Effect of Antiplatelet Therapy on Thromboembolic Complications of Elective Coil Embolization of Cerebral Aneurysms

Yamada, Nicole K.; Cross, DeWitte T.; Pilgram, Thomas K.; Moran, Christopher J.; Derdeyn, Colin P.; Dacey, Ralph G.

doi:10.3174/ajnr.a0641

Cited by 143 publications

(104 citation statements)

References 11 publications

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“…1,15 Prior studies in coil embolization procedures have demonstrated that symptomatic thromboembolic complications (transient ischemic attack or stroke within 60 days) occurred in 4 (16%) of 25 cases when no antiplatelet drugs were given, in 2 (2.3%) of 86 cases when antiplatelet drugs were administered only after embolization, and in 5 (1.9%) of 258 cases when antiplatelet drugs were administered before and after embolization. 19 Our current practices reflect these observations. We tend to pretreat all of our patients with oral aspirin, 81 or 325 mg daily, unless contraindicated by an aspirin allergy.…”

Section: Frequency Of Complicationssupporting

confidence: 58%

“…Heparin is generally discontinued at the conclusion of the procedure. 19 Previous studies have not revealed significant differences in the complication rate between balloon-assisted coiling and simple coil embolization. 12 In our series, 4 of 6 ischemic strokes occurred in patients treated with simple coil embolization, and 2 of 6 ischemic strokes occurred in patients treated with stent-assisted coiling.…”

Section: Frequency Of Complicationsmentioning

confidence: 95%

“…Patients treated after procedures were generally given aspirin permanently and clopidogrel for 30-60 days. 19 In this series, 2 of the 3 patients with postprocedural hemorrhages were given boluses of aspirin and clopidogrel prior to the procedure due to inadequate platelet inhibition on preprocedure testing.…”

Section: Frequency Of Complicationsmentioning

confidence: 99%

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Timing and nature of in-house postoperative events following uncomplicated elective endovascular aneurysm treatment

Arias

Patel

Cross

et al. 2014

JNS

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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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Section: Frequency Of Complicationssupporting

confidence: 58%

Section: Frequency Of Complicationsmentioning

confidence: 95%

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Timing and nature of in-house postoperative events following uncomplicated elective endovascular aneurysm treatment

Arias

Patel

Cross

et al. 2014

JNS

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“…11,21,22 However, patients in these studies regarding antiplatelet resistance were mostly those with atherosclerotic steno-occlusive disease, especially in cardiointerventions. 23,24 Unlike atherosclerotic vessels, unruptured aneurysms do not always cause significant atherosclerotic burden.…”

Section: Discussionmentioning

confidence: 99%

“…Several studies support the idea that clopidogrel resistance can increase postprocedural thromboembolic complications, and our preliminary study showed similar results. 4,11,12,22 Hwang et al 10 recently reported that abnormal PRUs were associated with symptomatic infarction and that modified antiplatelet preparation could reduce the rate of thromboembolic events in coil embolization. In contrast, in this study, the occurrence of immediate postprocedural thromboembolic infarction was not closely associated with antiplatelet hyporesponders.…”

Section: Discussionmentioning

confidence: 99%

Association between Postprocedural Infarction and Antiplatelet Drug Resistance after Coiling for Unruptured Intracranial Aneurysms

Ms¹,

Yeon³

et al. 2016

AJNR Am J Neuroradiol

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BACKGROUND AND PURPOSE:Procedure-related thromboembolism is a major limitation of coil embolization, but the relationship between thromboembolic infarction and antiplatelet resistance is poorly understood. The purpose of this study was to verify the association between immediate postprocedural thromboembolic infarction and antiplatelet drug resistance after endovascular coil embolization for unruptured intracranial aneurysm.

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Standard vs Modified Antiplatelet Preparation for Preventing Thromboembolic Events in Patients With High On-Treatment Platelet Reactivity Undergoing Coil Embolization for an Unruptured Intracranial Aneurysm

et al. 2015

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IMPORTANCE Thromboembolism is the most common complication in coiling for an unruptured aneurysm and is frequent in patients with high on-treatment platelet reactivity (HTPR) who are prescribed a standard antiplatelet preparation for its prevention.OBJECTIVE To evaluate the effect of a modified antiplatelet preparation compared with a standard preparation in patients with HTPR undergoing coiling. DESIGN, SETTING, AND PARTICIPANTSA prospective randomized open-label active-control trial with blinded outcome assessment at the Seoul National University Bundang Hospital from May 27, 2013, to April 7, 2014. Patients with HTPR were randomly assigned (1 to 1) to the standard or modified preparation group. Patients without HTPR were assigned to the non-HTPR group. A total of 228 patients undergoing coiling for unruptured aneurysms were enrolled and allocated to the study, 126 in the HTPR group (63 to the standard preparation group and 63 to the modified preparation group) and 102 to the non-HTPR group. Intent-to-treat analysis was performed. INTERVENTIONSThe modified preparation (HTPR to aspirin, 300 mg of aspirin and 75 mg of clopidogrel bisulfate; and HTPR to clopidogrel, 200 mg of cilostazol added to the standard regimen) was performed before coiling in the modified preparation group. Standard preparation (100 mg of aspirin and 75 mg of clopidogrel) was maintained in the standard preparation and non-HTPR groups. MAIN OUTCOMES AND MEASURESThe primary outcome was a thromboembolic event defined as thromboembolism during coiling and a transient ischemic attack or ischemic stroke within 7 days after coiling. The principal secondary outcome was a bleeding complication according to Thrombolysis in Myocardial Infarction bleeding criteria within 30 days after coil embolization. RESULTSThe thromboembolic event rate was low in the modified preparation group (1 of 63 [1.6%]) compared with the standard preparation group (7 of 63 [11.1%]; adjusted risk difference, −11.7% [95% CI, −21.3% to −2.0%]; P = .02), which had a higher thromboembolic risk than the non-HTPR group (1 of 102 [1.0%]; adjusted risk difference, 8.6% [95% CI, 1.0% to 16.3%]; P = .03). All bleeding complications were of minimal grade according to Thrombolysis in Myocardial Infarction bleeding criteria. The bleeding rate was not different between the modified (6 of 63 [9.5%]) and standard (4 of 63 [6.3%]) preparation groups (adjusted risk difference, 5.6% [95% CI, −4.2% to 15.4%]; P = .26). CONCLUSIONS AND RELEVANCEModified antiplatelet preparation for patients with HTPR compared with standard antiplatelet preparation reduced the thromboembolic event rate in coiling for an unruptured aneurysm without increasing bleeding.TRIAL REGISTRATION Clinical Research Information Service Identifier: KCT0000804.

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Effect of Antiplatelet Therapy on Thromboembolic Complications of Elective Coil Embolization of Cerebral Aneurysms

Abstract: BACKGROUND AND PURPOSE:Thromboembolic events are the most common complications of elective coil embolization of cerebral aneurysms. Administration of oral clopidogrel and/or aspirin could lower the thromboembolic complication rate.

Cited by 143 publications

References 11 publications

Timing and nature of in-house postoperative events following uncomplicated elective endovascular aneurysm treatment

Timing and nature of in-house postoperative events following uncomplicated elective endovascular aneurysm treatment

Association between Postprocedural Infarction and Antiplatelet Drug Resistance after Coiling for Unruptured Intracranial Aneurysms

Standard vs Modified Antiplatelet Preparation for Preventing Thromboembolic Events in Patients With High On-Treatment Platelet Reactivity Undergoing Coil Embolization for an Unruptured Intracranial Aneurysm

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