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

Abstract

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.

Initial experience with the novel p64MW HPC flow diverter from a cohort study in unruptured anterior circulation aneurysms under dual antiplatelet medication

“…DAPT through ASA plus prasugrel or ticagrelor has been found suitable for flow diversion. 27 ASA adds little impact compared to prasugrel alone 28 and is subject to several drug interactions and situational effects such as fever, trauma, SAH and pregnancy, which may significantly reduce the efficacy of ASA at standard dosage. It therefore appears logical—and has been proposed during recent presentations—to use prasugrel as a SAPT when implanting surface-modified flow diverters.…”

Early Treatment of Ruptured Blood Blister-Like Aneurysms of the Internal Carotid Artery With Flow Diverters Using Single Antiplatelet Therapy: A Single-Center Experience With Long-Term Follow-Up

“…Due to the lack of appropriate platelet inhibition following clopidogrel administration (clopidogrel resistance), which inhibits the P2Y12 adenosine diphosphate (ADP) receptor and has been associated with higher rates of ischemic complications following neuroendovascular procedures ( 39 ), our institutional approach is to use new P2Y12 antagonists for intracranial stenting, especially for FDs. Although DAPT with acetylsalicylic acid plus clopidogrel is still the main choice for FDs, Podlasek et al recently reported in their meta-analyses that new-generation P2Y12 antagonists (ticagrelor and prasugrel) are safe for patients undergoing flow diversion ( 11 ). Another study demonstrated the safety of prasugrel loading 50 mg before 2 h from stent delivery for thromboembolic and hemorrhagic complications in ruptured BBAs treated with PED in nine patients ( 40 ).…”

“…There have been limited data obtained from previous studies on single antiplatelet therapy (SAPT) in preventing thromboembolic complications associated with FDs ( 10 ). New-generation P2Y12 antagonist (ticagrelor and prasugrel) usage in neurointervention is a novel topic ( 11 ). This study aims to report the safety and efficacy of a single-center FD treatment for ruptured BBAs in the early phase of SAH using new-generation P2Y12 antagonists as SAPT regimen.…”

Prevalence of aspirin and clopidogrel resistance in neurovascular stenting: a single-center experience

“…The premedications with new antiplatelets, such as prasugrel and ticagrelor, are becoming increasingly used in neurovascular stenting, particularly with FDDs. In our unit, we prefer ticlopidine and prasugrel as premedication in patients who are resistant to clopi-In a systematic review, dual antiplatelet regimens including ticagrelor or prasugrel are found to be safe for patients undergoing FDD procedures [29]. Besides, in another research, it was demonstrated that more than 98% of patients were within the optimal range with Multiplate ® test after half-dose (30 mg) loading of prasugrel [30].…”