Thromboelastography (TEG) results are predictive of ischemic and hemorrhagic complications in patients with unruptured intracranial aneurysms treated with flow diversion

Javed, Kainaat; Unda, Santiago R.; Holland, Ryan; Fortunel, Adisson; Fluss, Rose; Inocencio, Julio; Haranhalli, Neil; Altschul, David

doi:10.1177/15910199211025917

Cited by 4 publications

(7 citation statements)

References 16 publications

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“…We acknowledge that platelet inhibition testing in the setting of flow diversion of intracranial aneurysms remains controversial, with questions regarding its efficacy, the best method of evaluating platelet inhibition levels (eg, light transmission platelet aggregation, thromboelastography (TEG)/platelet mapping system) as well as the optimum PRU range in centers using the VerifyNow assay. Yet, several prior investigations have now demonstrated an association between low VerifyNow PRU values and hemorrhagic complications following flow diversion 9–15…”

Section: Discussionmentioning

confidence: 99%

“…However, implantation of the flow diverter requires patients to be on antiplatelet therapy to prevent acute clotting, even for the newest version of PED with its thrombogenicity-reducing surface modification 6–8. Although controversial, multiple prior studies have now identified low and high levels of platelet inhibition to be associated with thromboembolic and hemorrhagic complications, respectively, during PED treatment 9–15. Consequently, based on the emerging literature, as well as our own experience, we have elected to strive to maintain a moderate level of platelet inhibition throughout the periprocedural period in flow diversion patients by titrating clopidogrel dosing based on the results of the VerifyNow P2Y12 platelet inhibition assay (Accumetrics, San Diego, California, USA).…”

Section: Introductionmentioning

confidence: 99%

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Excessive platelet inhibition following Pipeline embolization of intracranial aneurysms

Miller

Khunte

Caffes

et al. 2022

J NeuroIntervent Surg

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BackgroundHigh levels of platelet inhibition have been associated with hemorrhagic complications following Pipeline embolization of intracranial aneurysms. We therefore titrate clopidogrel dosing to maintain a moderate level of platelet inhibition using the VerifyNow P2Y12 assay. However, many patients demonstrate dramatic increases in platelet inhibition following treatment despite being on a consistent antiplatelet regimen. We therefore elected to explore the incidence of this phenomenon and possible predisposing factors.MethodsAll successful Pipeline aneurysm treatments performed at our institution from 2011 to 2019 with moderate procedure-day platelet inhibition levels as indicated by a VerifyNow PRU of 60–235 were included. Patients who received glycoprotein IIb/IIIa inhibitors and those treated for ruptured/symptomatic lesions were excluded. The incidence of excessive platelet inhibition defined by a PRU<60 within 8 weeks of treatment was noted. Multivariable logistic regression was performed to determined independent predictors of the phenomenon.ResultsSome 190 treatments were performed in 178 qualifying patients. A post-procedure PRU <60 occurred following 79% of treatments, documented on average after 8.5 (range 1–47) days. A higher procedure day hematocrit level (P=0.003, OR 1.09, 95% CI 1.029 to 1.152) was an independent predictor of reaching a PRU <60, while intra-procedural midazolam exposure (P=0.044, OR 0.44, 95% CI 0.201 to 0.980) and a higher procedure-day PRU (P=0.047, OR 0.99, 95% CI 0.982 to 1.000) were associated with a reduced odds. Time-since-procedure and hematocrit levels were associated with excessive platelet inhibition when excluding patients who initially demonstrated hyperresponse.ConclusionElevations in platelet inhibition were frequently observed following flow diversion with Pipeline.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Excessive platelet inhibition following Pipeline embolization of intracranial aneurysms

Miller

Khunte

Caffes

et al. 2022

J NeuroIntervent Surg

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Section: Neurologicalmentioning

confidence: 99%

“…TEG parameters showed an evitable role in improving hematological outcomes in people who underwent neurosurgeries whether they were adults [164][165][166][167][168] or children [169]. TEG parameters like TEG-R, TEG-MA, TEG-K, and TEG α-angle could predict hypercoagulation or thrombotic complications [164,166,168,169]; however, compared to control treatment, no difference was observed [170]. In addition, these parameters predicted bleeding and hypo-coagulation status whether intraoperative or postoperative [166,169,171,172] besides using them could decrease bleeding complications risk compared to other conventional labs [170].…”

Section: Neurologicalmentioning

confidence: 99%

Thromboelastography in the Perioperative Period: A Literature Review

Ramanujam¹,

DiMaria²,

Varma³

2023

Cureus

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Assessing coagulation status is essential for prompt intervention to reduce morbidity and mortality related to bleeding and thrombotic complications during the perioperative period. Traditional coagulation tests such as platelet count, activated partial thromboplastin time (aPTT), prothrombin time (PT), international normalized ratio (INR), and activated clotting time (ACT) provide only static evaluation. These tests are not designed for assessment of dynamically changing coagulation conditions during the perioperative time. However, viscoelastic coagulation testing such as thromboelastography (TEG) produces a rapid numerical and graphical representation that helps to detect and direct targeted hemostatic therapy. Searching the literature through PubMed, Medline, Ovid, CINAHL, and ClinicalTrials.gov we retrieved 210 studies, which represent the use of TEG in the perioperative period. The included studies were categorized under various settings such as trauma, obstetrics, orthopedics, intensive care unit (ICU), cardiovascular, transplant, and miscellaneous scenarios. TEG showed promising results in trauma surgeries in predicting mortality, hypercoagulability, and bleeding even when it was compared to conventional methods. TEG was also useful in monitoring anticoagulant therapy in orthopedic and obstetric surgeries; however, its role in predicting thrombotic events, hypercoagulability, or complications was questionable. In ICU patients, it showed promising results, especially in the prediction or improvement of sepsis, coagulopathy, thrombotic events, ICU duration, hospital stay, and ventilator duration. TEG parameters effectively predicted hypercoagulation in transplant surgeries. Regarding cardiovascular surgeries, they were effective in the prediction of the need for blood products, coagulopathy, thrombotic events, and monitoring anticoagulation therapy. More randomized clinical trials comparing TEG parameters with standardized tools are needed to produce robust results to standardize its use in different perioperative settings.

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“…Loss of function genotypes for these alleles do not alter the pharmacodynamics of other P2Y12 inhibitors such as prasugrel or ticagrelor. There is an increasing body of evidence that suggests that the PRU as assessed by the VerifyNow P2Y12 assay—though sometimes limited by low platelet count or low hematocrit—is the most useful assay at predicting periprocedural hemorrhagic and thrombotic complications during FD placement, although thromboelastography may also be useful in predicting CNS ischemic and access site hemorrhagic complications 20–23…”

Section: Reversal Of Direct Oral Anticoagulantsmentioning

confidence: 99%

Antiplatelets and antithrombotics in neurointerventional procedures: Guideline update

Schirmer

Bulsara

Al‐Mufti

et al. 2023

J NeuroIntervent Surg

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BackgroundAntiplatelet and antithrombotic medication management before, during, and after neurointerventional procedures has significant practice variation. This document updates and builds upon the 2014 Society of NeuroInterventional Surgery (SNIS) Guideline ‘Platelet function inhibitor and platelet function testing in neurointerventional procedures’, providing updates based on the treatment of specific pathologies and for patients with specific comorbidities.MethodsWe performed a structured literature review of studies that have become available since the 2014 SNIS Guideline. We graded the quality of the evidence. Recommendations were arrived at through a consensus conference of the authors, then with additional input from the full SNIS Standards and Guidelines Committee and the SNIS Board of Directors.ResultsThe management of antiplatelet and antithrombotic agents before, during, and after endovascular neurointerventional procedures continues to evolve. The following recommendations were agreed on. (1) It is reasonable to resume anticoagulation after a neurointerventional procedure or major bleeding episode as soon as the thrombotic risk exceeds the bleeding risk in an individual patient (Class I, Level C-EO). (2) Platelet testing can be useful to guide local practice, and specific approaches to using the numbers demonstrate marked local variability (Class IIa, Level B-NR). (3) For patients without comorbidities undergoing brain aneurysm treatment, there are no additional considerations for medication choice beyond the thrombotic risks of the catheterization procedure and aneurysm treatment devices (Class IIa, Level B-NR). (4) For patients undergoing neurointerventional brain aneurysm treatment who have had cardiac stents placed within the last 6–12 months, dual antiplatelet therapy (DAPT) is recommended (Class I, Level B-NR). (5) For patients being evaluated for neurointeventional brain aneurysm treatment who had venous thrombosis more than 3 months prior, discontinuation of oral anticoagulation (OAC) or vitamin K antagonists should be considered as weighed against the risk of delaying aneurysm treatment. For venous thrombosis less than 3 months in the past, delay of the neurointerventional procedure should be considered. If this is not possible, see atrial fibrillation recommendations (Class IIb, Level C-LD). (6) For patients with atrial fibrillation receiving OAC and in need of a neurointerventional procedure, the duration of TAT (triple antiplatelet/anticoagulation therapy=OAC plus DAPT) should be kept as short as possible or avoided in favor of OAC plus single antiplatelet therapy (SAPT) based on the individual’s ischemic and bleeding risk profile (Class IIa, Level B-NR). (7) For patients with unruptured brain arteriovenous malformations there is no indication to change antiplatelet or anticoagulant management instituted for management of another disease (Class IIb, Level C-LD). (8) Patients with symptomatic intracranial atherosclerotic disease (ICAD) should continue DAPT following neurointerventional treatment for secondary stroke prevention (Class IIa, Level B-NR). (9) Following neurointerventional treatment for ICAD, DAPT should be continued for at least 3 months. In the absence of new stroke or transient ischemic attack symptoms, reversion to SAPT can be considered based on an individual patient’s risk of hemorrhage versus ischemia (Class IIb, Level C-LD). (10) Patients undergoing carotid artery stenting (CAS) should receive DAPT before and for at least 3 months following their procedure (Class IIa, Level B-R). (11) In patients undergoing CAS during emergent large vessel occlusion ischemic stroke treatment, it may be reasonable to administer a loading dose of intravenous or oral glycoprotein IIb/IIIa or P2Y12 inhibitor followed by maintenance intravenous infusion or oral dosing to prevent stent thrombosis whether or not the patient has received thrombolytic therapy (Class IIb, C-LD). (12) For patients with cerebral venous sinus thrombosis, anticoagulation with heparin is front-line therapy; endovascular therapy may be considered particularly in cases of clinical deterioration despite medical therapy (Class IIa, Level B-R).ConclusionsAlthough the quality of evidence is lower than for coronary interventions due to a lower number of patients and procedures, neurointerventional antiplatelet and antithrombotic management shares several themes. Prospective and randomized studies are needed to strengthen the data supporting these recommendations.

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Thromboelastography (TEG) results are predictive of ischemic and hemorrhagic complications in patients with unruptured intracranial aneurysms treated with flow diversion

Cited by 4 publications

References 16 publications

Excessive platelet inhibition following Pipeline embolization of intracranial aneurysms

Excessive platelet inhibition following Pipeline embolization of intracranial aneurysms

Thromboelastography in the Perioperative Period: A Literature Review

Antiplatelets and antithrombotics in neurointerventional procedures: Guideline update

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