- Email: [email protected]
Periprocedural antithrombotic medication in acute ischemic stroke treated by catheter-based thrombectomy. A review
cor et vasa 57 (2015) e139–e142
Available online at www.sciencedirect.com
ScienceDirect journal homepage: http://www.elsevier.com/locate/crvasa
Review article – Special issue: Cardiovascular Surgery
Periprocedural antithrombotic medication in acute ischemic stroke treated by catheter-based thrombectomy. A review Petr Widimsky * Cardiocenter, Third Faculty of Medicine, Charles University Prague, Czech Republic
article info
abstract
Article history:
This review summarized limited information known about periprocedural antithrombotic
Received 31 January 2015
therapy before, during and immediately after percutaneous catheter-based thrombectomy
Accepted 19 February 2015
for acute ischemic stroke. Very few data on this topic were published so far. In general, rtPA
Available online 18 March 2015
should be used upfront whenever clinically clearly indicated (0–3 h from stroke onset,
Keywords:
mechanical treatment follows after thrombolysis, neither anticoagulation, nor antiplatelet
Acute stroke
agents should be used in the acute phase. No data exist about the periprocedural use of
absence of contraindications) irrespective of subsequent mechanical thrombectomy. If
Catheter-based thrombectomy
anticoagulation or antiplatelet therapy in patients who cannot receive fibrinolysis and
Thrombolysis
undergo direct mechanical thrombectomy alone. Most centers use no or very low dose
Anticoagulation
heparin and a single dose of aspirin.
Antiplatelet therapy
# 2015 The Czech Society of Cardiology. Published by Elsevier Sp. z o.o. All rights reserved.
Heparin Aspirin Fibrinolysis
Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . What is (not) mentioned in the US guidelines?. . . . . . . . . Periprocedural therapy in published trials and registries . Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ethical statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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* Correspondence to: Cardiocenter Kralovske Vinohrady, Charles University Prague, Czech Republic. Tel.: +420 267162621. E-mail address: [email protected] http://dx.doi.org/10.1016/j.crvasa.2015.02.012 0010-8650/# 2015 The Czech Society of Cardiology. Published by Elsevier Sp. z o.o. All rights reserved.
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e140 e140 e141 e141 e142 e142 e142
e140
cor et vasa 57 (2015) e139–e142
Introduction Interventional therapy of acute ischemic stroke is slowly emerging as an alternative treatment option besides thrombolytic therapy. Frequently both treatments are combined (‘‘bridging’’ thrombolysis or intraarterial ‘‘local’’ thrombolysis). Among various technical approaches to interventional therapy thrombectomy with stent-retrievers dominates after 2012, when the first devices (Solitaire® and Trevo®) were approved by the FDA. There is very limited information available on periprocedural antiplatelet or anticoagulant therapy before/during/after catheter-based thrombectomy (CBT). The aim of this article is to summarize the available published information on this topic.
What is (not) mentioned in the US guidelines? Possibly the most comprehensive document on this subject – the American guidelines for the management of acute stroke [1] – describes the reperfusion strategies and the use of anticoagulant and antiplatelet agents as the primary therapy for stroke, but not as periprocedural therapy during CBT. There are 22 contraindications for the use of thrombolysis in acute stroke within 0–3 h from stroke onset, 27 contraindications for its use between 3 and 4.5 h and intravenous (systemic) thrombolysis is not recommended after 4.5 h (Table 1). Among important contraindications is very high blood pressure (due to increased risk of intracranial bleeding). Arterial blood pressure should be below 180/ 105 mmHg before iv. rtPA is initiated. Intravenous rtPA in the dose of 0.9 mg/kg (max. 90 mg total) is indicated for selected patients (without contraindications) who can be
treated within 3 h of stroke onset (IA recommendation) or within 3–4.5 h (IB recommendation). Interestingly, rtPA has FDA approval only for the use within 0–3 h from stroke onset and not for more delayed use. In other words, iv. thrombolysis between 3 and 4.5 h from stroke onset is recommended by the guidelines, but not approved by the FDA. Similarly, intraarterial rtPA is not approved by FDA, but was frequently used as part of acute intervention prior to the era of stent-retrievers. Nowadays, when stent-retrievers are much faster and much more effective, i.a. use of rtPA is reserved only for patients with more distal occlusions, not accessible with stent-retrievers. The guidelines also recommend, that patients eligible for rtPA should receive iv. rtPA even if endovascular treatment is considered (IA recommendation). The total ischemic time (stroke onset – reperfusion) is even more critical in acute stroke than in acute myocardial infarction. Thus, the guidelines recommend door-to-needle time <60 min (from hospital arrival to initiation of rtPA infusion) as an important parameter for quality control. Thrombectomy devices can be useful in achieving recanalization alone or in combination with pharmacological fibrinolysis (IIaB recommendation). Mechanical thrombectomy is reasonable in patients who have contraindications to the use of intravenous fibrinolysis (IIaC recommendation). As mentioned above, no information is given in these guidelines about the use of anticoagulants during CBT in patients with contraindications for thrombolysis. In general, urgent anticoagulation with the goal of preventing early recurrent stroke or improving stroke outcomes or for the management of noncerebrovascular conditions is not recommended due to the risk of serious intracranial hemorrhage (IIIA recommendation). Anticoagulant therapy within 24 h after rtPA is not recommended (IIIB).
Table 1 – Contraindications for thrombolytic therapy of acute stroke [1]. Absolute contraindications Significant head trauma or prior stroke in previous 3 months Symptoms suggest subarachnoid hemorrhage Arterial puncture at noncompressible site in previous 7 days History of previous intracranial hemorrhage Intracranial neoplasm, arteriovenous malformation, or aneurysm Recent intracranial or intraspinal surgery Elevated blood pressure (systolic >185 mm Hg or diastolic >110 mm Hg) Active internal bleeding Acute bleeding diathesis Platelet count <100,000/mm 3 Heparin received within 48 h, resulting in abnormally elevated aPTT greater than the upper limit of normal Current use of anticoagulant with INR >1.7 or PT >15 s Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated sensitive laboratory tests (such as aPTT, INR, platelet count, and ECT; TT; or appropriate factor Xa activity assays) Blood glucose concentration <2.7 mmol/L CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere)
Relative contraindications Only minor or rapidly improving stroke symptoms (clearing spontaneously) Pregnancy Seizure at onset with postictal residual neurological impairments Major surgery or serious trauma within previous 14 days Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days) Recent acute myocardial infarction (within previous 3 months) Aged >80 years Severe stroke (NIHSS > 25) Taking an oral anticoagulant regardless of INR History of both diabetes and prior ischemic stroke Imaging evidence of ischemic injury involving more than one third of the MCA territory
e141
cor et vasa 57 (2015) e139–e142
Table 2 – Antithrombotic therapy in acute stroke. Medical only management of acute ischemic stroke (initial 24 h)
Periprocedural therapy before/during CBT
rtPA
Yes: within 0–3 ( 4.5) hours from stroke onset if no contraindication is present
Yes: as bridging therapy or as intraarterial therapy (i.a. not approved by FDA).
Heparin
No role for acute anticoagulation.
Not for patients who received rtPA. Heparin use for patients treated with mechanical thrombectomy (without lytics) should be subject to research.
Aspirin
Not as acute treatment, not within 24 h after rtPA. Yes as oral secondary prevention within 24–48 h.
Not for patients who received rtPA. ASA use for patients treated with mechanical thrombectomy (without lytics) should be subject to research.
Clopidogrel GPIIb/IIIa inhibitors
Limited information, further research needed. No.
No information. No.
Modified from [1].
Similarly, no recommendation is given for periprocedural use of antiplatelet agents. Acetylsalicylic acid (ASA) is not recommended as a substitute for other acute interventions (IIIB), ASA is not recommended as adjunctive therapy within 24 h of iv. rtPA (IIIC). Oral ASA should be initiated within 24–48 h after stroke onset (IA recommendation). The usefulness of clopidogrel in acute ischemic stroke is not well established and further research is required (IIbC). Intravenous GPIIb/IIIa inhibitors are not recommended (IIIB). Table 2 shows extracted message from the AHA/ASA guidelines on antithrombotic therapy. Similar to AHA/ASA guidelines, no information about periprocedural anticoagulation or antiplatelet treatment is provided in the important multisociety consensus paper on catheter-based interventions in acute stroke [2].
Periprocedural therapy in published trials and registries One of the largest European registries – the Bernese registry – included 227 patients treated during one year period with CBT. Symptomatic intracranial bleeding occurred in 9.7% and asymptomatic in 15%. Unfortunately, no information about periprocedural antithrombotic medication was provided [3]. The recent landmark Dutch randomized trial MR CLEAN enrolled 500 patients, 233 of them randomized to mechanical intervention. Thrombolysis was used before randomization in 89% of them, but no information about periprocedural anticoagulant of antiplatelet medication was given [4]. A small single center registry of 23 consecutive cases of emergency carotid stenting followed by mechanical thrombectomy found successful carotid stenting in all cases, and establishment of TICI flow 2a/2b/3 in 91%. Symptomatic intracranial hemorrhage (SICH) occurred in 5/23 patients (22%). Of 13 patients receiving an intravenous loading dose of abciximab during the procedure, 4/13 had SICH (31%) compared with 1/10 (10%) of those who did not. Of seven patients who received intravenous tissue plasminogen activator prior to the procedure, none had SICH. 90-day mortality was 9/23 (39%). All patients who had SICH were
above the median age [5]. A large single center registry of 471 patients undergoing carotid surgery compared outcomes after ASA alone vs. after ASA + clopidogrel [6]. When divided by indication, there was an increased long-term mortality rate in patients with asymptomatic carotid disease receiving dual antiplatelet therapy as compared with aspirin alone (47% vs. 40%; P = .05), while patients with symptomatic carotid disease had a nonsignificant decrease in all-cause mortality if they received dual antiplatelet therapy (38% vs. 39%; P = .53). The most recent study [7] on retrievable stent also did not describe details of antithrombotic regimen. The text merely mentioned ‘‘Lytic administration and/or systemic anticoagulation were performed at the discretion of the treating physician.’’ In the TREVO study it was recommended, that administration of anticoagulants and antiplatelets be suspended for 24 h post-thrombectomy in patients who were not in direct need of these agents. Heparin use within previous 48 h with aPTT >2 times normal was even an exclusion criterion. Intravenous thrombolysis was used in 60% of patients prior to the endovascular procedure. Periprocedural antithrombotic treatment included i.a. rtPA in 10% and GP IIb/IIIa inhibitors in 5% [8]. One study [9] used neither i.v. heparin nor intra-arterial fibrinolytics at any time during the mechanical thrombectomy procedure, even if the recanalization attempt was unsuccessful. When stent placement was needed, antiplatelet management consisted of 500 mg of aspirin i.v. during the procedure, and double antiplatelet was discussed after the 24-h CT control in view of any serious hemorrhagic complications. Patients treated by direct CBT in a Turkish study [10] received 100 mg ASA before CBT in the emergency department. During interventional stroke procedure, 2000 units of bolus heparin were given routinely. No further antiplatelet or heparin was administered within 24 h of procedure. A CT or MRI was performed 24 h after the procedure. If no hemorrhage was present, aspirin 300 mg/day was given.
Conflict of interest No conflict of interest.
e142
cor et vasa 57 (2015) e139–e142
Funding Charles University project P35.
Ethical statement No ethical issues.
references
[1] E.C. Jauch, J.L. Saver, H.P. Adams, et al., on behalf of AHA/ ASA, Guidelines for the early management of patients with acute ischemic stroke, Stroke 44 (2013) 870–947. [2] D. Sacks, C.M. Black, C. Cognard, et al., American Society of Neuroradiology; Canadian Interventional Radiology Association; Cardiovascular and Interventional Radiological Society of Europe; Society for Cardiovascular Angiography and Interventions; Society of Interventional Radiology; Society of NeuroInterventional Surgery; European Society of Minimally Invasive Neurological Therapy; Society of Vascular and Interventional Neurology, Multisociety consensus quality improvement guidelines for intraarterial catheter-directed treatment of acute ischemic stroke, from the American Society of Neuroradiology, Canadian Interventional Radiology Association, Cardiovascular and Interventional Radiological Society of Europe, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, European Society of Minimally Invasive Neurological Therapy, and Society of Vascular and Interventional Neurology, Journal of Vascular and Interventional Radiology 24 (2013) 151–163.
[3] P.P. Gratz, S. Jung, G. Schroth, et al., Outcome of standard and high-risk patients with acute anterior circulation stroke after stent retriever thrombectomy, Stroke 45 (2014) 152– 158. [4] O.A. Berkhemer, P.S. Fransen, D. Beumer, et al., MR CLEAN Investigators, A randomized trial of intraarterial treatment for acute ischemic stroke, New England Journal of Medicine 372 (2015) 11–20. [5] D.V. Heck, M.D. Brown, Carotid stenting and intracranial thrombectomy for treatment of acute stroke due to tandem occlusions with aggressive antiplatelet therapy may be associated with a high incidence of intracranial hemorrhage, Journal of Neurointerventional Surgery (November) (2014) (Epub ahead of print). [6] F. Alcocer, Z. Novak, B.R. Combs, et al., Dual antiplatelet therapy (clopidogrel and aspirin) is associated with increased all-cause mortality after carotid revascularization for asymptomatic carotid disease, Journal of Vascular Surgery 59 (2014) 950–955. [7] W. Humphries, D. Hoit, V.T. Doss, et al., Distal aspiration with retrievable stent assisted thrombectomy for the treatment of acute ischemic stroke, Journal of Neurointerventional Surgery 7 (2015) 90–94. [8] O. Jansen, J.M. Macho, M. Killer-Oberpfalzer, et al., TREVO Study Group, Neurothrombectomy for the treatment of acute ischemic stroke: results from the TREVO study, Cerebrovascular Diseases 36 (2013) 218–225. [9] G. Gascou, K. Lobotesis, P. Machi, et al., Stent retrievers in acute ischemic stroke: complications and failures during the perioperative period, American Journal of Neuroradiology 35 (2014) 734–740. [10] O. Ozdemir, S. Giray, Z. Arlier, et al., Predictors of a good outcome after endovascular stroke treatment with stent retrievers, The Scientific World Journal (2014), Article ID 403726 (in press).
Available online at www.sciencedirect.com
ScienceDirect journal homepage: http://www.elsevier.com/locate/crvasa
Review article – Special issue: Cardiovascular Surgery
Periprocedural antithrombotic medication in acute ischemic stroke treated by catheter-based thrombectomy. A review Petr Widimsky * Cardiocenter, Third Faculty of Medicine, Charles University Prague, Czech Republic
article info
abstract
Article history:
This review summarized limited information known about periprocedural antithrombotic
Received 31 January 2015
therapy before, during and immediately after percutaneous catheter-based thrombectomy
Accepted 19 February 2015
for acute ischemic stroke. Very few data on this topic were published so far. In general, rtPA
Available online 18 March 2015
should be used upfront whenever clinically clearly indicated (0–3 h from stroke onset,
Keywords:
mechanical treatment follows after thrombolysis, neither anticoagulation, nor antiplatelet
Acute stroke
agents should be used in the acute phase. No data exist about the periprocedural use of
absence of contraindications) irrespective of subsequent mechanical thrombectomy. If
Catheter-based thrombectomy
anticoagulation or antiplatelet therapy in patients who cannot receive fibrinolysis and
Thrombolysis
undergo direct mechanical thrombectomy alone. Most centers use no or very low dose
Anticoagulation
heparin and a single dose of aspirin.
Antiplatelet therapy
# 2015 The Czech Society of Cardiology. Published by Elsevier Sp. z o.o. All rights reserved.
Heparin Aspirin Fibrinolysis
Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . What is (not) mentioned in the US guidelines?. . . . . . . . . Periprocedural therapy in published trials and registries . Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ethical statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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* Correspondence to: Cardiocenter Kralovske Vinohrady, Charles University Prague, Czech Republic. Tel.: +420 267162621. E-mail address: [email protected] http://dx.doi.org/10.1016/j.crvasa.2015.02.012 0010-8650/# 2015 The Czech Society of Cardiology. Published by Elsevier Sp. z o.o. All rights reserved.
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e140 e140 e141 e141 e142 e142 e142
e140
cor et vasa 57 (2015) e139–e142
Introduction Interventional therapy of acute ischemic stroke is slowly emerging as an alternative treatment option besides thrombolytic therapy. Frequently both treatments are combined (‘‘bridging’’ thrombolysis or intraarterial ‘‘local’’ thrombolysis). Among various technical approaches to interventional therapy thrombectomy with stent-retrievers dominates after 2012, when the first devices (Solitaire® and Trevo®) were approved by the FDA. There is very limited information available on periprocedural antiplatelet or anticoagulant therapy before/during/after catheter-based thrombectomy (CBT). The aim of this article is to summarize the available published information on this topic.
What is (not) mentioned in the US guidelines? Possibly the most comprehensive document on this subject – the American guidelines for the management of acute stroke [1] – describes the reperfusion strategies and the use of anticoagulant and antiplatelet agents as the primary therapy for stroke, but not as periprocedural therapy during CBT. There are 22 contraindications for the use of thrombolysis in acute stroke within 0–3 h from stroke onset, 27 contraindications for its use between 3 and 4.5 h and intravenous (systemic) thrombolysis is not recommended after 4.5 h (Table 1). Among important contraindications is very high blood pressure (due to increased risk of intracranial bleeding). Arterial blood pressure should be below 180/ 105 mmHg before iv. rtPA is initiated. Intravenous rtPA in the dose of 0.9 mg/kg (max. 90 mg total) is indicated for selected patients (without contraindications) who can be
treated within 3 h of stroke onset (IA recommendation) or within 3–4.5 h (IB recommendation). Interestingly, rtPA has FDA approval only for the use within 0–3 h from stroke onset and not for more delayed use. In other words, iv. thrombolysis between 3 and 4.5 h from stroke onset is recommended by the guidelines, but not approved by the FDA. Similarly, intraarterial rtPA is not approved by FDA, but was frequently used as part of acute intervention prior to the era of stent-retrievers. Nowadays, when stent-retrievers are much faster and much more effective, i.a. use of rtPA is reserved only for patients with more distal occlusions, not accessible with stent-retrievers. The guidelines also recommend, that patients eligible for rtPA should receive iv. rtPA even if endovascular treatment is considered (IA recommendation). The total ischemic time (stroke onset – reperfusion) is even more critical in acute stroke than in acute myocardial infarction. Thus, the guidelines recommend door-to-needle time <60 min (from hospital arrival to initiation of rtPA infusion) as an important parameter for quality control. Thrombectomy devices can be useful in achieving recanalization alone or in combination with pharmacological fibrinolysis (IIaB recommendation). Mechanical thrombectomy is reasonable in patients who have contraindications to the use of intravenous fibrinolysis (IIaC recommendation). As mentioned above, no information is given in these guidelines about the use of anticoagulants during CBT in patients with contraindications for thrombolysis. In general, urgent anticoagulation with the goal of preventing early recurrent stroke or improving stroke outcomes or for the management of noncerebrovascular conditions is not recommended due to the risk of serious intracranial hemorrhage (IIIA recommendation). Anticoagulant therapy within 24 h after rtPA is not recommended (IIIB).
Table 1 – Contraindications for thrombolytic therapy of acute stroke [1]. Absolute contraindications Significant head trauma or prior stroke in previous 3 months Symptoms suggest subarachnoid hemorrhage Arterial puncture at noncompressible site in previous 7 days History of previous intracranial hemorrhage Intracranial neoplasm, arteriovenous malformation, or aneurysm Recent intracranial or intraspinal surgery Elevated blood pressure (systolic >185 mm Hg or diastolic >110 mm Hg) Active internal bleeding Acute bleeding diathesis Platelet count <100,000/mm 3 Heparin received within 48 h, resulting in abnormally elevated aPTT greater than the upper limit of normal Current use of anticoagulant with INR >1.7 or PT >15 s Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated sensitive laboratory tests (such as aPTT, INR, platelet count, and ECT; TT; or appropriate factor Xa activity assays) Blood glucose concentration <2.7 mmol/L CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere)
Relative contraindications Only minor or rapidly improving stroke symptoms (clearing spontaneously) Pregnancy Seizure at onset with postictal residual neurological impairments Major surgery or serious trauma within previous 14 days Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days) Recent acute myocardial infarction (within previous 3 months) Aged >80 years Severe stroke (NIHSS > 25) Taking an oral anticoagulant regardless of INR History of both diabetes and prior ischemic stroke Imaging evidence of ischemic injury involving more than one third of the MCA territory
e141
cor et vasa 57 (2015) e139–e142
Table 2 – Antithrombotic therapy in acute stroke. Medical only management of acute ischemic stroke (initial 24 h)
Periprocedural therapy before/during CBT
rtPA
Yes: within 0–3 ( 4.5) hours from stroke onset if no contraindication is present
Yes: as bridging therapy or as intraarterial therapy (i.a. not approved by FDA).
Heparin
No role for acute anticoagulation.
Not for patients who received rtPA. Heparin use for patients treated with mechanical thrombectomy (without lytics) should be subject to research.
Aspirin
Not as acute treatment, not within 24 h after rtPA. Yes as oral secondary prevention within 24–48 h.
Not for patients who received rtPA. ASA use for patients treated with mechanical thrombectomy (without lytics) should be subject to research.
Clopidogrel GPIIb/IIIa inhibitors
Limited information, further research needed. No.
No information. No.
Modified from [1].
Similarly, no recommendation is given for periprocedural use of antiplatelet agents. Acetylsalicylic acid (ASA) is not recommended as a substitute for other acute interventions (IIIB), ASA is not recommended as adjunctive therapy within 24 h of iv. rtPA (IIIC). Oral ASA should be initiated within 24–48 h after stroke onset (IA recommendation). The usefulness of clopidogrel in acute ischemic stroke is not well established and further research is required (IIbC). Intravenous GPIIb/IIIa inhibitors are not recommended (IIIB). Table 2 shows extracted message from the AHA/ASA guidelines on antithrombotic therapy. Similar to AHA/ASA guidelines, no information about periprocedural anticoagulation or antiplatelet treatment is provided in the important multisociety consensus paper on catheter-based interventions in acute stroke [2].
Periprocedural therapy in published trials and registries One of the largest European registries – the Bernese registry – included 227 patients treated during one year period with CBT. Symptomatic intracranial bleeding occurred in 9.7% and asymptomatic in 15%. Unfortunately, no information about periprocedural antithrombotic medication was provided [3]. The recent landmark Dutch randomized trial MR CLEAN enrolled 500 patients, 233 of them randomized to mechanical intervention. Thrombolysis was used before randomization in 89% of them, but no information about periprocedural anticoagulant of antiplatelet medication was given [4]. A small single center registry of 23 consecutive cases of emergency carotid stenting followed by mechanical thrombectomy found successful carotid stenting in all cases, and establishment of TICI flow 2a/2b/3 in 91%. Symptomatic intracranial hemorrhage (SICH) occurred in 5/23 patients (22%). Of 13 patients receiving an intravenous loading dose of abciximab during the procedure, 4/13 had SICH (31%) compared with 1/10 (10%) of those who did not. Of seven patients who received intravenous tissue plasminogen activator prior to the procedure, none had SICH. 90-day mortality was 9/23 (39%). All patients who had SICH were
above the median age [5]. A large single center registry of 471 patients undergoing carotid surgery compared outcomes after ASA alone vs. after ASA + clopidogrel [6]. When divided by indication, there was an increased long-term mortality rate in patients with asymptomatic carotid disease receiving dual antiplatelet therapy as compared with aspirin alone (47% vs. 40%; P = .05), while patients with symptomatic carotid disease had a nonsignificant decrease in all-cause mortality if they received dual antiplatelet therapy (38% vs. 39%; P = .53). The most recent study [7] on retrievable stent also did not describe details of antithrombotic regimen. The text merely mentioned ‘‘Lytic administration and/or systemic anticoagulation were performed at the discretion of the treating physician.’’ In the TREVO study it was recommended, that administration of anticoagulants and antiplatelets be suspended for 24 h post-thrombectomy in patients who were not in direct need of these agents. Heparin use within previous 48 h with aPTT >2 times normal was even an exclusion criterion. Intravenous thrombolysis was used in 60% of patients prior to the endovascular procedure. Periprocedural antithrombotic treatment included i.a. rtPA in 10% and GP IIb/IIIa inhibitors in 5% [8]. One study [9] used neither i.v. heparin nor intra-arterial fibrinolytics at any time during the mechanical thrombectomy procedure, even if the recanalization attempt was unsuccessful. When stent placement was needed, antiplatelet management consisted of 500 mg of aspirin i.v. during the procedure, and double antiplatelet was discussed after the 24-h CT control in view of any serious hemorrhagic complications. Patients treated by direct CBT in a Turkish study [10] received 100 mg ASA before CBT in the emergency department. During interventional stroke procedure, 2000 units of bolus heparin were given routinely. No further antiplatelet or heparin was administered within 24 h of procedure. A CT or MRI was performed 24 h after the procedure. If no hemorrhage was present, aspirin 300 mg/day was given.
Conflict of interest No conflict of interest.
e142
cor et vasa 57 (2015) e139–e142
Funding Charles University project P35.
Ethical statement No ethical issues.
references
[1] E.C. Jauch, J.L. Saver, H.P. Adams, et al., on behalf of AHA/ ASA, Guidelines for the early management of patients with acute ischemic stroke, Stroke 44 (2013) 870–947. [2] D. Sacks, C.M. Black, C. Cognard, et al., American Society of Neuroradiology; Canadian Interventional Radiology Association; Cardiovascular and Interventional Radiological Society of Europe; Society for Cardiovascular Angiography and Interventions; Society of Interventional Radiology; Society of NeuroInterventional Surgery; European Society of Minimally Invasive Neurological Therapy; Society of Vascular and Interventional Neurology, Multisociety consensus quality improvement guidelines for intraarterial catheter-directed treatment of acute ischemic stroke, from the American Society of Neuroradiology, Canadian Interventional Radiology Association, Cardiovascular and Interventional Radiological Society of Europe, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, European Society of Minimally Invasive Neurological Therapy, and Society of Vascular and Interventional Neurology, Journal of Vascular and Interventional Radiology 24 (2013) 151–163.
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