Intraprocedural thrombosis affects nearly 5% of patients, but current protocols can prevent stroke 80% of the time, researchers say.
Current approaches to treating intraprocedural thrombosis that occurs during neuroendovascular procedures for intracranial aneurysm appear to be effective, a new analysis shows.
Postprocedural ischemic stroke and hemorrhage can be prevented in the vast majority of cases, with no difference based on whether patients receive abciximab or eptifibatide.
“Thromboembolic complications are the most common cause of morbidity after neuroendovascular procedures,” lead author Nimer Adeeb, MD (Beth Israel Deaconess Medical Center, Boston, MA), and colleagues write in a brief report published online February 28, 2017, in Stroke. “Intraprocedural thrombosis poses a formidable challenge,” they add. “Concern for postprocedural hemorrhage may lead to undertreatment with antiplatelet and thrombolytic agents, which may have deleterious consequences.”
To take a closer look at how affected patients fare, and whether differences in treatment have an effect, Adeeb et al conducted a retrospective analysis of 802 intracranial aneurysms treated via stent-assisted coiling or flow diversion between 2007 and 2016 at four academic medical centers. Intraprocedural thrombosis occurred in 4.6% of cases, which resulted in complete vascular occlusion 29.4% of the time. Half of cases were treated using IV abciximab (ReoPro; Centocor) and half using IV eptifibatide (Integrilin; Millennium Pharmaceuticals). Additionally, 17% received heparin (2,000 IU) and 8.8% were given intra-arterial tPA (3 to 4 mg). Complete recanalization was achieved at a rate of 82.3% overall and didn’t differ significantly between abciximab and eptifibatide (76.5% vs 88.2%; P = 0.368).
Postprocedural ischemic stroke and hemorrhage rates of 20.6% and 11.8%, respectively, were seen among patients who had experienced intraprocedural thrombosis. Again, no difference was seen by choice of drug.
On multivariate analysis, the only significant predictor of ischemic stroke risk was current smoking (adjusted OR 11.8; 95% CI 1.06-144.1).
“There is no consensus in the neurointerventional literature regarding the optimal agent for the treatment of acute periprocedural thromboembolic complications after stents or [Pipeline embolization device] placement,” the investigators say.
As of now, the only approved drug for treating acute occlusion of cerebral vessels is IV tPA, they note. “However, the use of this agent during intra-arterial procedures must be balanced against the high risk of intracranial hemorrhage and low recanalization rate.” Other options, the authors add, include not only abciximab and eptifibatide, but also tirofiban (Aggrastat; Medicure Pharma).
Adeeb N, Griessenauer CJ, Moore JM, et al. Ischemic stroke after treatment of intraprocedural thrombosis during stent-assisted coiling and flow diversion. Stroke. 2017;Epub ahead of print.
Adeeb reports no relevant conflicts of interest.
- With Intracranial Stenting, Tandem Stenting and Antiplatelet Resistance Emerge as Players in Subacute Thrombosis
- Early Angiographic Signs Hint at Thrombus Formation Within Pipeline