Strategies to Prevent Ischemic Complications after Stent-assisted Coil Embolization of Cerebral Aneurysms

Abstract

There have been no delayed ischemic complications related to stent-assisted coil embolization (SACE) of cerebral aneurysms at our institution. We demonstrate our strategies for stent placement and postoperative management of antiplatelet therapy to reduce the risk of ischemic complications. Methods:We analyzed 57 cases of SACE retrospectively. In the procedure, an appropriate stent was selected and placed to fit the arterial wall without impeding on small arterial branches. Two different antiplatelet drugs, including clopidogrel, were used. Six to twelve months after surgery, follow-up angiography was performed to assess the safety of terminating antiplatelet therapy. In cases in which antiplatelet therapy was tapered, the two antiplatelet drugs were switched to clopidogrel alone, and it was subsequently tapered and finally discontinued.Results: There were 49 cases of SACE in which postoperative antiplatelet therapy was tapered. Among these cases, antiplatelet therapy was discontinued in 35 cases. The mean duration of dual antiplatelet therapy was 10.6 ± 2.8 months, and the mean duration of total antiplatelet therapy was 15.0 ± 2.1 months. Three patients developed SACE-related ischemic stroke, which developed in the early phase after surgery in all. Conclusion:Antiplatelet therapy can safely be terminated in most cases of SACE. In order to reduce the risk of ischemic complications, stent selection, stent placement, and management of antiplatelet therapy should be performed appropriately. Furthermore, careful follow-up should be continued even after the termination of antiplatelet therapy. Keywords▶ stent-assisted coil embolization, ischemic complications, antiplatelet therapy, clopidogrel This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives International License.

Discontinuation of antiplatelet therapy after stent-assisted coil embolisation of cerebral aneurysm: a nationwide cohort study

“…Neurointerventionalists generally agree that the use of APT after SACE does not need to be lifelong. [8][9][10][11][12][13] A French national survey revealed that only 16% of centres prescribed lifelong APT after SACE. 13 Complete endothelialisation of the stent reduces the need for lifelong APT by ensuring a living, non-thrombogenic surface within the lumen of the parent artery and eliminating direct stentblood flow contact.…”

“…27 Although previous retrospective studies predominantly relied on descriptive results, they proposed diverse regional protocols (3-24 months) for the safe timing for discontinuation of APT after SACE. [8][9][10][11][12] All of these protocols emphasised the selection of patients with a low risk of ischaemia and documented complete neointimalisation of the parent artery. [8][9][10][11][12] In line with the previous studies, our study findings suggest that APT benefits cerebral infarction prevention until 1 year after SACE, [8][9][10][11][12][13] making it a reasonable strategy to consider discontinuing APT at that time.…”

“…Second, in the claims data, we could not identify the location of the artery where SACE was performed and cerebral infarction occurred; therefore, determining whether the occurrence of cerebral infarction was related to the SACE procedure was impossible. Information regarding aneurysm characteristics, SACE procedure-associated factors including stent type, no recanalisation of the aneurysm, adequate stent apposition without deformity, retreatment, and, most importantly, results of follow-up angiography regarding neointima formation were unavailable, [8][9][10][11][12] given the basis of this study on a nationwide claims-based cohort study. Third, its generalisability may be limited to South Korean cohorts.…”

“…Stent implantation in normal arteries, as opposed to atherosclerotic arteries, might carry a lower risk of thromboembolic events and require a less invasive APT strategy. Based on the aforementioned assumption, several clinicians advocate the discontinuation of APT 3-36 months after SACE in clinical practice [8][9][10][11][12] ; however, the duration for which APT should be maintained after SACE remains largely unexplored. 13 Although determining the optimal duration of APT necessitates finding a balance between thromboembolic…”