A DELPHI consensus statement on antiplatelet management for intracranial stenting due to underlying atherosclerosis in the setting of mechanical thrombectomy

Goyal, Mayank; Orlov, Kirill; Jensen, Mary E.; Taylor, Allan; Majoie, Charles B. L. M.; Jayaraman, Mahesh; Liu, Jianmin; Milot, Geneviève; Brouwer, Patrick A.; Yoshimura, Shinichi; Albuquerque, Felipe C; Arthur, Adam S; Kallmes, David F.; Sakai, Nobuyuki; Fraser, Justin F.; Nogueira, Raul G; Yang, Pengfei; Dorn, Franziska; Thibault, Lucie; Fiehler, Jens; Chapot, René; Ospel, Johanna M.

doi:10.1007/s00234-020-02556-z

Cited by 12 publications

(14 citation statements)

References 11 publications

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“…In contrast, the stroke etiology of large artery atherosclerosis was observed more frequently in the cICA true occlusion group. Several studies have shown that combining acute angioplasty with endovascular thrombectomy may increase the successful recanalization rate in the large artery atherosclerosis stroke subtype ( 20 – 22 ). Therefore, accurate evaluation of occlusion type and clot burden before endovascular procedures could help determine the optimal therapeutic planning, which may promote better outcomes ( 23 ).…”

Section: Discussionmentioning

confidence: 99%

Outcomes in acute ischemic stroke patients undergoing endovascular thrombectomy: Cervical internal carotid artery pseudo-occlusion vs. true occlusion

Yang

Jia

et al. 2023

Front. Neurol.

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Background and purposePseudo-occlusion of the cervical internal carotid artery (cICA) refers to an absence of intraluminal contrast on computed tomography angiography (CTA), while the artery is patent on digital subtraction angiography during endovascular thrombectomy. We aimed to compare the outcomes between the cICA pseudo-occlusion and true occlusion after thrombectomy.MethodsWe retrospectively analyzed patients with apparent cICA occlusion on CTA who underwent thrombectomy between January 2016 and August 2021, and divided them into the pseudo-occlusion and true occlusion groups based on angiographic exploration. Recanalization failure was defined as a modified Thrombolysis in Cerebral Infarction score of 0–2a. Poor outcome was defined as a 90-day modified Rankin Scale score of 3–6. Propensity score matching was performed to compare the outcomes. Sensitivity analysis using multivariate-adjusted regression in the original cohort was conducted to test the robustness of the findings.ResultsOf the 146 patients included, 79 patients (54.1%) had cICA pseudo-occlusion and 67 patients (45.9%) had true occlusion. Following 1:1 propensity score-matched analysis, patients with pseudo-occlusion had an increased likelihood of recanalization failure (OR, 3.18; 95% CI, 1.06–9.59; P = 0.040) and poor outcome (OR, 2.80; 95% CI, 1.07–7.30; P = 0.035) compared with patients with true occlusion. Sensitivity analysis showed that cICA pseudo-occlusion remained independently associated with recanalization failure (OR, 2.55; 95% CI, 1.07–6.09; P = 0.036) and poor outcome (OR, 2.48; 95% CI, 1.08–5.67; P = 0.032).ConclusionsPatients with cICA pseudo-occlusion on CTA treated with thrombectomy had an increased risk of reperfusion failure and poor outcome compared with true occlusion patients.

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Section: Discussionmentioning

confidence: 99%

Outcomes in acute ischemic stroke patients undergoing endovascular thrombectomy: Cervical internal carotid artery pseudo-occlusion vs. true occlusion

Yang

Jia

et al. 2023

Front. Neurol.

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“…Unfortunately, there are little data and a lack of consensus up to now. In a Delphi study, an oral loading dose of aspirin in combination with a P2Y12 inhibitor was suggested if a stent deployed during EVT ( 28 ). Recent studies indicated a more promising role of tirofiban as the periprocedural antiplatelet treatment of EVT ( 29 , 30 ).…”

Section: Discussionmentioning

confidence: 99%

Safety and Efficacy of Direct Angioplasty in Acute Basilar Artery Occlusion Due to Atherosclerosis

Sun²,

Tong³

et al. 2021

Front. Neurol.

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Background and Purpose: Endovascular treatment (EVT) is one of the promising treatment options in patients with intracranial atherosclerotic disease (ICAD)-related basilar artery occlusion (BAO). In this study, we compared the safety and efficacy of direct angioplasty (DA) with stent-retriever thrombectomy (SRT) with or without rescue treatment in ICAD-related BAO.Methods: We retrospectively evaluated 187 patients who underwent EVT for BAO from January 2012 to July 2018. We identified patients who underwent EVT due to ICAD-related BAO. Patients who accepted SRT with or without rescue treatment were classified into the SRT group. Patients treated with DA with or without stent placement were classified into DA group. Clinical and laboratory findings and outcomes were compared between groups.Results: A total of 108 patients were enrolled, among them 77 underwent SRT and 31 underwent DA; 61 (79.2%) SRT group patients underwent angioplasty with or without stent placement. Compared with patients in the SRT group, those in the DA group experienced a significantly shorter procedure time [60 min (60–120 min) vs. 120 min (60–120 min); p = 0.038] and a lower number of device passes [2 passes (1–2 passes) vs. 3 passes (2–4 passes); p < 0.001]. No significant differences in balloon angioplasty (35.5 vs. 22.1%; p = 0.150), emergent stent placement (64.5 vs. 57.1%; p = 0.481), successful recanalization (93.5 vs. 85.7%; p = 0.340), embolization in distal or new territory (3.2 vs. 9.1%, p = 0.314), and reocclusion (22.6 vs. 9.1%; p = 0.109) among DA and SRT groups were found. Additionally, no differences in symptomatic intracranial hemorrhage incidence [adjusted odds ratio (OR), 0.74; 95% CI, 0.06–9.44; p = 0.815], functional independence (adjusted OR, 1.44; 95% CI, 0.50–4.16; p = 0.497), and mortality rate (adjusted OR, 0.36; 95% CI, 0.06–2.04; p = 0.247) were noted among groups.Conclusions: In certain patients with ICAD-related BAO, DA may shorten procedure time and reduce required device passes compared to SRT. In this study, DA was retrospectively found to be of similar safety and efficacy as SRT.

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“…The utilization of PFT in neuroendovascular patients is controversial. Recent consensus guidelines that address antiplatelet management during neuroendovascular procedures state that the PFT may not be necessary in flow diversion repair of aneurysms and a consensus could not be reached for use after intracranial stenting 17,18 . The vast majority of literature related to PFT is derived from the use of oral P2Y12 inhibitors 2 .…”

Section: Discussionmentioning

confidence: 99%

“…The main disadvantage of cangrelor is high cost and limited evidence. Recent guidelines acknowledge that cangrelor is an option in the setting of neuroendovascular procedures but are similarly limited by insufficient data 17,18 . Furthermore, GP IIb/IIIa inhibitors are highly potent antiplatelet inhibitors and have significant platelet dissolution effects, 26 which may be advantageous during acute ischemic stroke treatment, but a theoretical concern exists for use during aneurysm repair as clot dissolution may cause re‐bleeding.…”

Section: Discussionmentioning

confidence: 99%

Characterization of antiplatelet response to low‐dose cangrelor utilizing platelet function testing in neuroendovascular patients

et al. 2021

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Study Objectives The optimal antiplatelet therapy for emergent neuroendovascular stenting is uncertain. Cangrelor is an intravenous P2Y12 inhibitor that is an attractive option due its favorable pharmacokinetic profile and ease of measurability but optimal dosing remains unclear. The primary objective of this study is to characterize the dose response of low dose cangrelor (<2 mcg/kg/min) with the utilization of platelet function testing (PFT). Design A retrospective review of all patients treated with cangrelor for either procedural stenting or bridging was conducted between January 1st, 2019 and October 31st, 2020. Seventy‐two patients met inclusion criteria. An in‐depth analysis of dose response to low dose cangrelor based on PFT was performed. Patients Neuroendovascular patients treated with cangrelor. Setting Albany Medical Center Hospital. Intervention and Main Results Patients who underwent procedural stenting were given a bolus of 5 mcg/kg and an initial infusion rate of either 0.75 mcg/kg/min or 1 mcg/kg/min. Patients who were bridged with cangrelor were administered an initial infusion rate of 0.75 mcg/kg/min or 1 mcg/kg/min. Twelve patient’s doses were titrated to achieve a platelet reactivity unit (PRU) between 50–150; three patient’s doses were titrated multiple times. Based on initial PFT results, utilizing the 1 mcg/kg/min maintenance dose resulted in more patients being in the acceptable (10–180) and desired (50–150) PRU range than the 0.75 mcg/kg/min dose (47% vs 56% and 70% vs 80%, respectively). Final recorded PRU results showed that 64% of patients had PRUs in the optimal range (50–150) and 88% of patients had PRUs in the desire range (10–180). Conclusions Utilizing low doses of cangrelor with platelet function testing is an option during emergent neuroendovascular stenting and bridging. Cangrelor demonstrates significant variability in response at low doses and exhibits a dose response relationship when PFT is utilized.

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A DELPHI consensus statement on antiplatelet management for intracranial stenting due to underlying atherosclerosis in the setting of mechanical thrombectomy

Cited by 12 publications

References 11 publications

Outcomes in acute ischemic stroke patients undergoing endovascular thrombectomy: Cervical internal carotid artery pseudo-occlusion vs. true occlusion

Outcomes in acute ischemic stroke patients undergoing endovascular thrombectomy: Cervical internal carotid artery pseudo-occlusion vs. true occlusion

Safety and Efficacy of Direct Angioplasty in Acute Basilar Artery Occlusion Due to Atherosclerosis

Characterization of antiplatelet response to low‐dose cangrelor utilizing platelet function testing in neuroendovascular patients

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