Abciximab (ReoPro) Dosing Strategy for the Management of Acute Intraprocedural Thromboembolic Complications during Pipeline Flow Diversion Treatment of Intracranial Aneurysms

Abstract

Background: Flow diversion with the Pipeline embolization device (PED) is an effective neuro­endovascular method and increasingly accepted for the treatment of cerebral aneurysms. Acute in situ thrombosis is a known complication of PED procedures. There is limited experience in the flow diversion literature on the use of abciximab (ReoPro) for the management of acute thrombus formation in PED cases. Methods: Data were collected retrospectively on patients who received intra-arterial (IA) ReoPro with or without subsequent intravenous (IV) infusion during PED flow diversion treatment of intracranial aneurysms. Results: A total of 30 cases in patients with a mean age of 56.7 years (range 36–84) and a mean aneurysm size of 8.6 mm (range 2–25) were identified to have intraprocedural thromboembolic complications during PED treatment. IA ReoPro was administered in all cases, with 20 cases receiving increments of 5-mg boluses and 10 cases receiving a 0.125 mg/kg IA bolus (half cardiac dosing). Complete or partial recanalization was achieved in 100% of the cases. IV ReoPro infusion at 0.125 μg/kg/min for 12 h was administered postprocedurally in 22 cases with a residual thrombus. Postprocedurally, 18 patients were transitioned from clopidogrel (Plavix) to prasugrel (Effient). The majority of the cases (23/30; 77%) were discharged home. Periprocedural intracranial hemorrhage was noted in 2 cases (7%) and radiographic infarct was noted in 4 cases (13%), with an overall mortality of 0% at the time of initial discharge. Clinical follow-up was available for 28/30 patients. The average duration of follow-up was 11.7 months, at which time 23/28 (82%) of the patients had a modified Rankin Scale score of 0. Conclusions: IA ReoPro administration is an effective and safe rescue strategy for the management of acute intraprocedural thromboembolic complications during PED treatment. Using a dosing strategy of either 5-mg increments or a 0.125 mg/kg IA bolus (half cardiac dosing) can provide high rates of recanalization with low rates of hemorrhagic complications and long-term morbidity.

Outcome of intracranial flow diversion according to the antiplatelet regimen used: a systematic review and meta-analysis

“…Administration of intra-arterial abciximab is an effective and safe rescue strategy for the management of acute intraprocedural thromboembolic complications during a flow diverting procedure. A dosing strategy of (1) 5 mg increments or (2) 0.125 mg/kg IA bolus (half cardiac dosing) can provide high rates of recanalization with low rates of hemorrhagic complications and long-term morbidity 59. A protocol of anticoagulation with tirofiban during flow diversion showed an encouraging safety profile 60.…”

Single-stage flow diversion with adjunctive coiling for cerebral aneurysm: outcomes and technical considerations in 72 cases

“…Specifically, there is a significantly increased risk of intra-procedural stent thrombosis which will progress to symptomatic ischemia without expeditious recognition and treatment23. When platelet aggregation is recognized during the embolization procedure and treated to stabilization or reversal, symptomatic complications can be avoided in a majority (7/9, 78%) of cases.…”

Unique Indications for Covered Stent Grafts in Neuroradiology Departments of Level 1 Trauma Centers

“…In order to treat in-stent thrombosis drugs like tirofiban and abciximab have proven their efficiency in clinical practice in small patient populations with acute in-stent thrombosis of flow diverters, carotid artery stents, and intracranial stents. [36][37][38] Further studies could evaluate if these drugs should be administered before in-stent thrombosis occurs in emergency patients who could not be premedicated but have no eminent bleeding risk.…”

“…Even though IV heparin dissolved in-stent thrombosis, current literature indicates that glycoprotein IIb/IIIa inhibitors are very efficient and safe drugs for treatment of in-stent thrombosis in neuroradiologic cases. [36][37][38] The patient of case 4 developed in-stent thrombosis during intervention. In this case we have to point out that two GraftMaster stents and one Pipeline flow diverter had to be used and overlapped in the left ICA of this patient, immensely increasing the thrombogenicity.…”