Stent-Assisted Coiling of Wide-Necked Aneurysms in the Setting of Acute Subarachnoid Hemorrhage

Neurosurgery ◽  
2011 ◽  
Vol 70 (6) ◽  
pp. 1415-1429 ◽  
Author(s):  
Peter S. Amenta ◽  
Richard T. Dalyai ◽  
David Kung ◽  
Amy Toporowski ◽  
Sid Chandela ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Antiplatelet Therapy ◽  
Stent Thrombosis ◽  
Antiplatelet Agents ◽  
Bleeding Complications ◽  
Anterior Circulation ◽  
Fatal Hemorrhage ◽  
Ischemic Complications ◽  
Acute Subarachnoid Hemorrhage ◽  
Grade Iii

Abstract BACKGROUND: Stent-assisted coiling in the setting of subarachnoid hemorrhage remains controversial. Currently, there is a paucity of data regarding the utility of this procedure and the risks of hemorrhagic and ischemic complications. OBJECTIVE: To assess the utility of stent-assisted coil embolization and pretreatment with antiplatelet agents in the management of ruptured wide-necked aneurysms. METHODS: A retrospective study of 65 patients with ruptured wide-necked aneurysms treated with stent-assisted coiling. Patients with hydrocephalus or a Hunt and Hess grade ≥ III received a ventriculostomy before endovascular intervention. Patients were treated intraoperatively with 600 mg of clopidogrel and maintained on daily doses of 75 mg of clopidogrel and 81 mg of aspirin. The Glasgow outcome scale (GOS) score was recorded at the time of discharge. We identified major bleeding complications secondary to antiplatelet therapy and cases of in-stent thrombosis that required periprocedural thrombolysis. RESULTS: Of the aneurysms, 66.2% arose within the anterior circulation; 69.2% of patients presented with hydrocephalus or a Hunt and Hess grade ≥ III and required a ventriculostomy. A good outcome (GOS of 4 or 5) was achieved in 63.1% of patients, and the overall mortality rate was 16.9%. There were 10 (15.38%) major complications associated with bleeding secondary to antiplatelet therapy (5 patients, 7.7%) or intraoperative in-stent thrombosis (5 patients, 7.7%). Three (4.6%) patients had a fatal hemorrhage. CONCLUSION: Our findings suggest that stent-assisted coiling and routine treatment with antiplatelet agents is a viable option in the management of ruptured wide-necked aneurysms.

Abstract W P307: Novel Application of Reversible Parental Anti-platelets in Patients with Aneurysmal Subarachnoid Hemorrhage

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Siddhart Mehta ◽  
Mohammed Hussain ◽  
Jaskiran Brar ◽  
Daniel Korya ◽  
Harina Chahal ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Coil Embolization ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Antiplatelet Agents ◽  
Endovascular Coiling ◽  
International Subarachnoid Aneurysm Trial ◽  
Procedural Complications ◽  
Acute Subarachnoid Hemorrhage ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background and Objective: The International Subarachnoid Aneurysm Trial (ISAT) showed a greater likelihood of survival free 1 year disability in patients undergoing endovascular coiling who were started on antiplatelet agents after SAH compared to ones undergoing neurosurgical clipping. However, data on safety of acute parental antiplatelet agents after aneurysmal coiling is lacking. We report on the safety of IV Eptifibatide (rapidly reversible Glyprotein IIbIIIa inhibitor) on patients presenting with acute subarachnoid hemorrhage undergoing endovascular coiling for aneurysmal embolization. Methods: All the patients from 2009-13 who presented to our university affiliated comprehensive stroke center with aneurysmal subarachnoid hemorrhage and underwent endovascular coiling were included for the study. Patients that received IV Eptifibatide for various reasons including acute need for stent assist coiling after securing the ruptured aneurysm with endovascular coiling were reviewed. Eptifibatide was administered intra-arterially as a 135-μg/kg single-dose bolus, and then continued on intravenous infusion of 0.5-μg/kg/min post-procedurally. Charts were reviewed for all patients to assess for medical/procedural complications including symptomatic and asymptomatic intra- and extra-cranial hemorrhages, groin hematomas, epistaxis and gross hematuria. Results: Of the total of 93 patients treated with coil embolization during this period, 5 patients (mean age 56 years, 20% male [n=1]) received acute intra-procedural Eptifibatide followed by IV infusion for a mean duration of 77 hours (range 20-130 hours). Various reasons for use of Eptifibatide included: stent assist coiling [n=2], multiple stents for flow diversion [n=1], partial coil prolapse [n=1] and vascular lumen flow compromise [n=1]. None of the patients demonstrated symptomatic/asymptomatic hemorrhage, groin hematoma, epistaxis or hematuria. Conclusion: Our results may highlight safety of administering IV Eptifibatide to prevent thrombotic complications after endovascular coil embolization in select patients with aneurysmal subarachnoid hemorrhage. Multicenter prospective trials are warranted to corroborate our findings.

Abstract 15440: Bleeding Complications May Outweigh the Risk of Thrombosis in Patients With End-stage Liver Disease Taking Dual Antiplatelet Therapy After Percutaneous Coronary Intervention

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Sami J Natour ◽  
May Myint Thanda Kyaw ◽  
Ronald W Busuttil ◽  
Jonathan M Tobis ◽  
Henry M Honda
Keyword(s):  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
Coronary Intervention ◽  
Bleeding Complications ◽  
Bleeding Events ◽  
Stent Restenosis ◽  
Percutaneous Coronary ◽  
Ischemic Complications ◽  
End Stage

Introduction: Randomized trials have demonstrated the safety and efficacy of one month of dual antiplatelet therapy (DAPT) after placement of drug-eluting stents in patients with high bleeding risk. Patients with end-stage liver disease (ESLD) are underrepresented in these trials. Patients who undergo percutaneous coronary intervention (PCI) in preparation for orthotopic liver transplantation (OLT) exhibit a high incidence of bleeding complications on DAPT. The rates of bleeding versus thrombotic complications in ESLD patients placed on DAPT following PCI are poorly described. Methods: We retrospectively collected data from 61 patients who were evaluated for OLT between 2016 and 2019 and underwent PCI prior to listing. Bleeding events were classified using the Bleeding Academic Research Consortium (BARC) definitions and included if the following criteria were met: events occurred in the setting of DAPT, were non-procedural in etiology, and occurred during the time following PCI and prior to OLT. Ischemic complications were evaluated by the incidence of myocardial infarction (MI), stent thrombosis, in-stent restenosis (>50%) and all-cause mortality at 1 year follow-up. Results: A total of 55/61 patients (90%) were placed on DAPT following PCI. Among them, 21/55 patients (38%) bled while taking DAPT, including 15 patients (27%) with BARC types 3-5 first-time bleeding events and 10 patients (18%) requiring early discontinuation of therapy. The median time to first bleeding event was 8 days (range 1 to 477 days, 85 th percentile 17 days). Among ischemic complications, MI occurred in 11/55 patients (20%) however only one patient had a type 1 MI with the remaining being type 2 in etiology. There were no episodes of stent thrombosis and 2 episodes of in-stent restenosis during the 1 year follow-up. A total of 12/55 patients (22%) went on to receive OLT and 18/55 (33%) passed away by 1 year post-PCI. Conclusions: Patients with ESLD exhibit a high rate of clinically significant bleeding on DAPT when compared to overall thrombotic events. The majority of bleeds occurred within the first month after PCI. These findings illustrate the need for larger studies to assess the safety of single instead of dual antiplatelet therapy in patients with ESLD who receive PCI.

scholarly journals Antiplatelet drugs: a review of pharmacology and the perioperative management of patients in oral and maxillofacial surgery

2020 ◽  
Vol 102 (1) ◽  
pp. 9-13
Author(s):  
H Mahmood ◽  
I Siddique ◽  
A McKechnie
Keyword(s):  
Antiplatelet Therapy ◽  
Oral Surgery ◽  
Safety Concern ◽  
Maxillofacial Surgery ◽  
Antiplatelet Agents ◽  
Antiplatelet Drugs ◽  
Current Evidence ◽  
Bleeding Complications ◽  
Oral And Maxillofacial Surgery ◽  
Number Of Patients

Introduction An increasing number of patients are taking oral antiplatelet agents. As a result, there is an important patient safety concern in relation to the potential risk of bleeding complications following major oral and maxillofacial surgery. Surgeons are increasingly likely to be faced with a dilemma of either continuing antiplatelet therapy and risking serious haemorrhage or withholding therapy and risking fatal thromboembolic complications. While there are national recommendations for patients taking oral antiplatelet drugs undergoing invasive minor oral surgery, there are still no evidence-based guidelines for the management of these patients undergoing major oral and maxillofacial surgery. Methods MEDLINE and EMBASE databases were searched to retrieve all relevant articles published to 31 December 2017. Findings A brief outline of the commonly used antiplatelet agents including their pharmacology and therapeutic indications is discussed, together with the haemorrhagic and thromboembolic risks of continuing or altering the antiplatelet regimen in the perioperative period. Finally, a protocol for the management of oral and maxillofacial patients on antiplatelet agents is presented. Conclusions Most current evidence to guide decision making is based upon non-randomised observational studies, which attempts to provide the safest possible management of patients on antiplatelet therapy. Large randomised clinical trials are lacking.

Individualized antithrombotic therapy in high risk patients after coronary stenting. A double-edged sword between thrombosis and bleeding

2008 ◽  
Vol 99 (03) ◽  
pp. 487-493 ◽  
Author(s):  
Tobias Geisler ◽  
Meinrad Gawaz ◽  
Andreas May
Keyword(s):  
High Risk ◽  
Antiplatelet Therapy ◽  
Stent Thrombosis ◽  
Antithrombotic Therapy ◽  
Bleeding Complications ◽  
Severe Bleeding ◽  
High Risk Patients ◽  
Coronary Stent Implantation ◽  
Risk Patients ◽  
The Individual

SummaryDual antiplatelet therapy with aspirin and clopidogrel is currently the standard therapy after coronary stent implantation to prevent a life-threatening stent thrombosis. However, a variety of procedural and individual factors contribute to the individual patient risk and have to be taken into account to allow for an individual recommendation for both the duration and intensity of the antiplatelet therapy. Obviously, the benefit of the prevention of stent thrombosis by antithrombotic therapy has to outweigh the risk of severe bleeding complications. Depending on the individual clinical situation and procedural characteristics (stent type, length, angiographic result etc.), the recommended duration of the combined antiplatelet therapy currently varies from four weeks to at least one year.These recommendations are mainly based on large, prospective, randomized trials and evidence-based guidelines. However, in a subgroup of high-risk patients there is insufficient evidence for the benefit of conventional dual antiplatelet regimen.These include i) patients with an indication for anticoagulation, ii) patients with urgent need for an operation requiring a perioperative withholding of antiplatelet therapy, as well as iii) clopidogrel low responders.This review aims to provide a stratification to define patient collectives who may benefit from more individualized antithrombotic regimens on behalf of currently available literature and guidelines.

scholarly journals Bivalirudin Versus Heparin During Intervention in Acute Coronary Syndrome: A Systematic Review of Randomized Trials

2020 ◽  
Vol 20 (1) ◽  
pp. 3-15
Author(s):  
Sukhdee Bhogal ◽  
Debabrata Mukherjee ◽  
Jayant Bagai ◽  
Huu T. Truong ◽  
Hemang B. Panchal ◽  
...  
Keyword(s):  
Systematic Review ◽  
Stent Thrombosis ◽  
Systematic Reviews ◽  
Bleeding Complications ◽  
Controlled Trials ◽  
Cochrane Central Register ◽  
Coronary Syndrome ◽  
Ischemic Complications ◽  
Meta Analyses ◽  
Acute Stent Thrombosis

Introduction: Bivalirudin and heparin are the two most commonly used anticoagulants used during Percutaneous Coronary Intervention (PCI). The results of Randomized Controlled Trials (RCTs) comparing bivalirudin versus heparin monotherapy in the era of radial access are controversial, questioning the positive impact of bivalirudin on bleeding. The purpose of this systematic review is to summarize the results of RCTs comparing the efficacy and safety of bivalirudin versus heparin with or without Glycoprotein IIb/IIIa Inhibitors (GPI). Methods: This systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses PRISMA statements for reporting systematic reviews. We searched the National Library of Medicine PubMed, Clinicaltrial.gov and the Cochrane Central Register of Controlled Trials to include clinical studies comparing bivalirudin with heparin in patients undergoing PCI. Sixteen studies met inclusion criteria and were reviewed for the summary. Findings: Several RCTs and meta-analyses have demonstrated the superiority of bivalirudin over heparin plus routine GPI use in terms of preventing bleeding complications but at the expense of increased risk of ischemic complications such as stent thrombosis. The hypothesis of post- PCI bivalirudin infusion to mitigate the risk of acute stent thrombosis has been tested in various RCTs with conflicting results. In comparison, heparin offers the advantage of having a reversible agent, of lower cost and reduced incidence of ischemic complications. Conclusion: Bivalirudin demonstrates its superiority over heparin plus GPI with better clinical outcomes in terms of less bleeding complications, thus making it as anticoagulation of choice particularly in patients at high risk of bleeding. Further studies are warranted for head to head comparison of bivalirudin to heparin monotherapy to establish an optimal heparin dosing regimen and post-PCI bivalirudin infusion to affirm its beneficial effect in reducing acute stent thrombosis.

Expanding the Indications for Flow Diversion: Treatment of Posterior Circulation Aneurysms

Neurosurgery ◽  
2019 ◽  
Vol 86 (Supplement_1) ◽  
pp. S76-S84
Author(s):  
Nimer Adeeb ◽  
Christopher S Ogilvy ◽  
Christoph J Griessenauer ◽  
Ajith J Thomas
Keyword(s):  
Antiplatelet Agents ◽  
Posterior Circulation ◽  
Flow Diversion ◽  
High Morbidity ◽  
Complication Rates ◽  
Anterior Circulation ◽  
Risk Of Rupture ◽  
Lower Complication ◽  
Ischemic Complications ◽  
Posterior Circulation Aneurysms

Abstract Posterior circulation aneurysms are often associated with a higher risk of rupture and compressive symptoms compared to their anterior circulation counterpart. Due to high morbidity and mortality associated with microsurgical treatment of those aneurysms, endovascular therapy gained ascendance as the preferred method of treatment. Flow diversion has emerged as a promising treatment option for posterior circulation aneurysms with a higher occlusion rate compared to other endovascular techniques and a lower complication rate compared to microsurgery. While treatment of saccular and dissecting aneurysms is often associated with comparatively good outcomes, fusiform and dolichoectatic aneurysms should be carefully selected prior to treatment to avoid devastating thromboembolic complications. Occlusion of covered posterior circulation branches showed no correlation with ischemic complications, and appropriate antiplatelet regimen and switching Clopidogrel nonresponders to different antiplatelet agents were associated with lower complication rates following flow diversion of posterior circulation aneurysms.

Antiplatelet Therapy Bridging With Cangrelor in Patients With Coronary Stents: A Case Series

2018 ◽  
Vol 53 (2) ◽  
pp. 171-177 ◽  
Author(s):  
Stephanie Bowman ◽  
Jennifer Gass ◽  
Phillip Weeks
Keyword(s):  
Antiplatelet Therapy ◽  
Stent Thrombosis ◽  
Antiplatelet Agent ◽  
Case Series ◽  
Coronary Intervention ◽  
Platelet Inhibition ◽  
Coronary Stents ◽  
Bleeding Complications ◽  
Long Term Effects ◽  
Oral Agents

Background: Cangrelor is an intravenous P2Y12 receptor antagonist approved for use during percutaneous coronary intervention (PCI) to reduce ischemic events associated with new stent placement and has been used off-label at reduced doses guided by platelet function testing as a “bridge” from discontinuation of oral P2Y12 receptor antagonists to surgical procedures when the long-term effects of oral agents are undesirable. Objective: To describe the dosing, laboratory monitoring, and clinical outcomes of a series of patients who received cangrelor as a “bridging” antiplatelet agent. Methods: This study is a retrospective analysis of all patients within the study center with coronary stents who received cangrelor as a bridge to surgical procedure and had VerifyNow monitoring during treatment. Results: A total of 11 patients were identified for inclusion. The median cangrelor dose was 0.5 µg/kg/min (interquartile range = 0.5-0.5) and was maintained in 7 of 11 patients. Doses ranged from 0.25 to 2 µg/kg/min during therapy, and 81.6% of VerifyNow results assessed were within goal range (⩽208 P2Y12 reaction units). Bleeding complications during therapy occurred in 3 patients, all of whom were receiving concomitant heparin infusions, and no stent thrombosis was reported. Conclusion and Relevance: Low-dose cangrelor may represent an effective option for bridging antiplatelet therapy in patients with coronary stents. This study demonstrated that the majority of patients received adequate platelet inhibition without any incidence of stent thrombosis on 0.5 µg/kg/min using the VerifyNow assay to monitor platelet inhibition, which represents a lower dose than previously reported in the literature.

scholarly journals Antithrombotic treatments for patients with atrial fibrillation and a requirement for a coronary artery stent

2015 ◽  
Vol 1 (1) ◽  
pp. 5 ◽  
Author(s):  
Andrew Owen
Keyword(s):  
Atrial Fibrillation ◽  
Coronary Artery ◽  
Triple Therapy ◽  
Antiplatelet Therapy ◽  
Stent Thrombosis ◽  
Dual Antiplatelet Therapy ◽  
Bleeding Risk ◽  
Bleeding Complications ◽  
Coronary Artery Stent ◽  
Aspirin 325Mg

<p><span>Background: </span>Patients with atrial fibrillation and a coronary artery stent require anticoagulation to provide prophylaxis</p><p>against stroke and dual antiplatelet therapy to provide prophylaxis against stent thrombosis (triple therapy).</p><p>This combination increases the risk of major bleeding complications compared to either treatment alone. It is</p><p>suggested that an alternative to triple therapy is high dose dual antiplatelet therapy (aspirin 325mg/day and</p><p>clopidogrel 75 mg/day), which would have similar efficacy to triple therapy in relation to prophylaxis against</p><p>both stroke and stent thrombosis with a lower risk of bleeding complications.</p><p><span>Summary: </span>1. Patients with atrial fibrillation and a coronary artery stent require triple therapy, which is associated with</p><p>increased bleeding risk.</p><p>2. In everyday practice 50% of patients do not receive this, because of the excess bleeding risk.</p><p>3. It is suggested that for patients at increased bleeding risk and for whom it is felt that triple therapy is not</p><p>suitable, Aspirin (325mg daily) and clopidogrel (75mg daily) should be considered.</p><p> </p>

scholarly journals An unusual case of stent thrombosis: a case report

2019 ◽  
Vol 3 (3) ◽  
Author(s):  
Atifur Rahman ◽  
Sophia Wong
Keyword(s):  
Antiplatelet Therapy ◽  
Stent Thrombosis ◽  
Imaging Techniques ◽  
Antiplatelet Agents ◽  
Coronary Intervention ◽  
Rehabilitation Centre ◽  
Increased Risk ◽  
Significant Length ◽  
Testing Management ◽  
The Right

Abstract Background  Stent thrombosis is a serious and potentially life-threatening complication of percutaneous coronary intervention. It often presents dramatically, typically resulting in ST-elevation myocardial infarction which is associated with a high mortality rate. Premature discontinuation of antiplatelet therapy in the initial 30 days after stenting is arguably the most important predictor of stent thrombosis. In some cases, discontinuation of therapy is unintentional, such as in patients with short-bowel length or malabsorption syndromes. Case summary  A 70-year-old man presented to our hospital with stent thrombosis due to non-absorption of antiplatelet agents, 3 days after an elective percutaneous intervention to the right coronary artery. The patient, who had had a laparoscopic high anterior resection due to previous colorectal cancer, had noticed tablets passing whole into his colostomy bag. Repeat balloon angioplasty and stenting were performed and the patient received further antiplatelet therapy in a crushed form. Discussion  Drug absorption in the gastrointestinal tract is altered when a significant length of the gut has been resected. Reduced intestinal luminal transit time and insufficient contact time with intestinal mucosa leads to reduced bioavailability of drugs and increased risk of stent thrombosis. The aetiology of stent thrombosis can be investigated with intravascular imaging techniques and platelet function testing. Management includes using different drug formulations and doses and monitoring the outcomes of therapy. In some cases, it may also be appropriate to involve a gastroenterology team, preferably in the multidisciplinary environment of an intestinal rehabilitation centre.

scholarly journals Tailored Medical and Interventional Therapy Against Recurrent Stent Thrombosis After Drug-Eluting Stenting

2009 ◽  
Vol 16 (5) ◽  
pp. 591-593 ◽  
Author(s):  
Gianluca Campo ◽  
Marco Valgimigli ◽  
Chiara Carrescia ◽  
Roberto Carletti ◽  
Roberto Ferrari
Keyword(s):  
Antiplatelet Therapy ◽  
Stent Thrombosis ◽  
Platelet Function ◽  
Light Transmission ◽  
Platelet Reactivity ◽  
Artery Bypass ◽  
Bypass Graft ◽  
Poor Responder ◽  
Bleeding Complications ◽  
Single Coronary Artery

Dual antiplatelet therapy with aspirin and a thienopyridine (ticlopidine or clopidogrel) has strikingly improved the results of percutaneous coronary intervention (PCI) through a marked reduction in the rate of stent thrombosis (ST). Emerging data suggest that resistance to antiplatelet treatment may be a risk factor for ST. We report about a patient, aspirin and clopidogrel poor responder, who experienced 4 ST in 10 days. After the second ST, during antiplatelet therapy with aspirin (100 mg/die) and clopidogrel (75 mg/die), the patient’s platelet function was investigated with Platelet Function Analyzer 100, VerifyNow P2Y12 System and light transmission aggregometry (LTA). High platelet reactivity and combined resistance to aspirin and clopidogrel were found, and, as a consequence, treatment was switched to clopidogrel 150 mg and aspirin 300 mg/die. In spite of this adjustment, the third ST occurred. Poor responsiveness to aspirin and clopidogrel was still confirmed. Because of combined clopidogrel and aspirin resistance and to unsuccessful PCI treatment, a single coronary artery bypass graft (CABG) was planned. Awaiting surgery, 3 days later, the fourth ST occurred. It is angiographically confirmed and thus, CABG was performed. After CABG, in chronic treatment with aspirin (300 mg/die) and ticlopidine (500 mg/die), no bleeding complications occurred and the patient did not experience recurrent ischemia (2 years follow-up). A better platelet inhibition by ticlopidine than that obtained by clopidogrel was observed. Our case report remarks the importance to identify these poor responder patients as the treatment can be tailored with alternative therapeutic options (ticlopidine, prasugrel, warfarin) and/or different revascularization strategies (CABG).

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