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A New Protocol for Anticoagulation With Tirofiban During Flow Diversion
Nohra Chalouhi1, Pascal Jabbour, Badih Daou
1*Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania;‡Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City, Iowa.
Insights
A new tirofiban anticoagulation protocol during flow diversion shows excellent safety for intracranial aneurysms. This method offers an alternative to aspirin and clopidogrel pretreatment, especially for ruptured cases.
Area of Science:
- Neurology
- Interventional Neuroradiology
- Vascular Surgery
Background:
- Flow diversion is a common treatment for intracranial aneurysms.
- Traditional protocols involve pretreatment with aspirin and clopidogrel to prevent complications.
- A novel anticoagulation strategy using tirofiban is being investigated.
Purpose of the Study:
- To evaluate the safety and efficacy of a new anticoagulation protocol using tirofiban during flow diversion procedures.
- To compare this protocol with traditional aspirin and clopidogrel pretreatment.
Main Methods:
- A cohort of 46 patients undergoing flow diversion were treated with intraoperative tirofiban infusion without a loading dose.
- Aspirin and clopidogrel were administered intraoperatively or just before the procedure, without prior pretreatment.
- Thromboembolic and hemorrhagic complications were meticulously recorded.
Main Results:
- The protocol demonstrated a low complication rate, with only 2 events (1 thromboembolic, 1 hemorrhagic) out of 46 patients.
- No instances of thrombocytopenia or major bleeding were observed.
- A high rate of favorable outcomes was noted, with 95.7% of patients achieving a modified Rankin Scale score of 0 to 2.
Conclusions:
- The tirofiban-based anticoagulation protocol during flow diversion is safe and effective.
- This approach serves as a viable alternative to pretreatment with dual antiplatelet therapy.
- The protocol is particularly beneficial for patients with ruptured aneurysms or when unexpected stent use occurs.
Background:
Flow diversion is increasingly used to treat intracranial aneurysms. In previous reports, patients were pretreated with aspirin and clopidogrel before the intervention for the prevention of thromboembolic complications.
Objective:
To assess the safety and efficacy of a new protocol for anticoagulation using tirofiban during flow diversion.
Methods:
All patients received a 0.10-μg·kg·min maintenance infusion of tirofiban intraoperatively without a loading dose. All patients were loaded with aspirin (325 mg) and clopidogrel (600 mg) just before the procedure or intraoperatively. No patient was pretreated with aspirin or clopidogrel. Thromboembolic and hemorrhagic complications were recorded.
Results:
A total of 46 patients were treated with this protocol. Six patients (13%) had sustained a subarachnoid hemorrhage and were treated with the Pipeline Embolization Device within 24 hours of aneurysm rupture. The mean number of devices was 1.2 ± 0.66; adjunctive coiling was performed in 3 patients (6.5%). There were 2 complications (4.3%), 1 thromboembolic (2.2%) and 1 hemorrhagic (2.2%; monocular vision loss from occlusion of the central retinal artery in 1 patient and a parenchymal hemorrhage managed conservatively in another patient). No patient developed thrombocytopenia or retroperitoneal, gastrointestinal, or genitourinary bleeding. Of 46 patients, 44 (95.7%) had a modified Rankin Scale score of 0 to 2 at their follow-up visit.
Conclusion:
A protocol of anticoagulation with tirofiban during flow diversion has an excellent safety profile. This protocol provides a reasonable alternative to pretreatment with aspirin and clopidogrel and is useful in patients with ruptured aneurysms or when the use of a stent is unexpected.
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