Introduction
: Intraluminal thrombosis after endovascular therapy (EVT) is a peri‐procedural complication that carries a high burden of morbidity and mortality. The use of anti‐thrombotic therapies during EVT remains an evolving field. Recent surveys suggest the glycoprotein IIb/IIIa inhibitor, tirofiban, is often used during EVT. However, the increased intracranial hemorrhage risk and the medication’s long half‐life pose significant challenges to management. Cangrelor, an intravenous and reversible P2Y12 inhibitor, was first approved by FDA in 2015 for use in patients with coronary artery disease undergoing percutaneous intervention. Its rapid onset and offset are beneficial as an anti‐thrombotic during EVT. Our case series aim to characterize the safety and efficacy of cangrelor use in our institution and contribute towards its growing body of data.
Methods
: Chart review was conducted for patients that required endovascular therapy for acute stroke and received intravenous cangrelor at our center between January 2019 to December 2020. We included patients that underwent both extracranial and intracranial stent placement, as well as patients who suffered from intraluminal thromboses intra‐procedurally. Variables of interest included lesion pathophysiology, peri‐procedural complications including intraluminal re‐occlusion and intracranial hemorrhage, TICI score post‐procedurally, vessel patency and MRS on post‐hospitalization followup.
Results
: Nine patients received intravenous cangrelor during endovascular therapy. Mean age was 50 (range 41–67 years old), 3/9 patients were male. Seven patients (77.8%) had ischemic stroke, of whom five exhibited tandem intracranial occlusions and three required intraprocedural stent deployment. 3/7 patients received IV TPA prior to EVT. Interestingly, one patient had a previously placed Precise stent for acute internal carotid thrombus, briefly placed on eptifibatide (180mcg/kg), suffered from stent re‐occlusion on POD1 and required repeat thrombectomy with cangrelor intra‐procedurally; stent patency was maintained for the rest of her hospital course. One patient received balloon angioplasty of supraclinoid internal carotid artery. The remaining two patients required cangrelor for visualized intraluminal platelet aggregates during the EVT. Two patients presented with aneurysmal subarachnoid hemorrhage, one treated with flow diversion stent and the other requiring stenting for prolapsed aneurysm coiling. Dosing of cangrelor bolus and infusion varied. Six patients were bolused with 15 mcg/kg, while three patients received 7.5 mcg/kg. Infusion rates range from 0.5 to 4 mcg/kg/minute with all nine patients reaching therapeutic range P2Y12 levels on post‐procedural testing. Cangrelor infusion was transitioned to oral antiplatelet on post‐operative day 4 on average. In all nine patients, vessel and stent patency was maintained intra‐procedurally with cangrelor. Subsequent vascular imaging during hospitalization demonstrated no intraluminal thrombosis. One patient experienced intracranial hemorrhage, however they received intraprocedural eptifibatide (180mcg/kg) and cangrelor infusion (15 mcg/kg bolus, 2 mcg/kg/min) for their extensive clot burden and triple stent placement. Five patients attended three‐month post‐hospitalization followups. Their median MRS was 2 and all followup vessel imaging demonstrated patent vessels.
Conclusions
: Our case series demonstrate the promising efficacy of cangrelor in patients undergoing emergent endovascular therapy to prevent intraluminal thrombosis. Further studies with larger sample sizes can elucidate the optimal dose of cangrelor, length of treatment before oral transition, and compare its efficacy to eptifibatide.
P.195 Giant aneurysm, tiny patient: flow diversion stenting of a giant
MCA aneurysm in a young child
