Vorapaxar as an Alternative for Ticagrelor Resistance in Neuroendovascular Intervention

Perioperative dual-antiplatelet therapy for flow diversion limits thromboembolic complications. However, resistance to dual-antiplatelet therapy medications remains a concern for neuroendovascular intervention. To date, there is no standardized approach for resistance to ADP receptor antagonists.

We report a case of ticagrelor resistance for flow diversion of an intracranial aneurysm treated with vorapaxar, as well as a narrative review of the literature for previous cases of ticagrelor resistance.

Flow diversion with the Pipeline embolization device was deployed for a left internal carotid artery blister aneurysm and bilateral internal carotid artery dissecting pseudoaneurysms. The patient had 3 thromboembolic complications while on dual-antiplatelet therapy with ticagrelor or prasugrel, leading to transition of antiplatelet therapy to vorapaxar. At 84 days follow-up, the patient was fully recovered with complete occlusion of the aneurysms.

Our case suggests that vorapaxar is a promising alternative for patients with ticagrelor resistance in flow diversion-treated intracranial aneurysms. High-quality randomized controlled trials are needed to elucidate the safety and efficacy of vorapaxar in neuroendovascular procedures.