Safety and Efficacy of Tirofiban in Rescue Treatment for Acute Intracranial Intraprocedural Stent Thrombosis

Abstract

Background and Purpose: The incidence of acute intraprocedural stent thrombosis (AIST) during stenting of intracranial atherosclerotic stenosis (ICAS) has seldom been reported and evidence regarding the treatment of AIST is lacking. We aim to investigate the incidence of AIST during stenting of ICAS in our institute, assess the preliminary efficacy and safety of rescue treatment of tirofiban for these patients. Methods: From September 2016 to May 2019, all symptomatic ICAS patients who underwent intracranial stenting in our institute were prospectively registered into this study, of which patients with AIST were retrospectively reviewed to extract baseline characteristics, perioperative management, procedural details, angiographic, and clinical outcomes. Rescue treatment of tirofiban for AIST was assessed by recanalization of the culprit vessel and periprocedural death, hemorrhage, and ischemic stroke. Results: Acute intraprocedural stent thrombosis developed in 12 (6.2%) patients within 30 min after stent placement of 194 patients. All 12 cases were successfully recanalized with modified Treatment in Cerebral Ischemia (mTICI) 3 and Arterial Occlusive Lesion (AOL) 3 after rescue treatment of tirofiban alone. There was no perioperative death or any hemorrhagic complication. Three patients suffered perioperative ischemic stroke. Conclusions: We observed a non-negligible rate of AIST during intracranial stenting procedures for ICAS. Intra-arterial bolus followed by intravenous tirofiban infusion seems to be efficacious and safe for AIST during stent placement for ICAS, without increasing the rate of hemorrhagic complications and death.

Comparison of Safety and Efficacy after Emergency Stenting in Patients Exhibiting Intracranial Atherosclerotic Stenosis Associated with Large-vessel Occlusion with and without Intravenous Infusion of Tirofiban

“…Several retrospective studies and case series have demonstrated a favourable effect of the systemic administration of tirofiban on patients with intracranial dissection [30] and on patients after emergency angioplasty with and without intracranial stenting [31,32]. The main advantages of the drug are its ease of administration, rapid onset of action and short half-life.…”

Glycoprotein IIb/IIIa inhibitors for the neurointerventionalist

“…According to a single-centre observational study by Zhao W et al, intra-arterial “low-dose” tirofiban was used to cope with thromboembolic complications and the authors advised using a 0.25–0.5 mg (total) dose at a rate of 1 ml/min (0.05 mg/ml) or 0.4 µg/kg/min for 1000 s (up to 1 mg in total). 25 , 38 This was not associated with an increased incidence of symptomatic intracranial hemorrhage. In summary, both intravenous and intra-arterial approaches have been described with similar clinical outcomes and complication rates.…”

“…24 Moreover, during acute intraprocedural stent thrombosis in the context of intracranial atherosclerotic stenosis, intra-arterial bolus administration of tirofiban followed by IV infusion was efficacious and safe with no significant increased risk of intracranial hemorrhage or death. 25 With regards to mechanical thrombectomy, intra-arterial administration of tirofiban was beneficial predominantly for large artery atherosclerosis strokes relative to those of cardio-embolic origin. 26 Conversely, a randomized control trial found no significant effect of tirofiban in AIS on long-term survival, dependency or death without increasing the risk of bleeding compared to using aspirin.…”

Safety and efficacy of prophylactic tirofiban infusion for acute intracranial intraprocedural stent thrombosis

“…All patients were on dual antiplatelet agents (100 mg aspirin and 75 mg clopidogrel) daily for at least 5 days before stenting. The details of the interventional procedure have been described previously 8 , 9 . In brief, all endovascular procedures were performed by an experienced neurointerventionist under general anesthesia between 1 and 3 weeks after the symptoms onset of the last ischemic stroke.…”

“…When the stent was released, the intraoperative angiography showed a shadow defect within 5 mm to the stent or within the stent, AIST was recorded. For patients diagnosed with AIST, intra-arterial bolus followed by intravenous tirofiban infusion as a rescue therapy without other methods such as additional angioplasty or stenting was adopted as described in our previous study 8 and remedial recanalization was evaluated by modified Thrombolysis In Cerebral Infarction (mTICI) scale and Arterial Occlusive Lesion (AOL) scale 10 .…”