Flow-Diverting Stents for the Obliteration of Symptomatic, Infectious Cavernous Carotid Artery Aneurysms

Andrew Joshua Kobets; Aleka Scoco; Jonathan Nakhla; Allan Leonard Brook; Merritt Drew Kinon; Nrupen Baxi; David Altschul

doi:10.1093/ons/opx166

Flow-Diverting Stents for the Obliteration of Symptomatic, Infectious Cavernous Carotid Artery Aneurysms

Operative Neurosurgery ◽

10.1093/ons/opx166 ◽

2017 ◽

Vol 14 (6) ◽

pp. 681-685 ◽

Cited By ~ 3

Author(s):

Andrew Joshua Kobets ◽

Aleka Scoco ◽

Jonathan Nakhla ◽

Allan Leonard Brook ◽

Merritt Drew Kinon ◽

...

Keyword(s):

Antiplatelet Therapy ◽

Dual Antiplatelet Therapy ◽

Sinus Thrombosis ◽

Parent Vessel ◽

Management Options ◽

Postoperative Mri ◽

First Case ◽

Silk Stent ◽

Pipeline Stent

Abstract BACKGROUND Intracavernous aneurysms constitute up to 9% of all intracranial aneurysms and 6% are infectious (IIA). First line therapy is a protracted antibiotic course, yet with failure, surgery and endovascular parent vessel sacrifice have been utilized. Reconstructive endovascular therapies have emerged for aneurysm control and may demonstrate a safer therapeutic alternative. OBJECTIVE To present an IIA treated with a flow-diverting Pipeline stent (ev3 Neurovascular, Irvine, California). METHODS A 41-yr-old female presented with visual loss, ophthalmoplegia, and cavernous sinus thrombosis with an associated phlegmon. Transsphenoidal evacuation was performed without complication or bleeding and she continued on medical therapy. Two weeks postoperatively, she developed a worsening right third cranial nerve palsy and MRA demonstrated a 1-cm right IIA, not evident on postoperative MRI. Three days of dual antiplatelet therapy preceded successful pipeline embolization. Angiography demonstrated aneurysm obliteration at 3 mo and her right ophthalmoplegia resolved. RESULTS A literature review identified 6 reported cases of IIAs treated with stent embolization. Only 1 documented a flow-diverting Silk stent used in a child. All lesions were obliterated at follow-up without neurological sequelae. No complication arose with implantation in the setting of infection, and as few as 3 d of dual antiplatelet therapy was sufficient for preprocedural prophylaxis, although in Vivo antiplatelet activity may be more significant. CONCLUSION We report the first case of an IIA treated with a flow-diverting pipeline stent. These devices preserve native vasculature and neurological function compared to surgical and endovascular vessel sacrifice strategies. They appear to be safe management options for the treatment of IIAs.

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Two Cases and Review of the Literature: Primary Percutaneous Angiography and Antiplatelet Management in Patients with Immune Thrombocytopenic Purpura

ISRN Hematology ◽

10.1155/2013/174659 ◽

2013 ◽

Vol 2013 ◽

pp. 1-4 ◽

Cited By ~ 7

Author(s):

Estelle Torbey ◽

Harout Yacoub ◽

Donald McCord ◽

James Lafferty

Keyword(s):

Antiplatelet Therapy ◽

Immune Thrombocytopenic Purpura ◽

Dual Antiplatelet Therapy ◽

Coronary Intervention ◽

Review Of The Literature ◽

Thrombocytopenic Purpura ◽

Coronary Syndrome ◽

First Case ◽

St Elevation

We report two cases of immune thrombocytopenic purpura (ITP) associated with acute coronary artery syndrome highlighting the interventions done in every case along with the medications used during intervention and as outpatient. The first case is that of a woman with ITP exacerbation while on dual antiplatelet therapy and the second case is that of a male presenting with non-ST elevation myocardial infarction (NSTEMI) while in a thrombocytopenic crisis. In both cases antiplatelet therapy was held and thrombopoietic therapy was initiated before resuming full anticoagulation and coronary intervention. Given the paucity of data on ITP and antiplatelets treatment in the setting of acute coronary syndrome, no strict recommendations can be proposed, but antiplatelets appear to be safe acutely and in the long term in this category of patients as long as few measures are undertaken to minimize the risks of bleeding and thrombosis.

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Duration of Dual Antiplatelet Therapy After Implantation of Drug-Coated Balloon

Frontiers in Cardiovascular Medicine ◽

10.3389/fcvm.2021.762391 ◽

2021 ◽

Vol 8 ◽

Author(s):

Yuxuan Zhang ◽

Xinyi Zhang ◽

Qichao Dong ◽

Delong Chen ◽

Yi Xu ◽

...

Keyword(s):

Antiplatelet Therapy ◽

Dual Antiplatelet Therapy ◽

De Novo ◽

Bleeding Risk ◽

Coronary Intervention ◽

Total Occlusion ◽

Coronary Syndrome ◽

Optimal Duration ◽

Drug Coated Balloon

The drug-coated balloon (DCB) is an emerging percutaneous coronary intervention (PCI) device with theoretical advantages and promising results. Recent clinical observations have demonstrated that DCB tends to have both good efficacy and a good safety profile in the treatment of in-stent restenosis (ISR) for both bare-metal and drug-eluting stents (DES), de novo coronary artery disease (CAD), and other situation, such as high bleeding risk, chronic total occlusion, and acute coronary syndrome (ACS). Dual antiplatelet therapy (DAPT) has become an essential medication in daily clinical practice, but the optimal duration of DAPT after the implantation of a DCB remains unknown. At the time of the first in vivo implantation of paclitaxel-DCB for the treatment of ISR in 2006, the protocol-defined DAPT duration was only 1 month. Subsequently, DAPT duration ranging from 1 to 12 months has been recommended by various trials. However, there have been no randomized controlled trials (RCTs) on the optimal duration of DAPT after DCB angioplasty. Current clinical guidelines normally recommend the duration of DAPT after DCB-only angioplasty based on data from RCTs on the optimal duration of DAPT after stenting. In this review, we summarized current clinical trials on DCB-only angioplasty for different types of CADs and their stipulated durations of DAPT, and compared their clinical results such as restenosis, target lesion revascularization (TLR) and stent thrombosis event. We hope this review can assist clinicians in making reasonable decisions about the duration of DAPT after DCB implantation.

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Phosphorylcholine surface modified flow diverter associated with reduced intimal hyperplasia

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2018-013776 ◽

2018 ◽

Vol 10 (11) ◽

pp. 1097-1101 ◽

Cited By ~ 12

Author(s):

Jildaz Caroff ◽

Takamitsu Tamura ◽

Robert M King ◽

Pedro N Lylyk ◽

Erin T Langan ◽

...

Keyword(s):

Antiplatelet Therapy ◽

Dual Antiplatelet Therapy ◽

Neointimal Hyperplasia ◽

Diagnostic Technique ◽

Flow Diverter ◽

Cross Sectional ◽

Flow Diverter Stent ◽

Surface Modified ◽

Flow Diverters

BackgroundOptical coherence tomography (OCT) is a high-resolution, intra-vascular diagnostic technique widely used for the characterization of vascular pathologies and optimization of stent implantation during percutaneous coronary intervention. OCT was used to investigate the in vivo vascular response to a new phosphorylcholine surface modified flow diverter (sPED).MethodsIn an in vivo rabbit aneurysmal model, we used two different types of flow diverters (classic Pipeline – cPED; and sPED) with or without dual antiplatelet therapy (four groups, n=10 per group). OCT cross-sectional area measurements were compared with histology in all animals. Neointimal hyperplasia (NIH) ratio was compared between OCT and histology at five different levels for each stent. The severity of NIH was also compared between the different stents, antiplatelet protocols, and vessel locations.ResultsOCT was used to calculate in-stent hyperplasia in 227 different locations corresponding to histology sections. OCT measurement strongly correlated with gold standard histology (r2=0.83; slope=0.988; P<0.0001). sPED had significantly less in-stent NIH than non-treated flow diverters (mean percent of lumen reduction 5.7% for sPED versus 8.9% for cPED; P<0.0001). The NIH ratio was slightly higher with dual antiplatelet therapy (DAPT) (NIH ratio=7.9% with DAPT versus 6.8% without DAPT; P<0.05). Complete and near complete occlusion rates of the aneurysms were not different with the cPED or sPED.ConclusionOCT is a promising technique for immediate and long-term evaluation of flow diverter stent treatments. In an animal model, phosphorylcholine surface modified flow diverters induces less NIH after stent implant without reducing aneurysm occlusion rates.

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Acute Carotid Stent Thrombosis in an Ultrarapid Clopidogrel Metabolizer: Case Report and Literature Review

Vascular and Endovascular Surgery ◽

10.1177/1538574419857965 ◽

2019 ◽

Vol 53 (7) ◽

pp. 602-605

Author(s):

Karlo Toljan ◽

Ivan Jovanović ◽

Katarina Starčević ◽

Josip Ljevak ◽

Nikola Blažević ◽

...

Keyword(s):

Case Report ◽

Literature Review ◽

Antiplatelet Therapy ◽

Stent Thrombosis ◽

Dual Antiplatelet Therapy ◽

Carotid Artery Disease ◽

Rare Complication ◽

Poor Response ◽

First Case ◽

Ultrarapid Metabolizer

Introduction: Carotid angioplasty and stenting (CAS) represents an effective procedure for treating carotid artery disease. The acute in-stent thrombosis is an extremely rare complication of CAS especially when it occurs postprocedurally during the first 24 hours. Improper antiplatelet therapy or poor response to antiplatelet medications is known to be associated with a higher risk of in-stent thrombosis during early postprocedural period following a successful intervention. Material and Methods: A patient who experienced acute carotid in-stent thrombosis in early postprocedural period is described. He had been taking dual antiplatelet therapy for 2 weeks before undergoing a successful CAS. Moreover, pharmacogenetics studies showed the patient to be a clopidogrel ultrarapid metabolizer, which theoretically confers hyperresponsivity to medication. Alongside the report itself, a brief literature review of relevant sources pertinent to the case has been conducted. Results: According to the available literature, this is the first case report describing an ultrarapid clopidogrel metabolizer who underwent an uneventful CAS but experienced acute carotid in-stent thrombosis in early postprocedural period. A rescue procedure included an endovascular intervention consisting of thrombectomy and local alteplase application, followed by postprocedural administration of intravenous eptifibatide. At discharge, patient’s dual antiplatelet therapy included ticagrelor instead of clopidogrel. Conclusion: Acute carotid in-stent thrombosis is a highly unexpected complication of CAS and can occur despite ultrarapid clopidogrel metabolism trait.

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Dual Antiplatelet Therapy: Is More Better?

Internal Medicine News ◽

10.1016/s1097-8690(06)74048-3 ◽

2006 ◽

Vol 39 (16) ◽

pp. 39

Author(s):

JON O. EBBERT ◽

ERIC G. TANGALOS

Keyword(s):

Antiplatelet Therapy ◽

Dual Antiplatelet Therapy

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Anticoagulation in addition to dual antiplatelet therapy has no impact on long-term follow-up after endovascular treatment of (sub)acute lower limb ischemia

VASA ◽

10.1024/0301-1526/a000786 ◽

2019 ◽

Vol 48 (4) ◽

pp. 321-329

Author(s):

Mariya Kronlage ◽

Erwin Blessing ◽

Oliver J. Müller ◽

Britta Heilmeier ◽

Hugo A. Katus ◽

...

Keyword(s):

Endovascular Treatment ◽

Antiplatelet Therapy ◽

Dual Antiplatelet Therapy ◽

Limb Ischemia ◽

Bleeding Complications ◽

Severe Bleeding ◽

Short Term ◽

Long Term Follow Up

Summary. Background: To assess the impact of short- vs. long-term anticoagulation in addition to standard dual antiplatelet therapy (DAPT) upon endovascular treatment of (sub)acute thrombembolic occlusions of the lower extremity. Patient and methods: Retrospective analysis was conducted on 202 patients with a thrombembolic occlusion of lower extremities, followed by crirical limb ischemia that received endovascular treatment including thrombolysis, mechanical thrombectomy, or a combination of both between 2006 and 2015 at a single center. Following antithrombotic regimes were compared: 1) dual antiplatelet therapy, DAPT for 4 weeks (aspirin 100 mg/d and clopidogrel 75 mg/d) upon intervention, followed by a lifelong single antiplatelet therapy; 2) DAPT plus short term anticoagulation for 4 weeks, followed by a lifelong single antiplatelet therapy; 3) DAPT plus long term anticoagulation for > 4 weeks, followed by a lifelong anticoagulation. Results: Endovascular treatment was associated with high immediate revascularization (> 98 %), as well as overall and amputation-free survival rates (> 85 %), independent from the chosen anticoagulation regime in a two-year follow up, p > 0.05. Anticoagulation in addition to standard antiplatelet therapy had no significant effect on patency or freedom from target lesion revascularization (TLR) 24 months upon index procedure for both thrombotic and embolic occlusions. Severe bleeding complications occurred more often in the long-term anticoagulation group (9.3 % vs. 5.6 % (short-term group) and 6.5 % (DAPT group), p > 0.05). Conclusions: Our observational study demonstrates that the choice of an antithrombotic regime had no impact on the long-term follow-up after endovascular treatment of acute thrombembolic limb ischemia whereas prolonged anticoagulation was associated with a nominal increase in severe bleeding complications.

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TWILIGHT: A Randomized Trial of Ticagrelor Monotherapy Versus Ticagrelor Plus Aspirin Beginning at 3 Months in High-risk Patients Undergoing Percutaneous Coronary Intervention

US Cardiology Review ◽

10.15420/usc.2019.02 ◽

2020 ◽

Vol 14 ◽

Author(s):

Johny Nicolas ◽

Usman Baber ◽

Roxana Mehran

Keyword(s):

Percutaneous Coronary Intervention ◽

High Risk ◽

Antiplatelet Therapy ◽

Dual Antiplatelet Therapy ◽

Coronary Intervention ◽

Bleeding Events ◽

High Risk Patients ◽

Risk Of Death ◽

Percutaneous Coronary ◽

Risk Patients

A P2Y12 inhibitor-based monotherapy after a short period of dual antiplatelet therapy is emerging as a plausible strategy to decrease bleeding events in high-risk patients receiving dual antiplatelet therapy after percutaneous coronary intervention. Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention (TWILIGHT), a randomized double-blind trial, tested this approach by dropping aspirin at 3 months and continuing with ticagrelor monotherapy for an additional 12 months. The study enrolled 9,006 patients, of whom 7,119 who tolerated 3 months of dual antiplatelet therapy were randomized after 3 months into two arms: ticagrelor plus placebo and ticagrelor plus aspirin. The primary endpoint of interest, Bleeding Academic Research Consortium type 2, 3, or 5 bleeding, occurred less frequently in the experimental arm (HR 0.56; 95% CI [0.45–0.68]; p<0.001), whereas the secondary endpoint of ischemic events was similar between the two arms (HR 0.99; 95% CI [0.78–1.25]). Transition from dual antiplatelet therapy consisting of ticagrelor plus aspirin to ticagrelor-based monotherapy in high-risk patients at 3 months after percutaneous coronary intervention resulted in a lower risk of bleeding events without an increase in risk of death, MI, or stroke.

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