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Effect of antiplatelet therapy and platelet function testing on hemorrhagic and thrombotic complications in patients with cerebral aneurysms treated with the pipeline embolization device: a review and meta-analysis
  1. Susana L Skukalek1,
  2. Anne M Winkler2,
  3. Jian Kang3,
  4. Jacques E Dion4,
  5. C Michael Cawley5,
  6. Adam Webb6,
  7. Mark J Dannenbaum7,
  8. Albert J Schuette8,
  9. Bill Asbury9,
  10. Frank C Tong10
  1. 1Departments of Neurosurgery and Radiology, The Emory Clinic, Atlanta, Georgia, USA
  2. 2Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
  3. 3Department of Biostatistics and Bioinformatics, Emory Rollins School of Public Health, Atlanta, Georgia, USA
  4. 4Departments of Radiology and Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
  5. 5Departments of Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
  6. 6Departments of Neurology and Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
  7. 7Department of Neurosurgery, The University of Texas at Houston, Houston, Texas, USA
  8. 8Department of Neurosurgery, Tripler Army Medical Center, Honolulu, Hawaii, USA
  9. 9Emory University Hospital, Atlanta, Georgia, USA
  10. 10Departments of Radiology and Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
  1. Correspondence to Dr S L Skukalek, Departments of Neurosurgery and Radiology, The Emory Clinic, 1365B Clifton Road, Suite 2200, Atlanta, GA 30322, USA; susana.skukalek{at}emoryhealthcare.org

Abstract

Purpose The pipeline embolization device (PED) necessitates dual antiplatelet therapy (APT) to decrease thrombotic complications while possibly increasing bleeding risks. The role of APT dose, duration, and response in patients with hemorrhagic and thromboembolic events warrants further analysis.

Methods A PubMed and Google Scholar search from 2009 to 2014 was performed using the following search terms individually or in combination: pipeline embolization device, aneurysm(s), and flow diversion, excluding other flow diverters. Review of the bibliographies of the retrieved articles yielded 19 single and multicenter studies. A statistical meta-analysis between aspirin (ASA) dose (low dose ≤160 mg, high dose ≥300 mg), loading doses of APT agents, post-PED APT regimens, and platelet function testing (PFT) with hemorrhagic or thrombotic complications was performed.

Results ASA therapy for ≤6 months post-PED was associated with increased hemorrhagic events. High dose ASA ≤6 months post-PED was associated with fewer thrombotic events compared with low dose ASA. Post-PED clopidogrel for ≤6 months demonstrated an increased incidence of symptomatic thrombotic events. Loading doses of ASA plus clopidogrel demonstrated a decreased incidence of permanent symptomatic hemorrhagic events. PFT did not show a statistically significant relationship with symptomatic hemorrhagic or thrombotic complications.

Conclusions High dose ASA >6 months is associated with fewer permanent thrombotic and hemorrhagic events. Clopidogrel therapy ≤6 months is associated with higher rates of thrombotic events. Loading doses of ASA and clopidogrel were associated with a decreased incidence of hemorrhagic events. PFT did not have any significant association with symptomatic events.

  • Aneurysm
  • Complication
  • Flow Diverter

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