E-062 Intracranial Stenting for Atherosclerotic Disease with Aggressive Anti-platelet Therapy Management: A Consecutive Series of 154 Patients

Abstract

Introduction Contemporary studies of intracranial stenting have utilised standard or aggressive medical therapy involving dual anti-platelet therapy, but have not evaluated anti-platelet therapy resistance as a component of treatment failure. Methods The current study evaluates a prospective aggressive anti-platelet therapy management approach at two institutions in a consecutive series of 154 patients with symptomatic intracranial atherosclerotic disease (ICAD) treated with angioplasty and stenting with the Wingspan self-expanding nitinol stent. Anti-platelet medication therapeutic effects of aspirin and clopidogrel were measured prior to the procedures by platelet function assay, thromboelastography, aggregometry, or Accumetrics VerifyNow systems. Medications were adjusted or changed for subtherapeutic or supratherapeutic values with clopidogrel goal inhibition of 20–80% and aspirin reactive unit (ARU) less than 550. Results A total of 154 patients with symptomatic ICAD were treated from 2005 to 2014. The periprocedural complication rate was 3.9% (6/154) with 1 subarachnoid haemorrhage, 0 intraparenchymal haemorrhages, 5 perforator strokes, and no stent thrombosis. With a mean follow up of 2.3 years, the total ipsilateral stroke and death rate was 6.5% (10/154). The relative aspirin resistance rate was 7.8% and the relative clopidogrel resistance rate was 14.9% in this series. Eight of the patients (5.2%) required repeat angioplasty for symptomatic re-stenosis within the first year. The mean time to treatment was 10.7 days following the last stroke. Conclusions With aggressive monitoring and management of anti-platelet medications, intracranial stenting complications of stent thrombosis and distal emboli can be reduced, although there is still a significant risk of perforator strokes, particularly in the middle cerebral artery and basilar distributions. Disclosures M. Alexander: 1; C; Stryker Neurovascular. M. Nuno: None. J. Alexander: None. C. Agutos: None. W. Yu: 1; C; Stryker Neurovascular.

Association of thrombelastographic parameters with post-stenting ischemic events

“…However, some patients show resistance to clopidogrel or aspirin and impaired inhibition of platelet aggregation 12. It has been estimated that 4.2–31.0% of patients treated with clopidogrel do not achieve an appropriate level of efficacy of platelet activity,13–15 and aspirin resistance accounts for 7.8–32.0% of patients with recurrent events 16 17. Many platelet function tests have been used to define the responsiveness of patients with cardiovascular disease to clopidogrel or aspirin 16.…”

“…It has been estimated that 4.2–31.0% of patients treated with clopidogrel do not achieve an appropriate level of efficacy of platelet activity,13–15 and aspirin resistance accounts for 7.8–32.0% of patients with recurrent events 16 17. Many platelet function tests have been used to define the responsiveness of patients with cardiovascular disease to clopidogrel or aspirin 16. Different tests have provided wide-ranging figures for the prevalence of clopidogrel resistance, suggesting poor correlation between currently available platelet function tests 18.…”

Incidence and Risk Factors for Diffusion-Weighted Imaging (+) Lesions After Intracranial Stenting and Its Relationship With Symptomatic Ischemic Complications

“…It might affect the rates of in-stent thrombosis and intracranial hemorrhage in our study. Recently, Alexander et al 25 reported a proceeding in which, with adjustment or change of antiplatelet premedication for nonresponders or hyperresponder, no case of acute in-stent thrombosis or intraparenchymal hemorrhage occurred after Wingspan stenting in 154 patients. This result suggests that antiplatelet resistance test and adjustment of mediation for nonresponder or hyperresponder should be performed before intracranial stenting.…”