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Prevention and Treatment of Thromboembolism during Endovascular Aneurysm Therapy*

Prophylaxe und Therapie von thromboembolischen Komplikationen bei der endovaskulären Aneurysmabehandlung

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Abstract

Thromboembolic events with partially or completely persisting neurologic deficits are reported in a substantial number of patients after endovascular aneurysm therapy. The authors discuss the current status of periinterventional coagulation management in endovascular aneurysm therapy. First, some basic aspects of coagulation physiology relevant to neurointerventions are introduced. Second, the most important pharmacological aspects of heparin, protamine sulfate, low-molecular-weight heparin, tissue plasminogen activator, acetylsalicylic acid, clopidogrel, abciximab, tirofiban and eptifibatide for neurointerventions are considered. Third, the use of these drugs in periinterventional coagulation management are discussed with special emphasis on current standards in anticoagulation/antiplatelet strategy and their impact on aneurysm perforation rates. Moreover, treatment of thrombotic complications of endovascular therapy of cerebral aneurysms is discussed.

Zusammenfassung

Thromboembolische Ereignisse mit teilweise oder vollständig persistierenden neurologischen Defiziten werden in einer beträchtlichen Zahl von Patienten nach endovaskuläre Aneurysmabehandlung beobachtet. Die Autoren berichten über den Stand des periinterventionellen Gerinnungsmanagements bei der endovaskulären Aneurysmatherapie. Zunächst werden grundsätzliche Aspekte der Gerinnungsphysiologie diskutiert, soweit sie für neurointerventionelle Prozeduren relevant sind. Als Nächstes werden die wichtigsten pharmakologischen Aspekte von Heparin, Protamin, niedermolekularem Heparin, Gewebe-Plasminogenaktivator, Acetylsalicylsäure, Clopidogrel, Abciximab, Tirofiban und Eptifibatid diskutiert. Darüber hinaus wird die Verwendung dieser Medikamente im interventionellen Gerinnungsmanagement besprochen.

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References

  1. Murayama Y, Nien YL, Duckwiler G, Gobin YP, Jahan R, Frazee J, Martin N, Vinuela F. Guglielmi detachable coil embolization of cerebral aneurysms: 11 years’ experience. J Neurosurg 2003;98:959–66.

    Article  PubMed  Google Scholar 

  2. Gallas S, Pasco A, Cottier J, Gabrillargues J, Drouineau J, Cognard C, Herbreteau D. A multicenter study of 705 ruptured intracranial aneurysms treated with Guglielmi detachable coils. AJNR Am J Neuroradiol 2005;26:1723–31.

    PubMed  Google Scholar 

  3. Pelz DM, Lownie SP, Fox AJ. Thromboembolic events associated with the treatment of cerebral aneurysms with Guglielmi detachable coils. AJNR Am J Neuroradiol 1998;19:1541–7.

    PubMed  CAS  Google Scholar 

  4. Rordorf G, Bellon RJ, Budzik RE Jr, Farkas J, Reinking GF, Pergolizzi RS, Ezzeddine M, Norbash AM, Gonzalez RG, Putman CM. Silent thromboembolic events associated with the treatment of unruptured cerebral aneurysms by use of Guglielmi detachable coils: prospective study applying diffusion-weighted imaging. AJNR Am J Neuroradiol 2001;22:5–10.

    PubMed  CAS  Google Scholar 

  5. Soeda A, Sakai N, Murao K, Sakai H, Ihara K, Yamada N, Imakita S, Nagata I. Thromboembolic events associated with Guglielmi detachable coil embolization with use of diffusion-weighted MR imaging. Part II. Detection of the microemboli proximal to cerebral aneurysm. AJNR Am J Neuroradiol 2003;24:2035–8.

    PubMed  Google Scholar 

  6. Ries T, Buhk J, Kucinski T, Goebell E, Grzyska U, Zeumer H, Fiehler J. Intravenous administration of acetylsalicylic acid during endovascular treatment of cerebral aneurysms reduces the rate of thromboembolic events. Stroke 2006;37:1816–21.

    Article  PubMed  CAS  Google Scholar 

  7. Henkes H, Fischer S, Weber W, Miloslavski E, Felber S, Brew S, Kuehne D. Endovascular coil occlusion of 1811 intracranial aneurysms: early angiographic and clinical results. Neurosurgery 2004;54:268–80, discussion 280–5.

    Article  PubMed  Google Scholar 

  8. Grunwald IQ, Papanagiotou P, Politi M, Struffert T, Roth C, Reith W. Endovascular treatment of unruptured intracranial aneurysms: occurrence of thromboembolic events. Neurosurgery 2006;58:612–8, discussion 612–8.

    Article  PubMed  Google Scholar 

  9. Pierot L, Spelle L, Vitry F. Immediate clinical outcome of patients harboring unruptured intracranial aneurysms treated by endovascular approach. Results of the ATENA Study. Stroke 2008;39:2497–504.

    Article  PubMed  Google Scholar 

  10. Fiehler J, Boor S, Dörbecker R, Eckert, Hartmann, Koch C, Ries T, Kummer R von, Wickenhöfer R, Zeumer H. Table for Optimization and Monitoring of Cerebral Aneurysm Therapy (TOMCAT) – results and implications of the lead-in phase. Clin Neuroradiol 2008;18:168–76.

    Article  Google Scholar 

  11. Virchow R. Thrombose und Embolie. Gefässentzündung und septische Infektion. Frankfurt/Main, Meidinger & Sohn, 1856.

  12. Vermeulen M, van Vliet HH, Lindsay KW, Hijdra A, van Gijn J. Source of fibrin/fibrinogen degradation products in the CSF after subarachnoid hemorrhage. J Neurosurg 1985;63:573–7.

    Article  PubMed  CAS  Google Scholar 

  13. Kasuya H, Shimizu T, Okada T, Takahashi K, Summerville T, Kitamura K. Activation of the coagulation system in the subarachnoid space after subarachnoid hemorrhage: serial measurement of fibrinopeptide A and bradykinin of cerebrospinal fluid and plasma in patients with subarachnoid hemorrhage. Acta Neurochir (Wien) 1988;91:120–5.

    Article  CAS  Google Scholar 

  14. Ikeda K, Asakura H, Futami K, Yamashita J. Coagulative and fibrinolytic activation in cerebrospinal fluid and plasma after subarachnoid hemorrhage. Neurosurgery 1997;41:344–9; discussion 349–50.

    Article  PubMed  CAS  Google Scholar 

  15. Armstrong MJ, Schneck MJ, Biller J. Discontinuation of perioperative antiplatelet and anticoagulant therapy in stroke patients. Neurol Clin 2006;24:607–30.

    Article  PubMed  Google Scholar 

  16. Beckerath N von, Taubert D, Pogatsa-Murray G, Schomig E, Kastrati A, Schomig A. Absorption, metabolization, and antiplatelet effects of 300-, 600-, and 900-mg loading doses of clopidogrel: results of the ISAR-CHOICE (Intracoronary Stenting and Antithrombotic Regimen: Choose Between 3 High Oral Doses for Immediate Clopidogrel Effect) Trial. Circulation 2005;112:2946–50.

    Google Scholar 

  17. Cho L, Topol EJ, Balog C, Foody JM, Booth JE, Cabot C, Kleiman NS, Tcheng JE, Califf R, Lincoff AM. Clinical benefit of glycoprotein IIb/IIIa blockade with abciximab is independent of gender: pooled analysis from EPIC, EPILOG and EPISTENT trials. Evaluation of 7E3 for the Prevention of Ischemic Complications. Evaluation in Percutaneous Transluminal Coronary Angioplasty to Improve Long-Term Outcome with Abciximab GP IIb/IIIa Blockade. Evaluation of Platelet IIb/IIIa Inhibitor for Stent. J Am Coll Cardiol 2000;36:381–6.

    Article  PubMed  CAS  Google Scholar 

  18. Powner DJ, Hartwell EA, Hoots WK. Counteracting the effects of anticoagulants and antiplatelet agents during neurosurgical emergencies. Neurosurgery 2005;57:823–31.

    Article  PubMed  Google Scholar 

  19. Byrne JV, Molyneux AJ, Brennan RP, Renowden SA. Embolization of recently ruptured intracranial aneurysms. J Neurol Neurosurg Psychiatry 1995;59:616–20.

    Article  PubMed  CAS  Google Scholar 

  20. Gonzalez NR, Murayama Y, Nien YL, Martin N, Frazee J, Duckwiler G, Jahan R, Gobin YP, Vinuela F. Treatment of unruptured aneurysms with GDCs: clinical experience with 247 aneurysms. AJNR Am J Neuroradiol 2004;25:577–83.

    PubMed  Google Scholar 

  21. Friedman JA, Nichols DA, Meyer FB, Pichelmann MA, McIver JI, Toussaint LG 3rd, Axley PL, Brown RD Jr. Guglielmi detachable coil treatment of ruptured saccular cerebral aneurysms: retrospective review of a 10-year single-center experience. AJNR Am J Neuroradiol 2003;24:526–33.

    PubMed  Google Scholar 

  22. Workman MJ, Cloft HJ, Tong FC, Dion JE, Jensen ME, Marx WF, Kallmes DF. Thrombus formation at the neck of cerebral aneurysms during treatment with Guglielmi detachable coils. AJNR Am J Neuroradiol 2002;23:1568–76.

    PubMed  Google Scholar 

  23. Education ACoGM. Aneurysm endovascular therapy. AJNR Am J Neuroradiol 2001;22:Suppl:S4–7.

  24. Qureshi AI, Mohammad Y, Yahia AM, Luft AR, Sharma M, Tamargo RJ, Frankel MR. Ischemic events associated with unruptured intracranial aneurysms: multicenter clinical study and review of the literature. Neurosurgery 2000;46:282–9, discussion 289–90.

    Article  PubMed  CAS  Google Scholar 

  25. Cloft HJ, Kallmes DF. Cerebral aneurysm perforations complicating therapy with Guglielmi detachable coils: a meta-analysis. AJNR Am J Neuroradiol 2002;23:1706–9.

    PubMed  Google Scholar 

  26. Yamada NK, Cross DT 3rd, Pilgram TK, Moran CJ, Derdeyn CP, Dacey RG Jr. Effect of antiplatelet therapy on thromboembolic complications of elective coil embolization of cerebral aneurysms. AJNR Am J Neuroradiol 2007;28:1778–82.

    Article  PubMed  CAS  Google Scholar 

  27. Willard J, Lange R, Hillis L. The use of aspirin in ischemic heart disease. N Engl J Med 1992;327:175–81.

    Article  PubMed  CAS  Google Scholar 

  28. Schomig A, Neumann FJ, Kastrati A, Schuhlen H, Blasini R, Hadamitzky M, Walter H, Zitzmann-Roth EM, Richardt G, Alt E, Schmitt C, Ulm K. A randomized comparison of antiplatelet and anticoagulant therapy after the placement of coronary-artery stents. N Engl J Med 1996;334:1084–9.

    Article  PubMed  CAS  Google Scholar 

  29. Juvela S. Aspirin and delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. J Neurosurg 1995;82:945–52.

    Article  PubMed  CAS  Google Scholar 

  30. Dorhout Mees SM, Rinkel GJ, Hop JW, Algra A, van Gijn J. Antiplatelet therapy in aneurysmal subarachnoid hemorrhage: a systematic review. Stroke 2003;34:2285–9.

    Article  CAS  Google Scholar 

  31. Roy D, Milot G, Raymond J. Endovascular treatment of unruptured aneurysms. Stroke 2001;32:1998–2004.

    Article  PubMed  CAS  Google Scholar 

  32. Doerfler A, Wanke I, Egelhof T, Dietrich U, Asgari S, Stolke D, Forsting M. Aneurysmal rupture during embolization with Guglielmi detachable coils: causes, management, and outcome. AJNR Am J Neuroradiol 2001;22:1825–32.

    PubMed  CAS  Google Scholar 

  33. Sluzewski M, Bosch JA, van Rooij WJ, Nijssen PC, Wijnalda D. Rupture of intracranial aneurysms during treatment with Guglielmi detachable coils: incidence, outcome, and risk factors. J Neurosurg 2001;94:238–40.

    Article  PubMed  CAS  Google Scholar 

  34. Bendok BR, Hanel RA, Hopkins LN. Coil embolization of intracranial aneurysms. Neurosurgery 2003;52:1125–30; discussion 1130.

    Article  PubMed  Google Scholar 

  35. Hahnel S, Schellinger PD, Gutschalk A, Geletneky K, Hartmann M, Knauth M, Sartor K. Local intra-arterial fibrinolysis of thromboemboli occurring during neuroendovascular procedures with recombinant tissue plasminogen activator. Stroke 2003;34:1723–8.

    Article  PubMed  CAS  Google Scholar 

  36. Molyneux A, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J, Holman R. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet 2002;360:1267–74.

    Article  PubMed  Google Scholar 

  37. Cronqvist M, Pierot L, Boulin A, Cognard C, Castaings L, Moret J. Local intraarterial fibrinolysis of thromboemboli occurring during endovascular treatment of intracerebral aneurysm: a comparison of anatomic results and clinical outcome. AJNR Am J Neuroradiol 1998;19:157–65.

    PubMed  CAS  Google Scholar 

  38. The Abciximab in Ischemic Stroke Investigators. Abciximab in acute ischemic stroke: a randomized, double-blind, placebo-controlled, dose-escalation study. Stroke 2000;31:601–9.

    Google Scholar 

  39. Bruening R, Mueller-Schunk S, Morhard D, Seelos KC, Brueckmann H, Schmid-Elsaesser R, Straube A, Mayer TE. Intraprocedural thrombus formation during coil placement in ruptured intracranial aneurysms: treatment with systemic application of the glycoprotein IIb/IIIa antagonist tirofiban. AJNR Am J Neuroradiol 2006;27:1326–31.

    PubMed  CAS  Google Scholar 

  40. Park JH, Kim JE, Sheen SH, Jung CK, Kwon BJ, Kwon OK, Oh CW, Han MH, Han DH. Intraarterial abciximab for treatment of thromboembolism during coil embolization of intracranial aneurysms: outcome and fatal hemorrhagic complications. J Neurosurg 2008;108:450–7.

    Article  PubMed  Google Scholar 

  41. Velat GJ, Burry MV, Eskioglu E, Dettorre RR, Firment CS, Mericle RA. The use of abciximab in the treatment of acute cerebral thromboembolic events during neuroendovascular procedures. Surg Neurol 2006;65:352–8, discussion 358–9.

    Article  PubMed  Google Scholar 

  42. Aviv RI, O’Neill R, Patel MC, Colquhoun IR. Abciximab in patients with ruptured intracranial aneurysms. AJNR Am J Neuroradiol 2005;26:1744–50.

    PubMed  Google Scholar 

  43. Ries T, Grzyska U, Fiehler J. Antiaggregation before, during, and after coiling of unruptured aneurysms: growing evidence between Scylla and Charybdis. AJNR Am J Neuroradiol 2008;29:e33.

    Article  PubMed  CAS  Google Scholar 

  44. Muller-Schunk S, Linn J, Peters N, Spannagl M, Deisenberg M, Bruckmann H, Mayer TE. Monitoring of clopidogrel-related platelet inhibition: correlation of nonresponse with clinical outcome in supra-aortic stenting. AJNR Am J Neuroradiol 2008;29:786–91.

    Article  PubMed  CAS  Google Scholar 

  45. Fiorella D, Levy EI, Turk AS, Albuquerque FC, Niemann DB, Aagaard-Kienitz B, Hanel RA, Woo H, Rasmussen PA, Hopkins LN, Masaryk TJ, McDougall CG. US multicenter experience with the wingspan stent system for the treatment of intracranial atheromatous disease: periprocedural results. Stroke 2007;38:881–7.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Neuroradiology, University Hospital Eppendorf, Hamburg, Germany

    Thorsten Ries

  2. Department of Neuroradiology, University Hospital Eppendorf, Martinistraße 52, 20246, Hamburg, Germany

    Jens Fiehler MD, PhD

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  1. Jens Fiehler MD, PhD
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  2. Thorsten Ries
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Correspondence to Jens Fiehler MD, PhD.

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* Dedicated to Professor Hermann Zeumer, MD, on the occasion of his 65th birthday and his retirement.

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Fiehler, J., Ries, T. Prevention and Treatment of Thromboembolism during Endovascular Aneurysm Therapy*. Clin Neuroradiol 19, 73–81 (2009). https://doi.org/10.1007/s00062-009-8029-9

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  • DOI: https://doi.org/10.1007/s00062-009-8029-9

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