Antiplatelet Therapy and Periprocedural Risk Factor Analysis for Pipeline Embolization Device Treatment of Unruptured Internal Carotid Artery Aneurysms: A Retrospective, Multicenter Analysis

World Neurosurg. 2022 Jan;157:e102-e110. doi: 10.1016/j.wneu.2021.09.109. Epub 2021 Oct 2.


Background: Aneurysm treatment using the Pipeline Embolization Device has been established but appropriate maintenance of dual antiplatelet therapy (APT) is essential. This multicenter retrospective study assessed whether APT was properly adjusted for clopidogrel resistance and identified risk factors associated with periprocedural complications.

Methods: Consecutive cases of use of the Pipeline Embolization Device for internal carotid artery aneurysms (>10 mm) between November 2015 and April 2020 were analyzed. Dual APT (aspirin + clopidogrel) was prescribed before treatment. If preprocedural P2Y12 reaction unit (PRU) values were >240, APT was adjusted. Periprocedural complications were compared between APT nonadjustment and adjustment groups and periprocedural risk factors were also analyzed.

Results: A total of 162 procedures were assessed. The mean maximum aneurysm size was 15.35 mm. APT adjustment was required in 47 cases (29.0%), primarily by switching to prasugrel. There were no significant differences in complication incidence between the 2 groups even after propensity score matching. The risk factor independently associated with ischemic complications was a neck size of 8 mm or larger (odds ratio [OR], 5.25; P = 0.018) and restricting analysis to the APT nonadjustment group showed PRU values of 190 or higher (OR, 5.84; P = 0.047) and neck sizes of 8 mm or larger (OR, 7.05; P = 0.029) as significant factors. The risk factor independently associated with hemorrhagic complications was a neck size of 7 mm or larger (OR, 11.57; P = 0.023).

Conclusions: APT adjustment for clopidogrel resistance was safe and effective. Neck width was a risk factor for both ischemic and hemorrhagic complications. PRU values of 190 or higher were also associated with ischemic complications.

Keywords: Clopidogrel resistance; Dual antiplatelet therapy; Neck width; PRU; Pipeline Embolization Device.

Publication types

  • Multicenter Study

MeSH terms

  • Adult
  • Aged
  • Aspirin / administration & dosage
  • Aspirin / adverse effects
  • Carotid Artery, Internal* / diagnostic imaging
  • Clopidogrel / administration & dosage
  • Clopidogrel / adverse effects
  • Dual Anti-Platelet Therapy / methods*
  • Embolization, Therapeutic / adverse effects
  • Embolization, Therapeutic / methods*
  • Female
  • Humans
  • Intracranial Aneurysm / diagnostic imaging
  • Intracranial Aneurysm / therapy*
  • Male
  • Middle Aged
  • Perioperative Care / methods*
  • Platelet Aggregation Inhibitors / administration & dosage*
  • Platelet Aggregation Inhibitors / adverse effects
  • Prasugrel Hydrochloride / administration & dosage
  • Prasugrel Hydrochloride / adverse effects
  • Retrospective Studies
  • Risk Factors


  • Platelet Aggregation Inhibitors
  • Clopidogrel
  • Prasugrel Hydrochloride
  • Aspirin