Management of antiplatelet therapy in patients undergoing neuroendovascular procedures

Abstract

Neuroendovascular techniques for treating cerebral aneurysms and other cerebrovascular pathology are increasingly becoming the standard of care. Intraluminal stents, aneurysm coils, and other flow diversion devices typically require concomitant antiplatelet therapy to reduce thromboembolic complications. The variability inherent with the pharmacodynamic response to common antiplatelet agents such as aspirin and clopidogrel complicates optimal selection of antiplatelet agents by clinicians. This review serves to discuss the literature related to antiplatelet use in neuroendovascular procedures and provides recommendations for clinicians on how to approach patients with variable response to antiplatelet agents, particularly clopidogrel.

Periprocedural Neuroendovascular Antiplatelet Strategies for Thrombosis Prevention in Clopidogrel‐Hyporesponsive Patients

“…There remains concern for potential thrombotic events from inadequate antiplatelet response with clopidogrel due to significant interpatient variability in the ability to activate the parent compound metabolically. Clopidogrel hyporesponsiveness was reported in 21–53% of patients undergoing neuroendovascular procedures, similar to that reported in the cardiac literature (16–49%) . Although there is extensive experience with the use of clopidogrel as a component of dual antiplatelet therapy, the optimal strategy in patients who are clopidogrel hyporesponders is still unknown.…”

“…To minimize thrombotic complications, dual antiplatelet therapy is recognized as an important component of periprocedural management of neuroendovascular procedures involving intracranial stents. Antiplatelet therapy is frequently initiated a minimum of 1 week before elective and nonurgent procedures, whereas loading doses are commonly administered for emergent cases . Dual antiplatelet therapy with aspirin (81–325 mg/day) and a P2Y12 receptor antagonist, most commonly clopidogrel, is the mainstay of periprocedural and postprocedural therapy to reduce thromboembolic complications .…”

“…Reported incidence of thrombotic events following Guglielmi detachable coils is 2–10%, up to 12% after PED placement, and 3–6% following flow‐diverter stents, despite periprocedural prophylaxis with clopidogrel and aspirin therapy. However, the true incidence may be higher because diffusion‐weighted imaging is not routinely conducted for all nonsymptomatic patients . Longer procedure times, multiple stent deployments per procedure, and high preprocedure P2Y12 platelet reactivity were associated with an increased risk of thromboembolic complications .…”

“…Although there is extensive experience with the use of clopidogrel as a component of dual antiplatelet therapy, the optimal strategy in patients who are clopidogrel hyporesponders is still unknown. Previous reviews highlighted the data surrounding antiplatelet use in neuroendovascular procedures, primarily focusing on clopidogrel as a component of dual antiplatelet therapy with limited evidence for alternative strategies . Recent literature has provided further insight into the safety and effectiveness of alternative antiplatelet strategies that can guide clinical decision making.…”

Nöroendovasküler Girişimsel Tedavilerde Anti-trombotik İlaç Kullanımı

“…Ancak var olan az sayıda çalışma hemorajik komplikasyonlar açısından değerlendirildiğinde, çelişkili sonuçlar bildirmektedir. Güncel kabullere göre, nöroendovasküler girişimsel tedavilerde clopidogrel halen birinci sırada önerilmektedir, yeni anti-agregan ilaçlar ancak clopidogrel direnci saptanan olgularda kullanılmalıdır [7]. Bununla birlikte kardiyoloji literatüründeki bilgi birikimi göz önünde bulundurulduğunda aşağıdaki önerilerde bulunulabilir:…”