Local Tirofiban Infusion for Remnant Stenosis in Large Vessel Occlusion: Tirofiban ASSIST study

Abstract

Background Compared to embolic occlusions, intracranial atherosclerotic stenosis (ICAS)-related large vessel occlusions (LVOs) often require rescue treatment following mechanical thrombectomy (MT). Herein, we hypothesized that local tirofiban infusion can be effective and safe for remnant stenosis in LVO during endovascular treatment, and can improve clinical outcomes. Methods This observational multicenter registry study (January 2011 to February 2016) included patients with ICAS who underwent endovascular treatment for LVO within 24 hours after stroke onset. An underlying fixed focal stenosis at the occlusion site observed on a cerebral angiography during and after MT was retrospectively determined as a surrogate marker of ICAS. Procedural and clinical outcomes were compared between the tirofiban and non-tirofiban groups. Results Patients were older (median, 71 years vs. 63 years, p = 0.015) and the onset to puncture time was longer (median, 395 min vs. 275 min, p = 0.036) in the tirofiban group than in the non-tirofiban group. Final reperfusion success (modified Treatment In Cerebral Ischemic 2b–3) was more frequent (86.4% vs. 42.4%, p = 0.016) and post-procedure parenchymal hematoma type 2 and/or thick subarachnoid hemorrhages were less frequent (5.1% vs. 15.3%, p = 0.068) in the tirofiban group. The frequency of favorable outcomes 3 months after endovascular revascularization therapy (modified Rankin Scale 0–2) was significantly higher in the tirofiban group (52.5% vs. 32.2%, p = 0.025) and tirofiban administration was an independent predictor of favorable outcomes (odds ratio, 4.013; 95% confidence interval, 1.300–12.386; p = 0.016). Conclusions Local tirofiban infusion may be an effective and safe adjuvant treatment option for patients with ICAS-LVO.

Endovascular Treatment of Large Vessel Occlusion Strokes Due to Intracranial Atherosclerotic Disease

“…In this context, local or intravenous infusion of GPI has been associated with reduced reocclusion and improved clinical outcomes. 3,[63][64][65] The use of GPI is even more crucial in the setting of intracranial stenting given the even higher thrombogenicity associated with the addition of a foreign body. 66 Indeed, most studies involving acute intracranial stenting for underlying ICAD reported that GPI was administered whenever feasible (Table 1).…”

“…69 Finally, retrospective studies on the use of tirofiban during MT for ICAD-related LVO did not demonstrated any differences in the rates of sICH in patients who have versus not have received IVT. 5,63,65 Notably, cangrelor, an intravenous P2Y12 receptor inhibitor with a rapid onset/offset of action and a short (3 to 6 minutes) half-life, may become a viable alternative to GPI in the near future. 70,71 Once hemorrhagic complications have been excluded by post-procedural imaging, DAP should be started as soon as possible, especially when employing intracranial stenting.…”

Endovascular Recanalization for Acute Internal Carotid Artery Terminus Occlusion: A Subgroup Analysis From the Direct-MT Trial

“…31 By local infusion alone or with subsequent intravenous infusion, rescue tirofiban use improved 90-day clinical outcome even at low dose. 32,33 Given that tirofiban use might be protective in achieving good clinical outcome and eliminating futile recanalization, its in-depth value should be explored in the near future. However, no guideline or consensus is yet available to determine the occasion or accurate dosage for tirofiban use during thrombectomy.…”

European Stroke Organisation guidelines on treatment of patients with intracranial atherosclerotic disease

“…Our systematic review identified five retrospective studies of very low quality (see Table 2 for the GRADEpro ratings of the included studies) comparing the effects of an additional intraarterial infusion of glycoprotein IIb/IIIa inhibitors after initial mechanical thrombectomy to mechanical thrombectomy alone on functional outcome in patients with an ICAD-related LVO. [37][38][39][40][41] Two of these studies were excluded from further analysis due to the following reasons: the first study focused only on vertebrobasilar stroke 40 and the second study did not differentiate clearly enough between large vessel occlusion-stroke due to large arterial atherosclerosis and ICAD-related LVO stroke. 41 The remaining three studies included patients on a consecutive basis, however it remains unclear in these studies on which bases the type of rescue therapy was determined (administration of glycoprotein IIb/IIIa depended on operator's judgment).…”