32) or in the incidence of bleeding (28% vs 17.1%, p=0.14) or a thrombotic event (4% vs 5.3%, p=0.59). No patient experienced stent thrombosis and eight patients experienced in-stent stenosis. In a multivariate analysis, only the VerifyNow P2Y12 result predicted the development of either bleeding or a thrombotic event (p<0.01). CONCLUSIONS Bodyweight did not influence the likelihood of obtaining a therapeutic VerifyNow Aspirin result. The clinical utility of obtaining VerifyNow Aspirin assays for this patient population is unknown.
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Affiliation(s)
| | - Cuong Hoang
- Harborview Medical Center, Seattle, Washington, USA
| | - Hannah Y Mak
- Harborview Medical Center, Seattle, Washington, USA
| | - Michael R Levitt
- Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
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14
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Antiplatelet Drugs for Neurointerventions: Part 1 Clinical Pharmacology. Clin Neuroradiol 2020; 30:425-433. [DOI: 10.1007/s00062-020-00910-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 04/27/2020] [Indexed: 12/31/2022]
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15
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Linfante I, Ravipati K, Starosciak AK, Reyes D, Dabus G. Intravenous cangrelor and oral ticagrelor as an alternative to clopidogrel in acute intervention. J Neurointerv Surg 2020; 13:30-32. [PMID: 32414891 DOI: 10.1136/neurintsurg-2020-015841] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 04/07/2020] [Accepted: 04/10/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND Dual antiplatelet therapy (DAP) is necessary to prevent thromboembolic events during carotid stenting, stent-assisted coil embolization, and implant of flow diverters (FD). However, DAP in the acute phase may be challenging. An intravenous alternative, cangrelor, has rapid onset, short plasma half-life, and more reliable antiplatelet action for acute interventions. The study objective was to evaluate feasibility and safety of IV cangrelor during acute neuroendovascular surgery procedures. METHODS We performed a retrospective analysis of our database of patients treated with stent-assisted coil embolization, FD placement for aneurysmal subarachnoid hemorrhage (aSAH), or stenting for acute internal carotid artery (ICA) occlusion where IV cangrelor was used. Morbidity, mortality, incidence of thromboembolic events, hemorrhages, and 90-day outcomes were reported. RESULTS Ten patients were found in our database from June 2018 through January 2019. Four patients had aSAH, four had middle cerebral artery strokes with tandem lesions, one had an ICA occlusion, and one had a vertebral artery aneurysm. One of the ten patients experienced a thrombotic event. One patient developed new post-procedural bleeding and two had worsening intracranial hemorrhage. Five patients were discharged home in stable condition, two to acute rehabilitation, one to a nursing facility, and two others expired (likely the result of the severe and evolving strokes). Of the eight who were discharged, six (75%) had a good 90-day functional outcome (modified Rankin Scale 0-2). CONCLUSION Acute administration of IV cangrelor with or without oral ticagrelor is a feasible antiplatelet treatment option for acute neuroendovascular procedures.
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Affiliation(s)
- Italo Linfante
- Miami Cardiac & Vascular Institute, Baptist Health South Florida, Miami, Florida, USA .,Miami Neuroscience Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Kaushik Ravipati
- Translational Medicine, Florida International University Herbert Wertheim College of Medicine, Miami, Florida, USA
| | - Amy Kathryn Starosciak
- Miami Neuroscience Institute, Baptist Health South Florida, Miami, Florida, USA.,Translational Medicine, Florida International University Herbert Wertheim College of Medicine, Miami, Florida, USA
| | - Dennys Reyes
- Miami Cardiac & Vascular Institute, Baptist Health South Florida, Miami, Florida, USA.,Miami Neuroscience Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Guilherme Dabus
- Miami Cardiac & Vascular Institute, Baptist Health South Florida, Miami, Florida, USA.,Miami Neuroscience Institute, Baptist Health South Florida, Miami, Florida, USA
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16
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Kate MP, Shuaib A. A Need for Tailored Approach for Patients with Symptomatic Intracranial Atherosclerotic Stenosis. Ann Indian Acad Neurol 2020; 23:253-254. [PMID: 32606507 PMCID: PMC7313583 DOI: 10.4103/aian.aian_623_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 12/02/2019] [Accepted: 11/26/2019] [Indexed: 11/04/2022] Open
Affiliation(s)
- Mahesh P. Kate
- Division of Neurology, Department of Medicine, Alberta Health Services, University of Alberta Hospital, Edmonton, Canada,Address for correspondence: Dr. Mahesh P. Kate, Neurologist, 1T1-14, OPR, University of Alberta Hospital, 8440, 112 St NW, Edmonton - T6G2B7, AB, Canada. E-mail:
| | - Ashfaq Shuaib
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
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17
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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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18
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Platelet function testing in pigs using the Multiplate® Analyzer. PLoS One 2019; 14:e0222010. [PMID: 31465489 PMCID: PMC6715187 DOI: 10.1371/journal.pone.0222010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 08/20/2019] [Indexed: 01/02/2023] Open
Abstract
For endovascular research pigs are an established animal model. However, experiences regarding analyses of platelet inhibition in pigs using the Multiplate® Analyzer are limited. The aims of the present study were to investigate if (1) the Multiplate® Analyzer is a suitable method for examination of porcine platelet function using manufacturers’ recommendations for human blood, and (2) platelet inhibition can be induced with acetylsalicylic acid (ASA) and clopidogrel in pigs reliably, and if (3) non-responders to one of the drug can be detected. Additionally we examined differences in (4) the effectiveness of ASA between oral administration and intravenous application, and (5) between domestic pigs (German Landrace; GL) and miniature pigs (MP). We investigated platelet function of 36 unmedicated pigs (GL n = 28; MP n = 8). In addition, 32 blood samples taken from medicated pigs (GL n = 15; MP n = 17) were analysed. Platelet inhibition was induced in four different ways: (1) 500 mg ASA intravenously (n = 11), (2) 500 mg ASA intravenously and 450 mg clopidogrel orally (n = 5), (3) 250 mg ASA orally (n = 11), (4) 250 mg ASA orally and 75 mg clopidogrel orally (n = 5). Results of the ASPI and ADP test of the Multiplate® Analyzer subtests in unmedicated and medicated pigs were in a comparable range to results known from humans. Application of ASA decreased the mean values of the ASPI test significantly regardless of the application method. Joined administration of ASA and clopidogrel also decreased the mean values of the ADP test significantly. Both, oral and intravenous administrations of ASA as well as oral administration of clopidogrel effectively inhibited platelet function in pigs. One pig did not respond to clopidogrel. We found no differences between domestic and miniature pigs regarding reference values in unmedicated pigs and the effectiveness of ASA and clopidogrel.
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Karan V, Vyas D, Bohra V, Huded V. Ticagrelor Use in Indian Patients Undergoing Neuroendovascular Procedures: A Single Center Experience. Neurointervention 2019; 14:125-130. [PMID: 31387163 PMCID: PMC6736500 DOI: 10.5469/neuroint.2019.00087] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 06/27/2019] [Indexed: 12/21/2022] Open
Abstract
PURPOSE A safe and efficacious antiplatelet drug is needed for patients with clopidogrel resistance who undergo neuroendovascular procedures. Ticagrelor is a new reversibly binding, oral, direct-acting P2Y receptor antagonist with no known resistance. We describe our clinical experience using ticagrelor for neuroendovascular procedures in Indian patients with clopidogrel resistance at the NH Institute of Neurosciences, Narayana Health City, Bangalore. MATERIALS AND METHODS We retrospectively reviewed our endovascular procedure database for all patients with predefined clopidogrel resistance. Clopidogrel resistance was defined as P2Y12 inhibition <40%. Patients were administered ticagrelor along with aspirin prior to the procedure. RESULTS Of 127 patients, 32 (25%) were non-responders to clopidogrel (22 [69%] males, 10 [31%] females; median age, 54 years [range, 20-75]). All patients were treated with a 180-mg loading dose of ticagrelor, followed by 90 mg twice daily. Twenty patients (63%) underwent endovascular intervention for intracranial aneurysm, two (6%) for dissecting aneurysms, nine (28%) for stenotic lesions, and one (3%) for carotico-cavernous fistula. No patient experienced any adverse effects related to the use of Ticagrelor in the postoperative period. CONCLUSION Ticagrelor is an effective alternative to clopidogrel for use in conjunction with aspirin in patients with clopidogrel resistance. None of our patients had adverse effects from ticagrelor. Drug cost, twice-daily dosing, and risk of faster platelet aggregation activation after discontinuation should be taken into consideration prior to its use in such patients.
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Affiliation(s)
- Vivek Karan
- Division of Stroke and Interventional Neurology, NH Institute of Neurosciences, Bangalore, India
| | - Devashish Vyas
- Division of Stroke and Interventional Neurology, NH Institute of Neurosciences, Bangalore, India
| | - Vikram Bohra
- Division of Stroke and Interventional Neurology, NH Institute of Neurosciences, Bangalore, India
| | - Vikram Huded
- Division of Stroke and Interventional Neurology, NH Institute of Neurosciences, Bangalore, India
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20
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Farrokh S, Owusu K, Lara LR, Nault K, Hui F, Spoelhof B. Neuro-Interventional Use of Oral Antiplatelets: A Survey of Neuro-Endovascular Centers in the United States and Review of the Literature. J Pharm Pract 2019; 34:207-215. [PMID: 31327286 DOI: 10.1177/0897190019854868] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Intra- and postprocedural thrombosis are major complication of aneurysmal coil embolization, stent-assisted coiling, and pipeline embolization. The common but unproven practice of dual antiplatelet therapy with aspirin and a P2Y12 inhibitor in neuro-endovascular patients is inferred from the cardiology literature without large clinical trials to support it in neuro-endovascular patients. OBJECTIVE We conducted an electronic survey to identify practice variations surrounding the use of oral antiplatelets in patients undergoing endovascular neuro-interventional procedures across neuro-endovascular centers in the United States. METHODS An electronic survey was distributed via the Web. Any practicing neuro-intensive care unit (ICU), neuro-interventional or stroke physician, pharmacist, physician assistant, or nurse practitioner was eligible to respond to this survey between June and October 2017. RESULTS A total of 33 responses were collected during the survey period. A response rate of 16% was calculated after taking into account all comprehensive stroke centers in the United States. Aspirin and clopidogrel was the standard-of-care antiplatelet regimen utilized in the majority of institutions (82%). Alternatively, 4 institutions used monotherapy (aspirin [n = 2], clopidogrel [n = 1], either aspirin or clopidogrel [n = 1]) and 2 institutions reported practitioner-dependent practices. Just under half of the centers reported ticagrelor as the primary alternative in clopidogrel nonresponders (48%). CONCLUSION Dual antiplatelet therapy with aspirin and clopidogrel appears to be standard of care in this setting based on our survey. About half of responding institutions use ticagrelor in cases where clopidogrel resistance is suspected. Large society-wide patient registries are needed to provide data for future safety and efficacy studies.
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Affiliation(s)
- Salia Farrokh
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Kent Owusu
- Department of Pharmacy, Yale-New Haven Hospital, New Haven, CT, USA
| | | | - Katharine Nault
- Department of Pharmacy, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Ferdinand Hui
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Brian Spoelhof
- Department of Pharmacy, Boston Medical Center, Boston, MA, USA
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Liu LX, Zhang CW, Xie XD, Wang CH. Application of the Willis Covered Stent in the Treatment of Blood Blister-Like Aneurysms: A Single-Center Experience and Systematic Literature Review. World Neurosurg 2019; 123:e652-e660. [DOI: 10.1016/j.wneu.2018.11.245] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 11/29/2018] [Accepted: 11/30/2018] [Indexed: 10/27/2022]
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22
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Liu LX, Zhang CW, Lin S, Wu C, Wang T, Zhou LX, Wang CH, Xie XD. Application of the Willis Covered Stent in the Treatment of Ophthalmic Artery Segment Aneurysms: A Single-Center Experience. World Neurosurg 2019; 122:e546-e552. [DOI: 10.1016/j.wneu.2018.10.098] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 10/14/2018] [Accepted: 10/16/2018] [Indexed: 11/26/2022]
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Chung JW, Kim SJ, Hwang J, Lee MJ, Lee J, Lee KY, Park MS, Sung SM, Kim KH, Jeon P, Bang OY. Comparison of Clopidogrel and Ticlopidine/ Ginkgo Biloba in Patients With Clopidogrel Resistance and Carotid Stenting. Front Neurol 2019; 10:44. [PMID: 30761076 PMCID: PMC6363652 DOI: 10.3389/fneur.2019.00044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 01/14/2019] [Indexed: 11/25/2022] Open
Abstract
Background and Purpose: Patients undergoing carotid artery stenting (CAS) who show low responsiveness to clopidogrel may have a higher risk of peri-procedural embolic events. This study aimed to compare the effectiveness and safety of clopidogrel and ticlopidine plus Ginkgo biloba in clopidogrel-resistant patients undergoing CAS. Methods: In this multi-center, randomized, controlled trial, we used platelet reactivity test to select patients undergoing CAS who showed clopidogrel resistance, and compared treatments using clopidogrel and ticlopidine plus ginkgo. The primary outcome was the incidence of new ischemic lesion in the ipsilateral hemisphere of CAS. Detection of microembolic signal on transcranial Doppler was the secondary outcome. The clinical outcomes were also monitored. Results: This trial was discontinued after 42 patients were randomized after preplanned interim sample size re-estimation indicated an impractical sample size. The primary endpoint occurred in 12/22 patients (54.5%) in the clopidogrel group and 13/20 patients (65.0%) in the ticlopidine–ginkgo group (P = 0.610). No significant differences in the presence of microembolic signal (15.0 vs. 11.8%, P = 0.580), clinical outcomes (ischemic stroke or transient ischemic attack, 0.0 vs. 5.5%; acute myocardial infarction 0.0 vs. 0.0%; all-cause death, 4.5 vs. 0.0%), or incidence of adverse events were found in the two groups. In terms of resistance to clopidogrel, treatment with ticlopidine–ginkgo significantly increased the P2Y12 Reaction Units (difference, 0.0 [−0.3–3.0] vs. 21.0 [6.0–35.0], P < 0.001). Conclusions: In patients who showed clopidogrel resistance, ticlopidine–ginkgo treatment was safe and increased P2Y12 Reaction Units; however, compared to clopidogrel, it failed to improve surrogate and clinical endpoints in patients undergoing CAS. This multimodal biomarker-based clinical trial is feasible in neurointerventional research. Clinical Trial Registration:http://www.clinicaltrials.gov. Unique identifier: NCT02133989.
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Affiliation(s)
- Jong-Won Chung
- Department of Neurology, Samsung Medical Center Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Suk Jae Kim
- Department of Neurology, Samsung Medical Center Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jaechun Hwang
- Department of Neurology, Kyungpook National University School of Medicine Kyungpook National University Chilgok Hospital, Daegu, South Korea
| | - Mi Ji Lee
- Department of Neurology, Samsung Medical Center Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jun Lee
- Department of Neurology Yeungnam University Medical Center, Daegu, South Korea
| | - Kyung-Yul Lee
- Department of Neurology, Gangnam Severance Hospital Yonsei University College of Medicine, Seoul, South Korea
| | - Man-Seok Park
- Department of Neurology Chonnam National University Medical School, Gwangju, South Korea
| | - Sang Min Sung
- Department of Neurology Busan National University Hospital, Busan, South Korea
| | - Keon Ha Kim
- Department of Radiology, Samsung Medical Center Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Pyoung Jeon
- Department of Radiology, Samsung Medical Center Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center Sungkyunkwan University School of Medicine, Seoul, South Korea
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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: 7] [Impact Index Per Article: 1.2] [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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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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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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Tsujimoto M, Enomoto Y, Miyai M, Egashira Y, Iwama T. Optimal platelet function test for in-stent tissue protrusion following carotid artery stenting. J Int Med Res 2018; 46:1866-1875. [PMID: 29552932 PMCID: PMC5991223 DOI: 10.1177/0300060518762949] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Purpose To determine the best platelet function test for in-stent tissue protrusion following carotid artery stenting (CAS). Methods Patients who underwent CAS were recruited prospectively in this observational study. Combination of aspirin 100 mg/day and clopidogrel 75 mg/day was administered for a minimum of 7 days prior to procedure. Platelet aggregation was measured by light transmittance aggregometry (LTA) following stimulation by adenosine diphosphate (ADP), collagen, and thrombin receptor activating peptide (TRAP) and by the point of care assay, VerifyNow which measures aspirin and thienopyridine reaction units. Results In-stent tissue protrusion with maximum projection area of ≥1 mm2 was detected by optical coherence tomography (OCT) in 10/28 (36%) patients. Baseline characteristics were not significantly different between the two in-stent size groups (i.e., ≥1 mm2 vs. <1 mm2) but after stimulation by collagen at 10 and 20 μg/ml, platelet reactivity as measured by LTA was significantly higher in the ≥1 mm2 group compared with the <1 mm2 group. No other differences in platelet function were detected. Conclusions Collagen-induced platelet reactivity was related to in-stent tissue protrusion size following CAS.
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Affiliation(s)
- Masanori Tsujimoto
- 1 Department of Neurosurgery, 73882 Daiyukai General Hospital, Sakura, Ichinomiya city, Aichi, Japan.,2 Department of Neurosurgery, Gifu University Graduate School of Medicine, Yanagido, Gifu city, Gifu, Japan
| | - Yukiko Enomoto
- 2 Department of Neurosurgery, Gifu University Graduate School of Medicine, Yanagido, Gifu city, Gifu, Japan
| | - Masafumi Miyai
- 2 Department of Neurosurgery, Gifu University Graduate School of Medicine, Yanagido, Gifu city, Gifu, Japan
| | - Yusuke Egashira
- 2 Department of Neurosurgery, Gifu University Graduate School of Medicine, Yanagido, Gifu city, Gifu, Japan
| | - Toru Iwama
- 2 Department of Neurosurgery, Gifu University Graduate School of Medicine, Yanagido, Gifu city, Gifu, Japan
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Puentes JC, Quintero ST, Uriza LF, Rueda MA, Piedrahita A, Contreras V. Complicaciones trombóticas y hemorrágicas en pacientes con aneurismas cerebrales tratados por vía endovascular y su relación con el uso de antiagregantes plaquetarios: evaluación descriptiva. Neurocirugia (Astur) 2018; 29:18-24. [DOI: 10.1016/j.neucir.2017.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 08/08/2017] [Accepted: 08/16/2017] [Indexed: 11/28/2022]
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Labruyère C, Reny JL, Chapelle C, Piot M, Fontana P, Gris JC, Delavenne X, Mismetti P, Laporte S, Mallouk N. Prevalence of poor biological response to clopidogrel. Thromb Haemost 2017; 107:494-506. [DOI: 10.1160/th11-03-0202] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Accepted: 12/14/2011] [Indexed: 12/28/2022]
Abstract
SummaryThe existence of poor biological response to clopidogrel has been shown in some patients. Despite the increasing number of studies, this phenomenon remains difficult to quantify. We performed a systematic review to estimate the prevalence of poor biological response to clopidogrel and investigate the factors known to modulate this. An exhaustive search was performed. Altogether 171 publications were identified, providing data for a total of 45,664 subjects. The estimated prevalence of poor biological response to clopidogrel ranged from 15.9% to 49.5% according to the platelet function assay employed. The assays most frequently used were light transmittance aggregometry (LTA), the vasodilator-stimulated phosphoprotein (VASP) assay and the Verify -now® assay. For all these assays, higher cut-off values were associated with a lower prevalence of poor biological response to clopidogrel. However, when choosing a fixed cut-off point for each assay, the prevalence of poor biological response to clopidogrel was highly variable suggesting that other factors could modulate poor biological response to clopidogrel. Finally, none of the studied factors could apparently explain the variability of poor biological response to clopidogrel. This meta-analysis shows that the prevalence of poor biological response depends on the assay employed, the cut-off value and on various unidentified additional factors.
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Al-Jabi SW. Global Trends in Aspirin Resistance-Related Research from 1990 to 2015: A Bibliometric Analysis. Basic Clin Pharmacol Toxicol 2017; 121:512-519. [PMID: 28667787 DOI: 10.1111/bcpt.12840] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 06/27/2017] [Indexed: 12/14/2022]
Abstract
Aspirin resistance can be defined as the inability of the usual dose of aspirin medication to produce its antithrombotic effect. Patients with diabetes or cardiovascular disease are at higher risk of stroke, myocardial infarction or cardiovascular death due to aspirin resistance. The aim of this bibliometric study was to identify and analyse the status and trends of aspirin resistance research production at global level through publications indexed in the Scopus database; this will shed new light on future research trends and help researchers predict dynamic direction of research. Literature search using the Scopus database was conducted to assess publications related to aspirin resistance. The selected publications included the terms related to aspirin resistance in the title, abstract or keywords. The searching was accomplished on 20 March 2016 and can be considered to include all publications up to 31 December 2015. Global cumulative publication output on aspirin resistance consists of 986 papers during 1990-2015. Among the 986 documents, 19 (1.9%) were published before 2000, 567 (57.5%) were published from 2000 to 2009 and 400 (40.6%) were published from 2010 to 2015, with peak of publications on this topic in 2008. The leading country in the field of aspirin resistance was the United States, which had the greatest counts of independent articles (165) and international collaboration articles (44). Turkey was in the second rank with 78 articles, followed by Italy (68), the UK (62) and Poland (60). The total number of citations for all documents was 26,342, and the average citations per document were 26.7. The h-index for all aspirin resistance publications was 82. This study presents the results of the first bibliometric study (including quantitative and qualitative analysis) of scientific publications in the field of aspirin renitence at global level. Aspirin resistance-related researches have notably increased in the last years, especially from 2000 to 2015. The United States is the most prolific country, not only in research quantity but also in quality. Furthermore, Turkey and European countries provided more research related to aspirin resistance than other regions such as the developing countries.
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Affiliation(s)
- Samah W Al-Jabi
- Department of Clinical and Community Pharmacy, Faulty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
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Does i-T744C P2Y12 Polymorphism Modulate Clopidogrel Response among Moroccan Acute Coronary Syndromes Patients? GENETICS RESEARCH INTERNATIONAL 2017; 2017:9532471. [PMID: 28261502 PMCID: PMC5316454 DOI: 10.1155/2017/9532471] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 01/03/2017] [Accepted: 01/12/2017] [Indexed: 12/11/2022]
Abstract
Background. An interindividual variability in response to Clopidogrel has been widely described in patients with acute coronary syndromes (ACS). The contribution of genetics on modulating this response was widely discussed. The objective of our study was to investigate the potential effect of i-T744C P2Y12 polymorphism on Clopidogrel response in a sample of Moroccan ACS patients. We tried also to determine the frequency of this polymorphism among Moroccan ACS compared to healthy subjects. Methods and Results. 77 ACS patients versus 101 healthy controls were recruited. DNA samples were genotyped by PCR-RFLP method. The VerifyNow assay was used to evaluate platelet function among ACS patients. Our results show that the mutant allele C was more frequent among ACS ST (+) than ST (−) patients (39% versus 19.8%, resp.), when the wild-type allele was more represented in the ACS ST (−) group (80.2%). The C allele frequency was higher among resistant than nonresistant patients (30% versus 20.8%, resp.). Comparison of ACS patients and healthy controls shows higher frequency of mutant C allele among cases compared to controls (22.73% versus 19.31%, resp.); there was a statistically significant association of the recessive and additive transmission models with the ACS development risk (OR [95% CI] = 1.78 [1.58–5.05], P = 0.01 and OR [95% CI] = 1.23 [0.74–2.03], P < 0.001, resp.), increasing thus the association of this polymorphism with the pathology. Conclusion. Our results suggest that this polymorphism may have a potential effect on Clopidogrel response among our Moroccan ACS patients and also on ACS development.
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Liu LX, Song MY, Xie XD. In-stent stenosis in the patient with internal carotid aneurysm after treated by the Willis covered stent: Two case reports and literature review. Medicine (Baltimore) 2017; 96:e6101. [PMID: 28207524 PMCID: PMC5319513 DOI: 10.1097/md.0000000000006101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
UNLABELLED In-stent stenosis after treated by Willis covered stent-case reports. BACKGROUND Advancements in minimally invasive technology have allowed endovascular reconstruction of internal carotid aneurysm. However, in-stent stenosis is an important and well-characterized complication of stenting after the treatment of internal carotid aneurysm. CASE DESCRIPTION We would present 2 patients who were diagnosed with in-stent stenosis after the treatment of Willis covered stent. Case 1: A 57-year-old female with 2-week history of headache and vomiting before admission, whose digital subtraction angiography (DSA) demonstrated left internal carotid C6 aneurysm and showed about 20% stenosis 3 months later since operation in the position where Willis covered stent was deployed. Case 2: A 23-year-old male with skull base fracture, subarachnoid hemorrhage, right femoral fracture for 14 days and epistaxis for 9 hours caused by a car accident, whose DSA demonstrated left internal carotid paracliniod pseudoaneurysm. One year later, the patient went to our center again because he had headache and dizziness for 6 months after the interventional operation. His DSA demonstrated about 80% stenosis in the position where Willis covered stent was deployed. The clinical and radiologic characteristics and the experience in dealing with the stenosis are presented. CONCLUSIONS In-stent stenosis after treated with Willis covered is uncommon, but not rare. Operators should pay more attention to the in-stent stenosis during the period of follow-up observation and monitor P2Y12 Reaction Unit (PRU) in the antiplatelet period, especially for the Willis covered stent. What is more, the treatment for stenosis ought to be carefully considered.
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Affiliation(s)
- Lun-Xin Liu
- Department of Neurosurgery, West China Hospital
| | - Meng-Yuan Song
- School of Basic Science and Forensic Medicine, Sichuan University, Chengdu, Sichuan, People's Republic of China
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Duconge J, Hernandez-Suarez DF. Potential Usefulness of Clopidogrel Pharmacogenetics in Cerebral Endovascular Procedures and Carotid Artery Stenting. CURRENT CLINICAL PHARMACOLOGY 2017; 12:11-17. [PMID: 28245774 PMCID: PMC5478430 DOI: 10.2174/1574884712666170227154654] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 02/17/2017] [Accepted: 02/21/2017] [Indexed: 01/22/2023]
Abstract
BACKGROUND Previous reports have shown inadequate response to dual antiplatelet therapy (DAPT) with aspirin and clopidogrel in 5-30% of patients undergoing percutaneous coronary interventions (PCI), due mostly to clopidogrel resistance. This prevalence increases up to 66% in patients undergoing neurointerventional procedures. However, clinical significance of CYP2C19 genotypes in neurointerventional procedures or carotid artery stenting (CAS) is unknown. OBJECTIVE The purpose of this review is to update our current knowledge and understanding of the pharmacogenetic basis for poor clopidogrel responsiveness in patients undergoing CAS and endovascular interventions as well as to explore usefulness of genotyping to reduce the rate of procedure-related thrombosis that results in ischemic complications. METHOD A literature search for pharmacogenetic studies in cerebral endovascular interventions and CAS was conducted on three databases using a list of the most relevant pharmacogenetic biomarkers. RESULTS The review included 7 papers involving 3 genetic polymorphisms on CYP2C19 and 442 subjects. Patients harboring at least one loss-of-function CYP2C19 polymorphism (e.g., CYP2C19*2 and *3) are at an increased risk of thromboembolic complications such as stent thrombosis following neurointerventional procedures. Notably, patients who carry the gain-of-function CYP2C19*17 allele may have increased risk of ischemic events following endovascular treatment, independent of clopidogrel responsiveness. CONCLUSION Studies assessing the influence of CYP2C19 polymorphisms on high on-treatment platelet reactivity in CAS and cerebrovascular disease patients are still limited and need further validation in large multicenter studies. This review covers an important topic in the field of antiplatelet therapy for cerebral endovascular procedures and CAS.
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Affiliation(s)
- Jorge Duconge
- Pharmaceutical Sciences Department, School of Pharmacy, University of Puerto Rico Medical Sciences Campus (UPR-MSC), San Juan, PR, USA
| | - Dagmar F. Hernandez-Suarez
- Department of Medicine, School of Medicine, University of Puerto Rico Medical Sciences Campus (UPR-MSC), San Juan, PR, USA
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Runjaic S, Nordeen JD, Soto-Arenall MW, Johns GS, Miller D, Brown B, Freeman WD. Safety and Efficacy of Intensified Antiplatelet Therapy in Patients Undergoing Neuroendovascular Procedures. JOURNAL OF VASCULAR AND INTERVENTIONAL NEUROLOGY 2017; 9:51-56. [PMID: 28243352 PMCID: PMC5317284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
INTRODUCTION The purpose of this study was to evaluate safety and efficacy of intensified antiplatelet therapy guided by VerifyNow assay P2Y12 reaction unit (PRU) reported values in patients undergoing neuroendovascular procedures. METHODS An observational, retrospective review was conducted at a single academic tertiary referral center and comprehensive stroke center from December 1, 2012, to August 31, 2014. The primary objective was to determine the prevalence of thromboembolic complications stratified by preprocedural PRU values. Secondary outcomes were assessed by investigating whether the goal PRU value of 190 or less is sufficient to reduce thromboembolic complications on the day of the procedure, and 30- and 90-day postprocedure. RESULTS There was no statistically significant difference in the overall rate of complications in the two groups (two events in the group with preprocedural PRU values of 190 or more versus seven events in the group with preprocedural PRU values of less than 190, p = 0.668). Furthermore, the rates of thromboembolic events by 90 days were not significantly different in the two groups (one event in the group with preprocedural PRU ≥ 190 versus four events in patients with preprocedural PRU < 190, p = 1). Similarly, there was no statistically significant difference in the rate of hemorrhagic events in the two groups by 90-day postprocedure (one versus three events, p = 0.558). CONCLUSION The observed rate of thromboembolic and hemorrhagic complications in patients with preprocedural PRU values of less than 190 was not significantly different from the rate observed in patients with preprocedural PRU values of greater than 190. Sources of funding: No external funding used.
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Affiliation(s)
- Senka Runjaic
- Department of Pharmacy, Mayo Clinic, Jacksonville, FL, USA
| | | | | | - Gretchen S. Johns
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, FL, USA
| | - David Miller
- Neuroendovascular Division, Department of Neurosurgery, Mayo Clinic, Jacksonville, FL, USA
| | - Benjamin Brown
- Neuroendovascular Division, Department of Neurosurgery, Mayo Clinic, Jacksonville, FL, USA
| | - William D. Freeman
- Departments of Neurology, Neurosurgery, and Critical Care, Mayo Clinic, Jacksonville, FL, USA
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Establishing a predictive model for aspirin resistance in elderly Chinese patients with chronic cardiovascular disease. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2016; 13:458-64. [PMID: 27594876 PMCID: PMC4984570 DOI: 10.11909/j.issn.1671-5411.2016.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Background Resistance to anti-platelet therapy is detrimental to patients. Our aim was to establish a predictive model for aspirin resistance to identify high-risk patients and to propose appropriate intervention. Methods Elderly patients (n = 1130) with stable chronic coronary heart disease who were taking aspirin (75 mg) for > 2 months were included. Details of their basic characteristics, laboratory test results, and medications were collected. Logistic regression analysis was performed to establish a predictive model for aspirin resistance. Risk score was finally established according to coefficient B and type of variables in logistic regression. The Hosmer–Lemeshow (HL) test and receiver operating characteristic curves were performed to respectively test the calibration and discrimination of the model. Results Seven risk factors were included in our risk score. They were serum creatinine (> 110 μmol/L, score of 1); fasting blood glucose (> 7.0 mmol/L, score of 1); hyperlipidemia (score of 1); number of coronary arteries (2 branches, score of 2; ≥ 3 branches, score of 4); body mass index (20–25 kg/m2, score of 2; > 25 kg/m2, score of 4); percutaneous coronary intervention (score of 2); and smoking (score of 3). The HL test showed P ≥ 0.05 and area under the receiver operating characteristic curve ≥ 0.70. Conclusions We explored and quantified the risk factors for aspirin resistance. Our predictive model showed good calibration and discriminative power and therefore a good foundation for the further study of patients undergoing anti-platelet therapy.
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Daou B, Starke RM, Chalouhi N, Barros G, Tjoumakaris S, Rosenwasser RH, Jabbour P. P2Y12 Reaction Units: Effect on Hemorrhagic and Thromboembolic Complications in Patients With Cerebral Aneurysms Treated With the Pipeline Embolization Device. Neurosurgery 2016; 78:27-33. [PMID: 26571145 DOI: 10.1227/neu.0000000000000978] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The main concern with the use of the pipeline embolization device (PED) in treating cerebral aneurysms is the risk of hemorrhagic and thromboembolic complications. OBJECTIVE To investigate if P2Y12 reaction unit (PRU) values are associated with hemorrhagic and thromboembolic complications after treatment with the PED and to find an optimal range of preprocedural PRU values. METHODS Two hundred thirty-one patients with 248 cerebral aneurysms treated with the PED were retrospectively identified. Patients were started on dual-antiplatelet treatment at least 10 days before the intervention. PRU values were checked. Univariate and multivariate logistic regression were performed. Youden Indices were calculated to determine cutoffs for optimal PRU values. RESULTS Mean patient age was 57 years. Mean last preprocedural PRU was 132 (range: 1-382). The combined rate of major hemorrhagic complications (4%) and major thromboembolic complications (5.6%) was 9.6%. Analysis using Youden indices suggested an optimal PRU range of 70 to 150 with higher odds of complications outside this range (P = .01, odds ratio [OR] = 3 [1.2-7.5]). PRU <60 was a significant predictor of hemorrhagic complications (P = .04, OR = 2.45 [1.01-5.9]) and PRU >240 was a significant predictor of any thromboembolic complication (P = .04, OR = 3.6 [1.04-12]) and cerebral thromboembolic complications (P = .02, OR = 4 [1.2-14]). CONCLUSION Target preoperative PRU values should be between 60 and 240 and ideally between 70 and 150. Values below this range and above it carry higher odds of hemorrhagic and thromboembolic complications, respectively.
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Affiliation(s)
- Badih Daou
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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Tsujimoto M, Enomoto Y, Kokuzawa J, Iwama T. Diabetes mellitus and carotid artery plaques exhibiting high-intensity signals on MR angiography are related to increased platelet reactivity after carotid artery stenting. J Neurointerv Surg 2016; 9:106-110. [PMID: 27370776 PMCID: PMC5264231 DOI: 10.1136/neurintsurg-2016-012419] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 06/07/2016] [Accepted: 06/15/2016] [Indexed: 11/25/2022]
Abstract
Background Increased platelet reactivity after carotid artery stenting (CAS) may cause thromboembolic complications. Objective This study aimed to investigate the incidence of increased platelet reactivity after CAS and to determine the factors related to it. Methods Patients who underwent CAS were recruited prospectively. They received pre-procedural antiplatelet therapy comprising some combination of aspirin (100 mg/day), clopidogrel (75 mg/day), and/or cilostazol (200 mg/day) for a minimum of 7 days. ADP- and collagen-induced platelet aggregation were measured before and 4 days after CAS. Changes in platelet reactivity were reported as changes in the categorized platelet reactivity grade based on the effective dose 50%. Clinical characteristics of patients with and without increased platelet reactivity were compared. Results Among 38 consecutive patients who underwent CAS, 18 (47%) exhibited increased platelet reactivity. Diabetes mellitus (OR 15.0; 95% CI 2.1 to 106.5; p=0.007) and carotid artery plaques exhibiting high-intensity signals (HIS) on time-of-flight MR angiography (TOF-MRA) (OR 25.2; 95% CI 2.0 to 316.2; p=0.013) were independently associated with increased platelet reactivity in a multivariate analysis. Conclusions Increased platelet reactivity occurred in nearly half of the studied patients subjected to CAS and was independently associated with diabetes mellitus and carotid artery plaques exhibiting HIS on TOF-MRA.
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Affiliation(s)
- Masanori Tsujimoto
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yukiko Enomoto
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Jouji Kokuzawa
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Toru Iwama
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
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Khatri S, Pierce T. Comparing prasugrel to twice daily clopidogrel post percutaneous coronary intervention in a Veterans Affairs population. Am J Health Syst Pharm 2016; 72:S98-S103. [PMID: 26272900 DOI: 10.2146/sp150017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The purpose of this study was to compare various antiplatelet regimens in patients who experienced increased platelet reactivity on clopidogrel therapy with regards to cardiovascular outcomes, including need for revascularization, myocardial infarction (MI), stroke, and cardiovascular (CV) death. METHODS A retrospective chart review was conducted on patients who received percutaneous coronary intervention (PCI) at the Richard L. Roudebush Veterans Affairs Medical Center and were subsequently prescribed either clopidogrel 75 mg twice daily, prasugrel 10 mg daily, or clopidogrel 75 mg daily with high platelet reactivity between October 1, 2009 and November 30, 2010. Correlations between antiplatelet regimens and prevention of cardiovascular outcomes and bleeding events were evaluated. Groups were evaluated statistically as two separate comparisons; the first comparison being clopidogrel twice daily versus prasugrel and the second comparison being clopidogrel twice daily versus clopidogrel daily in those patients with a P2Y12 test result of less than 50%. RESULTS A total of 108 patients were included in the study. Eight events occurred in the clopidogrel twice daily group (n = 26), including five revascularizations and three MIs. Seven events occurred in the prasugrel group (n = 64), including two revascularizations, two MIs, two strokes, and one CV death. The difference between these groups was statistically significant (p = 0.031), with patients in the prasugrel group experiencing fewer events. Five events occurred in the clopidogrel daily group (n = 18), including one need for revascularization, two MIs, and two instances of CV death. There were no statistically significant differences in CV events between the clopidogrel twice daily group and clopidogrel daily group (p > 0.999). There were also no statistically significant differences in bleeding incidents for either of the comparisons; p > 0.999 and p = 0.676 respectively for the first and second comparisons. CONCLUSION Patients on prasugrel had fewer cardiovascular events as compared to patients on clopidogrel twice daily with no difference in bleeding events. No difference was seen with regards to cardiovascular or bleeding events when comparing clopidogrel twice daily to clopidogrel daily in patients with increased platelet reactivity. Study results suggest that there is no benefit to dosing clopidogrel twice daily when compared to either prasugrel or once daily clopidogrel dosing.
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Affiliation(s)
- Samreen Khatri
- Clinical Pharmacist, Richard L. Roudebush VA Medical Center, Indianapolis, IN
| | - Tamra Pierce
- Critical Care Clinical Pharmacy Specialist, Richard L. Roudebusch VA Medical Center, Indianapolis, IN
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Fan L, Tan X, Xiong Y, Zheng K, Li Z, Liu D, Zhong M, Zhao B. Stent-assisted coiling versus coiling alone of ruptured anterior communicating artery aneurysms: A single-center experience. Clin Neurol Neurosurg 2016; 144:96-100. [PMID: 27037864 DOI: 10.1016/j.clineuro.2016.03.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 03/21/2016] [Accepted: 03/24/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Endovascular coiling of anterior communicating artery (ACoA) aneurysms has evolved; however, stent-assisted coiling of ruptured aneurysms remains controversial. We aimed to compare periprocedural complications, angiographic and clinical outcomes after stent-assisted coiling with coiling alone of ruptured ACoA aneurysms. METHODS We performed a retrospective review of consecutive 222 patients with ruptured ACoA aneurysms treated with endovascular coiling within 7 days after ictus. Patients were grouped into stent-assisted coiling and coiling alone groups. Baseline characteristics, periprocedural complications, clinical outcomes, and angiographic results were compared between the two groups. RESULTS 63 (28.4%) patients underwent stent-assisted coiling and 159 (71.6%) underwent coiling alone. There were no statistically significant differences in age, sex, clinical grading and Fisher grade. Larger aneurysms (P=0.002) and wider-neck aneurysms (P<0.001) were more often treated with stent-assisted coiling within 72h (P=0.025). Intraprocedural aneurysm rupture occurred in 6 (9.5%) patients treated with stent-assisted coiling compared with in 5 (3.1%) treated with coiling alone (P<0.048). Thrombus formation occurred in 10 (15.9%) patients after stent-assisted coiling compared with 6 (3.8%) after coiling alone (P=0.002). Stent-assisted coiling achieved a lower rate of immediate occlusion than coiling alone (P=0.045). Postoperative complications, clinical outcomes, and follow-up aneurysm occlusion did not significantly differ. CONCLUSIONS Stent-assisted coiling of ruptured ACoA aneurysms was associated with a higher rate of intraprocedural complications and associated with a lower immediate occlusion rate. However, Postoperative complications and clinical outcomes did not differ. Long-term angiographic results require further study.
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Affiliation(s)
- Lianghao Fan
- Department of Interventional Radiology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xianxi Tan
- Department of Neurosurgery, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ye Xiong
- Department of Neurosurgery, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Kuang Zheng
- Department of Neurosurgery, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zequn Li
- Department of Neurosurgery, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Dajun Liu
- Department of Neurosurgery, the Second Renmin Hospital of Taizhou, Taizhou, China
| | - Ming Zhong
- Department of Neurosurgery, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Bing Zhao
- Department of Neurosurgery, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China; Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA.
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Flechtenmacher N, Kämmerer F, Dittmer R, Budde U, Michels P, Röther J, Eckert B. Clopidogrel Resistance in Neurovascular Stenting: Correlations between Light Transmission Aggregometry, VerifyNow, and the Multiplate. AJNR Am J Neuroradiol 2015; 36:1953-8. [PMID: 26272977 DOI: 10.3174/ajnr.a4388] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 03/03/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Clopidogrel resistance is blamed for thromboembolic complications in neurovascular stent placement. Platelet-function assays are weakly standardized. The aim of this study was to correlate the results of 3 different platelet-inhibition measurements (from light transmission aggregometry, the VerifyNow P2Y12 test, and the Multiplate analyzer) and their relation to periprocedural thromboembolic complications in elective neurovascular stent placement. MATERIALS AND METHODS Clopidogrel resistance was determined on the day of the intervention according to predefined platelet reactivity cutoff values. All 3 tests were performed in 103 consecutive neurovascular stent-placement procedures in 97 patients (extracranial, n = 77; intracranial, n = 26). RESULTS The clopidogrel resistance rates were 47.6% (light transmission aggregometry), 50.5% (VerifyNow), and 35.9% (Multiplate). In 67% of the patients, clopidogrel resistance was present according to at least one method. The correlations of qualitative results that classified a patient as responsive or resistant to clopidogrel were 67.9% for light transmission aggregometry with VerifyNow, 77.7% for light transmission aggregometry with the Multiplate, and 66% for VerifyNow with the Multiplate. Periprocedural thromboembolic complications (n = 9) occurred more frequently in patients who were determined by all 3 methods to be clopidogrel resistant. The difference was most pronounced with light transmission aggregometry (complication rates, 14.4% [clopidogrel-resistant patients] vs 3.7% [clopidogrel-responsive patients]). Sensitivity and specificity rates of clopidogrel resistance in relation to embolic complications were, respectively, 78% and 55% for light transmission aggregometry, 67% and 51% for VerifyNow, and 44% and 67% for the Multiplate. CONCLUSIONS Clopidogrel resistance is a frequent finding in patients who undergo neurovascular stent placement. The correlations among the different testing methods are only modest and differ considerably. Light transmission aggregometry results seem to correlate with thromboembolic complications more accurately than with VerifyNow and Multiplate point-of-care methods.
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Affiliation(s)
| | - F Kämmerer
- From the Departments of Neuroradiology (N.F., F.K., B.E.)
| | - R Dittmer
- Department of Laboratory Medicine (R.D., U.B.), Medilys Laboratory Company, Hamburg, Germany
| | - U Budde
- Department of Laboratory Medicine (R.D., U.B.), Medilys Laboratory Company, Hamburg, Germany
| | - P Michels
- Neurology (P.M., J.R.), Asklepios Klinik Altona, Hamburg, Germany
| | - J Röther
- Neurology (P.M., J.R.), Asklepios Klinik Altona, Hamburg, Germany
| | - B Eckert
- From the Departments of Neuroradiology (N.F., F.K., B.E.)
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Park WB, Sung JH, Huh J, Cho CB, Yang SH, Kim IS, Hong JT, Lee SW. Double Stent Assist Coiling of Ruptured Large Saccular Aneurysm in Proximal Basilar Artery Fenestration. J Cerebrovasc Endovasc Neurosurg 2015; 17:227-33. [PMID: 26523257 PMCID: PMC4626347 DOI: 10.7461/jcen.2015.17.3.227] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 08/24/2015] [Accepted: 09/10/2015] [Indexed: 11/23/2022] Open
Abstract
Basilar artery fenestration is infrequent and even rarer in association with a large aneurysm. With proximity to brain stem and vital perforators, endovascular coiling can be considered first. If the large ruptured aneurysm with a wide neck originated from fenestra of the proximal basilar artery and the fenestration loop has branches of posterior circulation, therapeutic consideration should be thorough and fractionized. We report endovascular therapeutic details for a case of a ruptured large saccular aneurysm in proximal basilar artery fenestration.
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Affiliation(s)
- Woong Bae Park
- Cerebrovascular center, Department of Neurosurgery, St. Vincent's Hospital, The Catholic University of Korea, Suwon, Korea
| | - Jae Hoon Sung
- Cerebrovascular center, Department of Neurosurgery, St. Vincent's Hospital, The Catholic University of Korea, Suwon, Korea
| | - Joon Huh
- Cerebrovascular center, Department of Neurosurgery, St. Vincent's Hospital, The Catholic University of Korea, Suwon, Korea
| | - Chul Bum Cho
- Cerebrovascular center, Department of Neurosurgery, St. Vincent's Hospital, The Catholic University of Korea, Suwon, Korea
| | - Seung Ho Yang
- Cerebrovascular center, Department of Neurosurgery, St. Vincent's Hospital, The Catholic University of Korea, Suwon, Korea
| | - Il Sup Kim
- Cerebrovascular center, Department of Neurosurgery, St. Vincent's Hospital, The Catholic University of Korea, Suwon, Korea
| | - Jae Taek Hong
- Cerebrovascular center, Department of Neurosurgery, St. Vincent's Hospital, The Catholic University of Korea, Suwon, Korea
| | - Sang Won Lee
- Cerebrovascular center, Department of Neurosurgery, St. Vincent's Hospital, The Catholic University of Korea, Suwon, Korea
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Lin M, Todaro M, Chan J, Churilov L, Zhu WS, Ramdave S, Mitchell PJ, Dowling RJ, Kwan P, Yan B. Association between CYP2C19 Polymorphisms and Outcomes in Cerebral Endovascular Therapy. AJNR Am J Neuroradiol 2015; 37:108-13. [PMID: 26338921 DOI: 10.3174/ajnr.a4481] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Accepted: 06/04/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Differing responses to clopidogrel following endovascular treatment of cerebrovascular diseases may increase the risk of vascular complications. CYP2C19 gene polymorphisms influence clopidogrel activity. We aimed to study the clinical impact of CYP2C19 gene polymorphisms in patients undergoing endovascular treatment. MATERIALS AND METHODS This was a prospective, longitudinal, observational study. Information on demographics and cerebrovascular status was collected as baseline. Clopidogrel response was tested by the VerifyNow P2Y12 assay. CYP2C19 genotyping was undertaken by polymerase chain reaction-restriction fragment length polymorphism. Three-month follow-up data included vascular complications, mortality, and modified Rankin Scale score. Associations were investigated among CYP2C19 genotypes, clopidogrel responsiveness, and clinical outcomes. RESULTS One hundred and eight participants were included. Median age was 56 years (interquartile range, 48.8-65.0 years), and 35 (32.4%) were male. Forty-four participants were classified into group 1 (homozygous CYP2C19*1/*1); 31, into group 2 (25 with CYP2C19*1/*2, two with CYP2C19*1/*3, three with CYP2C19*3/*3, one with CYP2C19*2/*3); 28, into group 3 (24 with CYP2C19*1/*17, four with CYP2C19*17/*17); and 5, into group 4 (CYP2C19*2/*17). A significantly higher proportion of participants in group 3 experienced ischemic events (9 of 28, 32.1%) compared with group 1 (5 of 44, 11.4%; P = .04; odds ratio, 3.7; 95% confidence interval, 1.1-12.6). There was no significant difference in clopidogrel response among the 4 genotype groups. CONCLUSIONS Individuals with CYP2C19*17 may have increased risk of ischemic events following endovascular treatment, independent of clopidogrel responsiveness. Larger studies are required to confirm the influence of CYP2C19*17 on clinical outcomes and to understand the mechanisms for increased ischemic events.
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Affiliation(s)
- M Lin
- From the Melbourne Brain Centre (M.L., W.S.Z., B.Y.)
| | - M Todaro
- Neurology (M.T., P.K., B.Y.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia Department of Medicine (M.T., J.C., S.R., P.K.), University of Melbourne, Melbourne, Victoria, Australia
| | - J Chan
- Department of Medicine (M.T., J.C., S.R., P.K.), University of Melbourne, Melbourne, Victoria, Australia
| | - L Churilov
- Florey Institute of Neurosciences and Mental Health (L.C.), Melbourne Brain Centre, Heidelberg, Victoria, Australia
| | - W S Zhu
- From the Melbourne Brain Centre (M.L., W.S.Z., B.Y.)
| | - S Ramdave
- Department of Medicine (M.T., J.C., S.R., P.K.), University of Melbourne, Melbourne, Victoria, Australia
| | | | - R J Dowling
- Departments of Radiology (P.J.M., R.J.D., B.Y.)
| | - P Kwan
- Neurology (M.T., P.K., B.Y.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia Department of Medicine (M.T., J.C., S.R., P.K.), University of Melbourne, Melbourne, Victoria, Australia
| | - B Yan
- From the Melbourne Brain Centre (M.L., W.S.Z., B.Y.) Departments of Radiology (P.J.M., R.J.D., B.Y.) Neurology (M.T., P.K., B.Y.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
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Kass-Hout T, Alderazi YJ, Amuluru K, Jin P, Ayala C, Prestigiacomo C, Gandhi CD. Neurointerventional Stenting and Antiplatelet Function Testing: To Do or Not to Do? INTERVENTIONAL NEUROLOGY 2015; 3:184-9. [PMID: 26279665 DOI: 10.1159/000431261] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND PURPOSE Platelet function testing in neurointerventional (NI) procedures is still controversial. We compared the clinical outcomes between antiplatelet responders and nonresponders based on the results of the VerifyNow (VN) testing method. METHODS This is a retrospective single-center analysis of all consecutive patients who underwent NI stenting procedures from January 2007 through July 2013 and had documented preprocedural aspirin (ASA) and clopidogrel VN assays. Patients were divided into two groups based on their responsiveness to antiplatelet. Baseline characteristics, good functional outcome measured by the modified Rankin Scale (mRS) at 90 days, combined procedural complication rate defined as postprocedural stroke, in-stent thrombosis, and intraoperative rupture were compared between the two groups. RESULTS Our cohort included 37 patients: 26 were in the responder group (RG) and 11 were in the nonresponder group (NRG). Baseline characteristics were similar between the two groups. Even though the combined complication rate was similar between the two groups [NRG: 2/11 (18%) vs. RG: 2/26 (7%); p = 0.33], there was a trend for a higher rate of good functional outcome (90-day mRS: 0-2) in the RG (22/22, 100%) as compared to the NRG (8/10, 80%) (p = 0.0907). CONCLUSION Overall, utilizing the VN antiplatelet function testing did not significantly change the clinical outcome after the NI procedures. Larger randomized trials are warranted to provide a better understanding of the utility of the antiplatelet testing in NI stenting procedures.
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Affiliation(s)
- Tareq Kass-Hout
- Department of Neurosurgery and Neuroscience, Rutgers University School of Medicine, Newark, N.J., USA
| | - Yazan J Alderazi
- Department of Neurosurgery and Neuroscience, Rutgers University School of Medicine, Newark, N.J., USA
| | - Krishna Amuluru
- Department of Neurosurgery and Neuroscience, Rutgers University School of Medicine, Newark, N.J., USA
| | - Peter Jin
- Department of Neurosurgery and Neuroscience, Rutgers University School of Medicine, Newark, N.J., USA
| | - Carlos Ayala
- Department of Neurosurgery and Neuroscience, Rutgers University School of Medicine, Newark, N.J., USA
| | - Charles Prestigiacomo
- Department of Neurosurgery and Neuroscience, Rutgers University School of Medicine, Newark, N.J., USA ; Department of Neurology, Rutgers University School of Medicine, Newark, N.J., USA ; Department of Radiology, Rutgers University School of Medicine, Newark, N.J., USA
| | - Chirag D Gandhi
- Department of Neurosurgery and Neuroscience, Rutgers University School of Medicine, Newark, N.J., USA ; Department of Neurology, Rutgers University School of Medicine, Newark, N.J., USA ; Department of Radiology, Rutgers University School of Medicine, Newark, N.J., USA
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Song J, Yeon JY, Kim JS, Hong SC, Kim KH, Jeon P. Delayed thromboembolic events more than 30 days after self expandable intracranial stent-assisted embolization of unruptured intracranial aneurysms. Clin Neurol Neurosurg 2015; 135:73-8. [DOI: 10.1016/j.clineuro.2015.05.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 05/13/2015] [Accepted: 05/14/2015] [Indexed: 10/23/2022]
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Briganti F, Delehaye L, Leone G, Sicignano C, Buono G, Marseglia M, Caranci F, Tortora F, Maiuri F. Flow diverter device for the treatment of small middle cerebral artery aneurysms. J Neurointerv Surg 2015; 8:287-94. [PMID: 25603808 DOI: 10.1136/neurintsurg-2014-011460] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 12/29/2014] [Indexed: 11/03/2022]
Abstract
PURPOSE Experience with the endovascular treatment of middle cerebral artery (MCA) aneurysms by flow diverter devices (FDD) is still limited. This study examines the results and complications of FDD for small aneurysms at this location. METHODS From February 2010 to December 2013, 14 patients (10 women; mean age 59 years) with 15 small MCA aneurysms were treated with FDD. All procedures were performed with the Pipeline embolization device (PED). RESULTS Complete occlusion was obtained in 12/15 aneurysms (80%) and partial occlusion in 3 (20%). Among 13 aneurysms with a side branch, this was patent at the angiographic control in 4 cases, showed decreased filling in 6, and was occluded in 3 (with neurological deficits in 2). All PEDs were patent at follow-up. Post-procedural ischemic complications occurred in 4 (27%) procedures with permanent neurological deficit (modified Rankin score 2) in 3 (21%). No early or delayed aneurysm rupture, no subarachnoid or intraparenchymal hemorrhage and no deaths occurred. CONCLUSIONS Endovascular treatment with FDD is a relatively safe treatment for small MCA aneurysms resulting in a high occlusion rate. The findings of this study suggest that complete occlusion after endovascular treatment with FDD can be delayed (>6 months). Ischemic complications may occur as early or delayed, particularly at clopidogrel interruption.
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Affiliation(s)
- Francesco Briganti
- Unit of Interventional Neuroradiology, Department of Advanced Biomedical Sciences, "Federico II" University, Naples, Italy
| | - Luigi Delehaye
- Unit of Interventional Neuroradiology, San Giovanni Bosco Hospital, Naples, Italy
| | - Giuseppe Leone
- Unit of Interventional Neuroradiology, Department of Advanced Biomedical Sciences, "Federico II" University, Naples, Italy
| | - Carmine Sicignano
- Unit of Interventional Neuroradiology, San Giovanni Bosco Hospital, Naples, Italy
| | - Giuseppe Buono
- Unit of Interventional Neuroradiology, San Giovanni Bosco Hospital, Naples, Italy
| | - Mariano Marseglia
- Unit of Interventional Neuroradiology, Department of Advanced Biomedical Sciences, "Federico II" University, Naples, Italy
| | - Ferdinando Caranci
- Unit of Interventional Neuroradiology, Department of Advanced Biomedical Sciences, "Federico II" University, Naples, Italy
| | - Fabio Tortora
- "Magrassi Lanzara" Clinical-Surgical Department, Second University of Naples, Naples, Italy
| | - Francesco Maiuri
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, "Federico II" University, Naples, Italy
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Arias EJ, Patel B, Cross DT, Moran CJ, Dacey RG, Zipfel GJ, Derdeyn CP. Timing and nature of in-house postoperative events following uncomplicated elective endovascular aneurysm treatment. J Neurosurg 2014; 121:1063-70. [DOI: 10.3171/2014.7.jns132676] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Most patients with asymptomatic intracranial aneurysms treated with endovascular methods are closely observed overnight in an intensive care unit setting for complications, including ischemic and hemorrhagic stroke, cardiac dysfunction, and groin access complications. The purpose of this study was to analyze the timing, nature, and rate of in-house postoperative events.
Methods
Patients who underwent endovascular treatment or retreatment of unruptured cerebral aneurysms from March 2002 to June 2012 were identified from a prospective case log and their medical records were reviewed. The presentation, patient characteristics, aneurysm size and location, and method of endovascular treatment of each cerebral aneurysm were recorded. Patients with adverse intraprocedural events including perforation and thromboembolism were excluded from this analysis. Overnight postprocedural monitoring was performed in a neurological intensive care unit or postanesthesia care unit for all patients, with discharge planned for postoperative Day 1. Postprocedural events occurring during hospitalization were categorized as intracranial hemorrhage, ischemic stroke, groin hematoma resulting in additional treatment or prolonged hospital stay, retroperitoneal hematoma, and cardiac events. The time from the completion of the procedure to event discovery was recorded.
Results
A total of 687 endovascular treatments of unruptured cerebral aneurysms were performed. Nine treatments were excluded from our analysis due to intraprocedural events. Endovascular procedures included coiling alone, stent-assisted coiling, balloon-assisted coiling, balloon-assisted embolization with a liquid embolic agent, and placement of a flow diversion device with or without coiling. Twenty-seven treatments (4.0%) resulted in postprocedural complications: 3 intracranial hemorrhages, 6 ischemic strokes, 4 cardiac events, 5 retroperitoneal hematomas, and 9 groin hematomas. The majority (20 [74.0%]) of these 27 complications were detected within 4 hours from the procedure. These included 1 hemorrhage, 4 ischemic strokes, 4 cardiac events, 2 retroperitoneal hematomas, and 9 groin hematomas. All cardiac events and groin hematomas were detected within 4 hours. Four (14%) of the 27 complications were detected between 4 and 12 hours, 1 (3.7%) between 12 and 24 hours, and 2 (7.4%) more than 24 hours after the procedure. The complications detected more than 4 hours from the conclusion of the procedure included 2 minor intracranial hemorrhages causing headache and resulting in no permanent deficits, 2 mild ischemic strokes, and 3 asymptomatic retroperitoneal hematomas identified by falling hematocrit levels that required no further intervention or treatment.
Conclusions
The large majority of significant postprocedural events after uncomplicated endovascular aneurysm intervention occur within the first 4 hours; these events become less frequent with increasing time. Transfer to a floor bed after 4–12 hours for further observation is reasonable to consider in some patients.
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Affiliation(s)
| | | | - DeWitte T. Cross
- 1Department of Neurological Surgery,
- 2Mallinckrodt Institute of Radiology, and
| | | | - Ralph G. Dacey
- 1Department of Neurological Surgery,
- 2Mallinckrodt Institute of Radiology, and
| | - Gregory J. Zipfel
- 1Department of Neurological Surgery,
- 2Mallinckrodt Institute of Radiology, and
- 3Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
| | - Colin P. Derdeyn
- 1Department of Neurological Surgery,
- 2Mallinckrodt Institute of Radiology, and
- 3Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
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Spiliopoulos S, Pastromas G, Diamantopoulos A, Katsanos K. Efficacy of clopidogrel treatment and platelet responsiveness in peripheral arterial procedures. Expert Opin Pharmacother 2014; 15:2205-17. [PMID: 25162471 DOI: 10.1517/14656566.2014.953054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Long-term antiplatelet therapy with clopidogrel has been recommended in patients undergoing peripheral arterial procedures. Poor antiplatelet effect of clopidogrel or high on-clopidogrel platelet reactivity (HCPR) has been recently identified in patients with peripheral arterial disease (PAD). AREAS COVERED This review focuses on the use of clopidogrel and the phenomenon of HCPR in PAD patients treated for intermittent claudication or critical limb ischaemia (CLI). The authors summarize current guidelines and recommendations for use of clopidogrel following peripheral arterial procedures and explore the prevalence and clinical impact of HCPR in the PAD population. Underlying mechanisms of HCPR and relevant clinical and genetic factors are analyzed with particular attention to the potential utility of point-of-care platelet function testing (PFT). EXPERT OPINION Clopidogrel is a safe, effective and well-tolerated antiplatelet agent in PAD patients following peripheral arterial revascularization. Dual-antiplatelet therapy could also be considered after complex endovascular procedures. HCPR has been identified in more than 50% of PAD patients on clopidogrel and has been related with significantly increased re-intervention rates. Incidence of HCPR is significantly higher in patients with CLI, diabetes mellitus and chronic renal disease. Personalized antiplatelet therapy on the basis of PFT is an elegant emerging concept for optimization of platelet inhibition and potential identification of patients at increased risk of bleeding and warrants investigation in future large-scale trials.
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The Roles and Issues of P2Y12 Percent Inhibition Assessed by VerifyNow Assay for Patients Undergoing Neurointervention: A Prospective Study. J Stroke Cerebrovasc Dis 2014; 23:1830-6. [DOI: 10.1016/j.jstrokecerebrovasdis.2014.04.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Revised: 04/04/2014] [Accepted: 04/07/2014] [Indexed: 11/18/2022] Open
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González A, Moniche F, Cayuela A, Gonzalez-Marcos JR, Mayol A, Montaner J. Antiplatelet effects of clopidogrel dose adjustment (75 mg/d vs 150 mg/d) after carotid stenting. J Vasc Surg 2014; 60:428-35. [DOI: 10.1016/j.jvs.2014.01.068] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Revised: 01/29/2014] [Accepted: 01/29/2014] [Indexed: 01/20/2023]
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