Cangrelor dose titration using platelet function testing during cerebrovascular stent placement

Entezami, Pouya; Holden, Devin N.; Boulos, Alan S.; Paúl, Alexandra; Field, Nicholas C.; Nourollahzadeh, Emad; Yamamoto, Junichi; Dalfino, John

doi:10.1177/1591019920936923

Cited by 23 publications

(26 citation statements)

References 38 publications

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“…When half the cardiac dose was used, similar to our study, all seven patients with acute ischemic stroke had adequate (PRU < 200) antiplatelet activity and no evidence of intracranial hemorrhage or in-stent thrombosis (29). Lastly, a study by Entezami et al treated 21 patients with ischemic stroke or symptomatic critical stenosis (32). A cangrelor bolus of 5 mcg/kg was followed by a maintenance infusion of 0.75 or 1 mcg/kg/min.…”

Section: Discussionsupporting

confidence: 68%

Safety of Low Dose Intravenous Cangrelor in Acute Ischemic Stroke: A Case Series

et al. 2021

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Background: Neurointerventional procedures in acute ischemic stroke often require immediate antiplatelet therapy in the cases of acute stenting and occasionally re-occluding vessels. Intravenous cangrelor is a P2Y12 receptor antagonist with short onset and quick offset. The study objective was to evaluate the safety and efficacy of intravenous cangrelor in patients with acute ischemic stroke requiring urgent antiplatelet effect.Methods: Patients who received intravenous cangrelor intra-procedurally during acute ischemic stroke treatment were identified from a prospectively collected database. Cangrelor was administered as a bolus of 15 mcg/kg, followed by an infusion rate of 2 mcg/kg/min. A historical control group consisting of anterior circulation tandem occlusions was used to compare to patients with similar lesions who received intravenous cangrelor. Outcomes of interest included in-stent thrombosis, thromboembolic complications, intracranial hemorrhage, and functional outcomes at 90 days.Results: Twelve patients received intravenous cangrelor for acute ischemic stroke between October 2018 and April 2020 at a comprehensive stroke center. Eleven patients had intra or extracranial stenting performed, which included two posterior circulation lesions. No cases of symptomatic intracranial hemorrhage were reported. At 90 day follow-up, two patients had died and 10 had a good functional outcome. Patients with anterior circulation tandem occlusions who received cangrelor and those who received dual antiplatelets orally had similar radiographic and clinical outcomes.Conclusion: Low dose intravenous cangrelor is similar in safety and efficacy to oral antiplatelets in acute ischemic stroke in a small case series. Larger prospective studies on the efficacy, safety, and effect on procedure times of intravenous cangrelor in neurointervention are warranted.

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Section: Discussionsupporting

confidence: 68%

Safety of Low Dose Intravenous Cangrelor in Acute Ischemic Stroke: A Case Series

et al. 2021

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“…17,18 More recently, efforts have been invested into defining a therapeutic window for cangrelor within the interventional cardiology and neuroendovascular literature, with no current consensus. 19 Studies have shown an increased risk of bleeding with PRUs of less than 50 to 80 and an increased risk of thrombosis at PRUs approaching 200. 10 Thus, our institution initially derived our PRU range of 50 to 194 as being optimal, to balance risk of bleeding and ischemic complications.…”

Section: Discussionmentioning

confidence: 99%

Clinical Use of Cangrelor After Percutaneous Coronary Intervention in Patients Requiring Mechanical Circulatory Support

et al. 2021

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Background: Patients with cardiogenic shock after percutaneous coronary intervention (PCI) may require mechanical circulatory support (MCS). The combination of dual antiplatelet therapy with cangrelor and continuous anticoagulation required for MCS may increase the risk of bleeding. Objective: The objective of the study is to describe the complications and outcomes of patients who received cangrelor during MCS following PCI. Methods: This is a single-center, retrospective, observational case series of 17 patients who received cangrelor while on MCS from June 2017 to September 2019. Results: In a case series of 17 patients, 8 patients (47%) were supported with an Impella device and 4 patients (24%) with venoarterial (VA) extracorporeal membrane oxygenation (ECMO); 5 required (29%) concomitant VA ECMO and Impella support in the setting of cardiogenic shock. All patients received triple antithrombotic therapy with aspirin, heparin, and cangrelor. Cangrelor was commonly initiated at a median dose of 0.75 (range 0.5-4) µg/kg/min. Cangrelor dose adjustments included changes in increments up to 0.25 µg/kg/min with review of P2Y12 levels. A total of 10 patients (59%) experienced a bleeding event, most commonly located at the peripheral cannulation site (40%) and in the gastrointestinal tract (30%). Seven (70%) and 3 (30%) of the bleeding complications were classified as major and minor, respectively. No patient developed in-stent thrombosis during the hospitalization; 14 (82%) patients survived their MCS course. Conclusion and Relevance: This case series suggests that cangrelor doses less than 0.75 µg/kg/min may be beneficial. Larger studies should evaluate alternative dosing regimens.

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“…74 Of course, caution in patients with intraventricular drains or those in need of surgical intervention is the rule, 75,76 it should be noted that there exists a patient population which receives anti-platelet drugs following coil embolization with minimal complications. 77–80 So why are anti-platelets not more widely used for aSAH patients? Despite their safety in use, trials of anti-platelet agents have not shown a clear clinical benefit.…”

Section: Platelets As a Therapeutic Target To Prevent DCImentioning

confidence: 99%

“…Several platelet activation receptors (protease activated receptors (PAR), thromboxane receptors, purinergic receptors (P2Y)) have been tested as therapeutic targets for aSAH. 74,78,91–95 Two activation receptors which may be promising are the GPIb-IX-V complex and GPVI. The GPIb-IX-V complex interacts with vWF and thrombin, and is crucial in platelet adhesion to endothelial cells and stabilizing microclots.…”

Section: Alternative Anti-platelet Targetsmentioning

confidence: 99%

Role of platelets in the pathogenesis of delayed injury after subarachnoid hemorrhage

Dienel

Blackburn

et al. 2021

J Cereb Blood Flow Metab

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Aneurysmal subarachnoid hemorrhage (aSAH) patients develop delayed cerebral ischemia and delayed deficits (DCI) within 2 weeks of aneurysm rupture at a rate of approximately 30%. DCI is a major contributor to morbidity and mortality after SAH. The cause of DCI is multi-factorial with contributions from microthrombi, blood vessel constriction, inflammation, and cortical spreading depolarizations. Platelets play central roles in hemostasis, inflammation, and vascular function. Within this review, we examine the potential roles of platelets in microthrombi formation, large artery vasospasm, microvessel constriction, inflammation, and cortical spreading depolarization. Evidence from experimental and clinical studies is provided to support the role(s) of platelets in each pathophysiology which contributes to DCI. The review concludes with a suggestion for future therapeutic targets to prevent DCI after aSAH.

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Cangrelor dose titration using platelet function testing during cerebrovascular stent placement

Cited by 23 publications

References 38 publications

Safety of Low Dose Intravenous Cangrelor in Acute Ischemic Stroke: A Case Series

Safety of Low Dose Intravenous Cangrelor in Acute Ischemic Stroke: A Case Series

Clinical Use of Cangrelor After Percutaneous Coronary Intervention in Patients Requiring Mechanical Circulatory Support

Role of platelets in the pathogenesis of delayed injury after subarachnoid hemorrhage

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