Safety and Tolerability of High-Intensity Anticoagulation with Bivalirudin During Neuroendovascular Procedures

Hassan, Ameer E.; Memon, Muhammad Zeeshan; Georgiadis, Alexandros; Vázquez, Gabriela; Suri, M. Fareed K.; Qureshi, Adnan I.

doi:10.1007/s12028-010-9421-7

Cited by 11 publications

(4 citation statements)

References 22 publications

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“…Provide a general interpretation of the results in the context of other evidence, and implications for future research. Geisbusch et al, 2012 26 Allie et al, 2005 19 Allie et al, 2003 18 Wayangankar et al, 2013 27 Stamler et al, 2009 21 Hassan et al, 2011 25 Kimmelstiel Table II. (Continued).…”

Section: Conclusion 26mentioning

confidence: 99%

A systematic review and meta-analysis of bivalirudin application in peripheral endovascular procedures

Liu

Zhang

et al. 2019

Journal of Vascular Surgery

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Objective: The direct thrombin inhibitor bivalirudin (BIV) was shown to be superior to unfractionated heparin (UFH) in percutaneous coronary interventions for reducing procedural blood loss. The aim of this study was to compare outcome profiles of BIV and UFH in peripheral endovascular procedures (PEPs) by synthesizing the currently available data. Methods: Following the PRISMA statement, we conducted a comprehensive literature search using Medline, Cochrane CENTRAL, PubMed, EMBASE, CINAHL Google scholar, and clinicaltrials.gov. We recruited randomized, controlled trials and well-conducted observational studies that compared UFH and BIV in PEPs requiring anticoagulation, excluding endovascular cardiac procedures and coronary interventions. Random-effects meta-analyses were conducted to compare the outcome profiles of these two agents. Results: Thirteen articles containing 17 studies involving a total of 21,057 patients were enrolled. Of these, 2 were randomized controlled trials, 2 were prospective cohort studies, and 10 were retrospective studies. There were no significant differences between BIV and UFH in terms of procedural success rates, major and minor perioperative bleeding, transfusion, perioperative transient ischemic attack, or hemorrhagic strokes. However, compared with UFH, BIV had significantly lower odds ratios (OR) of perioperative mortality (OR, 0.58; 95% confidence interval [CI], 0.40-0.86), major adverse cardiovascular events (OR, 0.65; 95% CI, 0.51-0.83), net adverse clinical events (OR, 0.75; 95% CI, 0.63-0.88), perioperative myocardial infarction (OR, 0.73; 95% CI, 0.55-0.98), major vascular complications (OR, 0.59; 95% CI, 0.39-0.91), and minor vascular complications (OR, 0.58; 95% CI, 0.40-0.84). Conclusions: Compared with UFH, PEPs using BIV had comparable procedural success rates and odds of perioperative transient ischemic attack and hemorrhagic stroke. However, procedures with BIV had a lower but nonsignificant odds of perioperative bleeding and transfusion. Depending on the procedures conducted, the patients who received BIV will have reduced or comparable odds of perioperative mortality, myocardial infarction, major adverse cardiovascular events, net adverse clinical events, and major and minor vascular complications. Therefore, BIV may be chosen solely as an alternative procedural anticoagulant to UFH for PEPs. (

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Section: Conclusion 26mentioning

confidence: 99%

A systematic review and meta-analysis of bivalirudin application in peripheral endovascular procedures

Liu

Zhang

et al. 2019

Journal of Vascular Surgery

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“…Various case reports exist for the administration of bivalirudin exist in the settings of cardiovascular, neuroendovascular, and CEA. 6,7,9-13 However, to our knowledge, this is the first case report evaluating intraoperative bivalirudin dosing in a patient with HIT during a lower extremity revascularization procedure. Endovascular approaches to lower extremity revascularization generally utilize heparin due to its familiarity, predictable pattern of response, and readily available reversal agent in protamine.…”

Section: Discussionmentioning

confidence: 92%

Intraoperative Bivalirudin Use in Patient Undergoing Femoral Endarterectomy with Heparin-Induced Thrombocytopenia: Case Report and Review of the Literature

Haffler,

Hughes,

Yeager

2023

Vasc Endovascular Surg

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Purpose To describe the intraoperative use of bivalirudin during lower extremity revascularization in the setting of heparin-induced thrombocytopenia (HIT). Case Summary A 65 year-old man presented with left common iliac, external iliac, and femoral artery occlusion necessitating revascularization with left femoral endarterectomy and common and external iliac stent angioplasty. Three months before the femoral endarterectomy, the patient was hospitalized for a coronary artery bypass procedure. During this admission, the patient tested positive for the presence of heparin-PF4 antibody complexes. With the patient’s recent history of HIT, bivalirudin was selected as the optimal agent for intraoperative anticoagulation. Bivalirudin was administered as a 50 mg bolus, followed by a continuous infusion initiated at 1.75 mg/kg/hr. Repeated bivalirudin boluses were necessary to maintain an activated clotting time (ACT) necessary for the revascularization procedures and recurrent subacute thrombi despite appropriate ACT values. Discussion Bivalirudin has been utilized for cardiopulmonary bypass and carotid endarterectomy (CEA), but data for dosing in lower extremity revascularization are lacking. As the risk for thrombosis with HIT continues for months after diagnosis, it is important to elucidate optimal dosing of non-heparin anticoagulant options, such as the direct thrombin inhibitor, bivalirudin. The absence of validated dosing strategies for bivalirudin can result in prolonged operative times, increased risk of bleeding, and inadequate anticoagulation. Conclusion Bivalirudin is an appropriate agent for intraoperative anticoagulation in lower extremity revascularization. However, further investigation into the optimal intraoperative bivalirudin dosing regimen is necessary.

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“…In a patient undergoing venous thrombectomy, if the patient is confirmed or suspected of having VITT, alternatives to heparinized saline flushes (eg, bivalirudin 56 ) may be considered.…”

Section: Diagnostic Evaluation Of Cvt and Vittmentioning

confidence: 99%

Cerebral Vein Thrombosis With Vaccine-Induced Immune Thrombotic Thrombocytopenia

Siegler

Klein

Yaghi

et al. 2021

Stroke

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In the spring of 2021, reports of rare and unusual venous thrombosis in association with the ChAdOx1 and Ad26.COV2.S adenovirus-based coronavirus vaccines led to a brief suspension of their use by several countries. Thromboses in the cerebral and splanchnic veins among patients vaccinated in the preceding 4 weeks were described in 17 patients out of 7.98 million recipients of the Ad26.COV2.S vaccine (with 3 fatalities related to cerebral vein thrombosis) and 169 cases of cerebral vein thrombosis among 35 million ChAdOx1 recipients. Events were associated with thrombocytopenia and anti-PF4 (antibodies directed against platelet factor 4), leading to the designation vaccine-induced immune thrombotic thrombocytopenia. Unlike the related heparin-induced thrombotic thrombocytopenia, with an estimated incidence of <1:1000 patients treated with heparin, and a mortality rate of 25%, vaccine-induced immune thrombotic thrombocytopenia has been reported in 1:150 000 ChAdOx1 recipients and 1:470 000 Ad26.COV.2 recipients, with a reported mortality rate of 20% to 30%. Early recognition of this complication should prompt testing for anti-PF4 antibodies and acute treatment targeting the autoimmune and prothrombotic processes. Intravenous immunoglobulin (1 g/kg for 2 days), consideration of plasma exchange, and nonheparin anticoagulation (argatroban, fondaparinux) are recommended. In cases of cerebral vein thrombosis, one should monitor for and treat the known complications of venous congestion as they would in patients without vaccine-induced immune thrombotic thrombocytopenia. Now that the Ad26.COV2.S has been reapproved for use in several countries, it remains a critical component of our pharmacological armamentarium in stopping the spread of the human coronavirus and should be strongly recommended to patients. At this time, the patient and community-level benefits of these two adenoviral vaccines vastly outweigh the rare but serious risks of vaccination. Due to the relatively low risk of severe coronavirus disease 2019 (COVID-19) in young women (<50 years), it is reasonable to recommend an alternative vaccine if one is available. Ongoing postmarketing observational studies are important for tracking new vaccine-induced immune thrombotic thrombocytopenia cases and other rare side effects of these emergent interventions.

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Safety and Tolerability of High-Intensity Anticoagulation with Bivalirudin During Neuroendovascular Procedures

Abstract: Our data supports that bivalirudin usage is likely a safe alternative to heparin for high-intensity anticoagulation in neuroendovascular procedures. Further studies are required for more definitive comparisons for efficacy and cost-effectiveness between the two agents.

Cited by 11 publications

References 22 publications

A systematic review and meta-analysis of bivalirudin application in peripheral endovascular procedures

A systematic review and meta-analysis of bivalirudin application in peripheral endovascular procedures

Intraoperative Bivalirudin Use in Patient Undergoing Femoral Endarterectomy with Heparin-Induced Thrombocytopenia: Case Report and Review of the Literature

Cerebral Vein Thrombosis With Vaccine-Induced Immune Thrombotic Thrombocytopenia

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