The safety profile of single antiplatelet therapy with flow diverters: Systematic review and meta-analysis

Abstract

Background Dual antiplatelet therapy (DAPT) is frequently used in treating cerebral aneurysms with flow diverters (FDs), whereas single antiplatelet therapy (SAPT) is used mostly with coated FDs and in ruptured aneurysms. We conducted a systematic review and meta-analysis to explore the safety profile of SAPT in FDs. Methods PubMed, Web of Science, OVID Embase, OVID Medline, and Scopus were searched to 1st November 2022. Outcomes of interest included ischemic and hemorrhagic complications, conversion to DAPTs, and in-stent stenosis rates under long-term SAPT. SAPT is divided into aspirin (ASA) vs. non-ASA group (ticagrelor or prasugrel). Subgroup analysis was performed for ruptured vs. non-ruptured aneurysms and coated vs. non-coated FDs. All data were analyzed using R software version 4.2.2. Results Twelve studies with 240 total patients (43 patients in the ASA group and 197 patients in the non-ASA group) were included in our meta-analysis. The pooled ischemic occlusion rate was 9.8% (95% CI = 4.87−18.95: p-value = 0.09) for SAPTs. The ASA group had significantly higher ischemic complication rates compared to the non-ASA group (20.8% vs. 6.3%, respectively, p-value = 0.02). The pooled hemorrhagic complication rate was 3.5% (95% CI = 1.38−8.81: p-value > 0.99). The hemorrhagic rates of ASA group were 9.3%% (95% CI = 3.54−22.30) over the non-ASA group 2.1% (95% CI = 0.58−7.54) ( p-value > 0.99). The overall in-stent stenosis rate was 2.3% (95% CI = 1.06−5.14: p-value > 0.99). The ischemic complication rates were comparable between coated vs non-coated FDs (10.7% vs. 5.5% p-value = 0.39). In stent stenosis rate were 1.9% (95% CI = 0.72−4.96) in coated FDs over 4.4% (95% CI = 1.11−16.11) ( p-value = 0.32). The ruptured and non-ruptured groups also showed comparable results in terms of ischemic (17.6% vs. 7.1% respectively, p-value = 0.24) and hemorrhagic complications (9.8% vs. 1.1%, respectively, p-value = 0.08). Conclusions Flow diverter treatment under ASA monotherapy resulted in relatively high ischemic complication rates. However, SAPT with prasugrel or ticagrelor monotherapy is promising for coated FDs and ruptured aneurysm treatments. Given the overall small sample size and also the likely presence of known and unknown biases regarding choice of antiplatelet therapy between groups, larger cohort studies are needed to evaluate SAPT treatment outcomes.

Trends in Dual Antiplatelet Therapy Use for Neurointerventional Procedures for the Management of Intracranial Aneurysms

“…Preliminary animal model studies found there to be significantly more thrombus formation in the PED-Shield group on aspirin versus the DAPT group [ 70 ]. A recent meta-analysis on ruptured and unruptured aneurysms demonstrated SAPT with aspirin resulted in significantly more thromboembolic and intracranial hemorrhagic complications than SAPT with prasugrel or ticagrelor [ 71 ]. However, there have been successful reports of aspirin monotherapy in flow diversion for unruptured aneurysms in patients with bleeding disorders [ 72 ].…”

Endovascular complications: Antiplatelet management for flow diversion

“…A meta-analysis study recently published has compared aspirin to ticagrelor or prasugrel in ruptured vs. unruptured aneurysms and coated vs. uncoated FDs (48). Their analysis suggested that aspirin as a monotherapy in FDs is associated with a relatively higher risk of ischemic events and the use of prasugrel or ticagrelor in ruptured aneurysms and coated FDs conveys potential promising outcomes (48). Another single retrospective study has introduced ticagrelor as a SAPT in 24 patients with 36 aneurysms, 14 of which were ruptured, who underwent FD stenting.…”