Antiplatelet therapy and the risk of ischemic and hemorrhagic complications associated with Pipeline embolization of cerebral aneurysms: a systematic review and pooled analysis

Saber, Hamidreza; Kherallah, Riyad; Hadied, Mohamad Omar; Kazemlou, Shaghayegh; Chamiraju, Parthasarathi; Narayanan, Sandra

doi:10.1136/neurintsurg-2018-014082

Cited by 33 publications

(20 citation statements)

References 35 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…However, ticagrelor remains significantly more expensive than clopidogrel and is currently reserved for patients who are intolerant to clopidogrel or for those who develop ischemic events while compliant with clopidogrel 11. Another option for those patients is to be switched to a higher ASA dose (>150 mg) or to use DAPT for at least 6 months as suggested by a recent meta-analysis 58. Our meta-analysis had scarce data on hemorrhagic complications.…”

Section: Discussionmentioning

confidence: 99%

Outcome of intracranial flow diversion according to the antiplatelet regimen used: a systematic review and meta-analysis

Podlasek

Sultan

Assis

et al. 2019

J NeuroIntervent Surg

View full text Add to dashboard Cite

BackgroundThromboembolic complications are not uncommon in patients undergoing neurointerventional procedures. The use of flow diverting stents is associated with higher risks of these complications despite current dual antiplatelet regimens.ObjectiveTo explore contemporary evidence on the safety of emerging dual antiplatelet regimens in flow diverting stenting procedures.MethodsWe performed a systematic review and meta-analysis to identify relevant articles in electronic databases, and relevant references. Studies reporting the complications and mortality of flow diverting stenting procedures using acetyl salicylic acid (ASA) + ticagrelor or ASA + prasugrel compared with ASA + clopidogrel were included.ResultsOf 452 potentially relevant studies, we identified 49 studies (2526 patients) which reported the safety of ticagrelor or prasugrel for pooled analysis, and five studies (1005 patients) for meta-analysis. The pooled overall mortality in all studies was 2.14%, ischemic complications 6.89%, and hemorrhagic complications 3.68%. The use of ticagrelor or prasugrel was associated with a lower risk of mortality compared with clopidogrel (RR=4.57, 95% CI 1.23 to 16.99; p=0.02). Considering ischemic events, ASA + clopidogrel was as safe as ASA + prasugrel (RR=0.55, 95% CI 0.11 to 2.74; p=0.47) and ASA + ticagrelor (RR=0.74, 95% CI 0.32 to 1.74; p=0.49). ASA +ticagrelor was not associated with a higher risk of hemorrhagic complications (RR=0.92, 95% CI 0.27 to 3.16; p=0.89).ConclusionsEvidence suggests that dual antiplatelet regimens including ticagrelor or prasugrel are safe for patients undergoing flow diversion procedures. Regimens using ticagrelor were associated with better survival than those using clopidogrel in the included studies.

show abstract

Section: Discussionmentioning

confidence: 99%

Outcome of intracranial flow diversion according to the antiplatelet regimen used: a systematic review and meta-analysis

Podlasek

Sultan

Assis

et al. 2019

J NeuroIntervent Surg

View full text Add to dashboard Cite

show abstract

“…[4][5][6] Small sample sizes explain this relatively wide distribution, retrospective study design, lack of anatomical stratification, and variation in DAPT between existing studies. Given these limitations, Saber et al 7 reported in their pooled analysis of 2,002 patients undergoing PED placement (2009 to 2017) an overall 7% (95% CI 6-9%) rate for thromboembolism and 5% (95% CI 4-6%) for hemorrhage For a concise overview, Table 1 summarizes ischemic and hemorrhagic event rates, as well as overall mortality rates for the respective DAPT regimens employed across six major prospective multicenter flow diversion trials for unruptured aneurysms.…”

Section: Resultsmentioning

confidence: 99%

P₂Y₁₂inhibitors in neuroendovascular surgery: An opportunity for precision medicine

et al. 2021

View full text Add to dashboard Cite

Introduction Dual antiplatelet therapy (DAPT), primarily the combination of aspirin with a P2Y12 inhibitor, in patients undergoing intravascular stent or flow diverter placement remains the primary strategy to reduce device-related thromboembolic complications. However, selection, timing, and dosing of DAPT is critical and can be challenging given the existing significant inter- and intraindividual response variations to P2Y12 inhibitors. Methods Assessment of indexed, peer-reviewed literature from 2000 to 2020 in interventional cardiology and neuroendovascular therapeutics with critical, peer-reviewed appraisal and extraction of evidence and strategies to utilize DAPT in cardio- and neurovascular patients with endoluminal devices. Results Both geno- and phenotyping for DAPT are rapidly and conveniently available as point-of-care testing at a favorable cost-benefit ratio. Furthermore, systematic inclusion of a quantifying clinical risk score combined with an operator-linked, technical risk assessment for potential adverse events allows a more precise and individualized approach to new P2Y12 inhibitor therapy. Conclusions The latest evidence, primarily obtained from cardiovascular intervention trials, supports that combining patient pharmacogenetics with drug response monitoring, as part of an individually tailored, precision medicine approach, is both predictive and cost-effective in achieving and maintaining individual target platelet inhibition levels. Indirect evidence supports that this gain in optimizing drug responses translates to reducing main adverse events and overall treatment costs in patients undergoing DAPT after intracranial stent or flow diverting treatment.

show abstract

“…Overall, thromboembolic events have been observed in approximately 6% of patients with higher rates of complications occurring in patients treated with aspirin and clopidogrel therapy for less than 6 months. 20 Therefore, the use of aneurysm obliteration via flow diversion should occur at least 6 months prior to any planned surgical intervention for the pituitary adenoma and may be best reserved for asymptomatic patients without optic apparatus compression or progressively enlarging adenomas where intervention may be safely delayed.…”

Section: Discussionmentioning

confidence: 99%

Management of Coincident Pituitary Macroadenoma and Cavernous Carotid Aneurysm: A Systematic Literature Review

et al. 2021

View full text Add to dashboard Cite

Introduction Pituitary adenomas are a common intracranial pathology with an incidence of 15 to 20% in the population while cerebral aneurysms are less common with a prevalence of 1:50 patients. The incidence of aneurysms in patients with pituitary adenoma has been estimated at 2.3 to 5.4% of patients; however, this remains unclear. Equally, the management of concomitant lesions lacks significant understanding. Methods A case report is presented of a concomitant cerebral aneurysm and pituitary adenoma managed by minimally invasive endovascular and endoscopic methods, respectively. A systematic review of the literature for terms “pituitary adenoma” and “aneurysm” yielded 494 studies that were narrowed to 19 relevant articles. Results We report a case of a 67-year-old patient with an enlarging pituitary macroadenoma, cavernous carotid aneurysm, and unilateral carotid occlusion. After successful treatment of the aneurysm by a pipeline flow diverter, the pituitary adenoma was surgically resected by an endoscopic transsphenoidal approach. Conclusion The use of a pipeline flow diverter and endonasal approach was feasible in the treatment of our patient. This is the first report to our knowledge of the use of pipeline flow diversion in the management of a cavernous carotid aneurysm prior to pituitary adenoma treatment.

show abstract

Antiplatelet therapy and the risk of ischemic and hemorrhagic complications associated with Pipeline embolization of cerebral aneurysms: a systematic review and pooled analysis

Abstract: High-dose ASA therapy and clopidogrel treatment for at least 6 months were associated with a reduced incidence of ischemic events, without affecting the risk of hemorrhagic events.

Cited by 33 publications

References 35 publications

Outcome of intracranial flow diversion according to the antiplatelet regimen used: a systematic review and meta-analysis

Outcome of intracranial flow diversion according to the antiplatelet regimen used: a systematic review and meta-analysis

P₂Y₁₂inhibitors in neuroendovascular surgery: An opportunity for precision medicine

Management of Coincident Pituitary Macroadenoma and Cavernous Carotid Aneurysm: A Systematic Literature Review

Contact Info

Product

Resources

About

Antiplatelet therapy and the risk of ischemic and hemorrhagic complications associated with Pipeline embolization of cerebral aneurysms: a systematic review and pooled analysis

Abstract: High-dose ASA therapy and clopidogrel treatment for at least 6 months were associated with a reduced incidence of ischemic events, without affecting the risk of hemorrhagic events.

Cited by 33 publications

References 35 publications

Outcome of intracranial flow diversion according to the antiplatelet regimen used: a systematic review and meta-analysis

Outcome of intracranial flow diversion according to the antiplatelet regimen used: a systematic review and meta-analysis

P2Y12inhibitors in neuroendovascular surgery: An opportunity for precision medicine

Management of Coincident Pituitary Macroadenoma and Cavernous Carotid Aneurysm: A Systematic Literature Review

Contact Info

Product

Resources

About

P₂Y₁₂inhibitors in neuroendovascular surgery: An opportunity for precision medicine