Use of Platelet Function Testing Before Pipeline Embolization Device Placement: A Multicenter Cohort Study

Nimer Adeeb; Christoph J Griessenauer; Paul M Foreman; Justin M Moore; Hussain Shallwani; Rouzbeh Motiei-Langroudi; Abdulrahman Alturki; Adnan H Siddiqui; Elad I Levy; Mark R Harrigan; Christopher S Ogilvy; Ajith J Thomas

doi:10.1161/STROKEAHA.116.015308

Use of Platelet Function Testing Before Pipeline Embolization Device Placement: A Multicenter Cohort Study

Stroke. 2017 May;48(5):1322-1330. doi: 10.1161/STROKEAHA.116.015308. Epub 2017 Apr 14.

Affiliations

¹ From the Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (N.A., C.J.G., J.M.M., R.M.-L., A.A., C.S.O., A.J.T.); Department of Neurosurgery, University of Alabama at Birmingham (P.M.F., M.R.H.); and Department of Neurosurgery, State University of New York at Buffalo (H.S., A.H.S., E.I.L.).
² From the Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (N.A., C.J.G., J.M.M., R.M.-L., A.A., C.S.O., A.J.T.); Department of Neurosurgery, University of Alabama at Birmingham (P.M.F., M.R.H.); and Department of Neurosurgery, State University of New York at Buffalo (H.S., A.H.S., E.I.L.). athomas6@bidmc.harvard.edu.

PMID: 28411263
DOI: 10.1161/STROKEAHA.116.015308

Abstract

Background and purpose: Thromboembolic complications constitute a significant source of morbidity after neurointerventional procedures. Flow diversion using the pipeline embolization device for the treatment of intracranial aneurysms necessitates the use of dual antiplatelet therapy to reduce this risk. The use of platelet function testing before pipeline embolization device placement remains controversial.

Methods: A retrospective review of prospectively maintained databases at 3 academic institutions was performed from the years 2009 to 2016 to identify patients with intracranial aneurysms treated with pipeline embolization device placement. Clinical and radiographic data were analyzed with emphasis on thromboembolic complications and clopidogrel responsiveness.

Results: A total of 402 patients underwent 414 pipeline embolization device procedures for the treatment of 465 intracranial aneurysms. Thromboembolic complications were encountered in 9.2% of procedures and were symptomatic in 5.6%. Clopidogrel nonresponders experienced a significantly higher rate of thromboembolic complications compared with clopidogrel responders (17.4% versus 5.6%). This risk was significantly lower in nonresponders who were switched to ticagrelor when compared with patients who remained on clopidogrel (2.7% versus 24.4%). In patients who remained on clopidogrel, the rate of thromboembolic complications was significantly lower in those who received a clopidogrel boost within 24 hours pre-procedure when compared with those who did not (9.8% versus 51.9%). There was no significant difference in the rate of hemorrhagic complications between groups.

Conclusions: Clopidogrel nonresponders experienced a significantly higher rate of thromboembolic complications when compared with clopidogrel responders. However, this risk seems to be mitigated in nonresponders who were switched to ticagrelor or received a clopidogrel boost within 24 hours pre-procedure.

Keywords: aneurysm; clopidogrel; complications; pipeline embolization device; platelet function test; responders; thromboembolic; ticagrelor.

MeSH terms

Adenosine / administration & dosage
Adenosine / analogs & derivatives
Adenosine / pharmacology
Adolescent
Adult
Aged
Aged, 80 and over
Clopidogrel
Embolization, Therapeutic / adverse effects
Embolization, Therapeutic / instrumentation*
Female
Humans
Intracranial Aneurysm / therapy*
Intracranial Embolism / etiology
Intracranial Embolism / prevention & control*
Intracranial Thrombosis / etiology
Intracranial Thrombosis / prevention & control*
Male
Middle Aged
Outcome Assessment, Health Care*
Platelet Aggregation Inhibitors / administration & dosage
Platelet Aggregation Inhibitors / pharmacology*
Platelet Function Tests*
Purinergic P2Y Receptor Antagonists / administration & dosage
Purinergic P2Y Receptor Antagonists / pharmacology
Retrospective Studies
Ticagrelor
Ticlopidine / administration & dosage
Ticlopidine / analogs & derivatives*
Ticlopidine / pharmacology
Young Adult

Substances

Platelet Aggregation Inhibitors
Purinergic P2Y Receptor Antagonists
Clopidogrel
Ticagrelor
Adenosine
Ticlopidine