Reduction of thromboembolic complications during the endovascular treatment of unruptured aneurysms by employing a tailored dual antiplatelet regimen using aspirin and prasugrel

Abstract

BackgroundThromboembolic complications (TECs) are frequent during the endovascular treatment of unruptured aneurysms. To prevent TECs, dual antiplatelet therapy using aspirin and clopidogrel is recommended for the perioperative period. In patients with a poor response, clopidogrel is a risk factor for TECs. To prevent TECs, our study assessed the stratified use of prasugrel.MethodsPatients who underwent endovascular therapy for unruptured cerebral aneurysms from April 2017 to August 2019 were enrolled in this clinical study and given premedication with aspirin and clopidogrel for 2 weeks prior to the procedure. P2Y12 reaction units (PRU) were measured using the VerifyNow assay on the day before the procedure (tailored group). In subgroups with PRU <240, the clopidogrel dose was maintained (CPG subgroup). In subgroups with PRU ≥240, clopidogrel was changed to prasugrel (PSG subgroup). We compared the occurrence of TECs with retrospective consecutive cases from January 2015 to March 2017 without PRU assessments (non-tailored group). The frequency of TECs within 30 days was assessed as the primary endpoint.ResultsThe tailored and non-tailored groups comprised 167 and 50 patients, respectively. TECs occurred in 11 (6.6%) and 8 (16%) patients in the tailored and non-tailored groups (P=0.048), respectively. The HR for TECs was significantly reduced in the tailored group (HR 0.3, 95% CI 0.11 to 0.81); P=0.017) compared with the non-tailored group.ConclusionThe results suggest that tailored dual antiplatelet therapy medication with PRU significantly reduces the frequency of TECs without increasing hemorrhagic complications.

Efficacy of the Flow Re-direction Endoluminal Device for cerebral aneurysms and causes of failed deployment

“…Still, some individuals show genetic variation, failing to respond to CPG [ 12 – 15 ], and there is no consensus regarding the exact types and doses of antiplatelet therapy. PSG has been reported to be effective for patients with inadequate response to CPG [ 6 ]. In this study, all patients received PSG and the PRU was significantly decreased after changing CPG to PSG.…”

“…Before the procedure, all patients received dual antiplatelet therapy with clopidogrel (CPG) at 75 mg and aspirin at 100 mg for 14 days. P2Y12 reaction unit (PRU) was monitored by VerifyNow (Accumetrics, San Diego, CA, USA) 2 days before the procedure, and CPG was changed to prasugrel (PSG) in all patients [ 6 ]. In patients whose PRU was greater than 210, a loading dose of PSG at 20 mg was administered; subsequently, a dose of PSG at 3.75 mg per day was maintained.…”

Safety of Oral P2Y12 Inhibitors in Interventional Neuroradiology: Current Status and Perspectives

“…Neurointerventional studies, however, have used different cutoffs in varied contexts, varying from 208 to 295. 12,20,[27][28][29]31,40,54 A value of ,60 was reported to be associated with a higher risk of hemorrhagic complications. 28,29 In a study of 279 patients under dual antiplatelet therapy, a value of 175 was observed to discriminate patients with hemorrhagic complications from those without.…”

“…In a recent study, Higashiguchi et al, 31 in 2021, proposed a tailored therapy in which prasugrel replaced clopidogrel when the result of the VerifyNow assay was inferior to 240 P2Y12 reactive units. They observed a reduction in the frequency of thromboembolic complications after treatment of unruptured aneurysms (16% versus 6%, P , .048, n = 217) after a 1-month follow-up without an increase in the rate of hemorrhagic complications.…”

“…2,3,14 Since the advice of the FDA on clopidogrel hyporesponsiveness in 2010, 22,23 alternative drugs have been studied at greater lengths. In the context of both preoperative preparation and postoperative antiaggregation, 2 other oral agents, prasugrel [24][25][26][27][28][29][30][31][32][33][34][35][36][37] and ticagrelor, 25,[38][39][40][41][42][43][44][45][46] have been intensively discussed (Online Supplemental Data). Prasugrel is a third-generation thienopyridine, a group of drugs that irreversibly inhibits the P2Y12 receptor and, consequently, adenosine diphosphate-dependent activation and platelet aggregation.…”