Background In-stent thrombosis and thromboembolism are major complication of aneurysmal coil embolization, stent-assisted coiling, and pipeline embolization. The common but unproven practice of dual antiplatelet therapy with aspirin and a P2Y12 inhibitor in neuroendovascular patients has been inferred from the cardiology literature without large clinical trials to support it in neuroendovascular patients.
Methods An electronic survey was distributed via the Web using Survey Monkey Inc. (Seattle, WA). Any practicing neuro ICU or stroke physician, pharmacist, physician assistant, or nurse practitioner was eligible to respond to this survey between June and October 2017.
Results A total of 33 responses were collected during the survey period. Only 29% of institutions had a standardized post-neuro-interventional procedure antiplatelet protocol. Aspirin and clopidogrel was standard of care antiplatelet regimen utilized in the majority of institutions (82%). Alternatively, four institutions used monotherapy (aspirin [n=2], clopidogrel [n=1], either aspirin or clopidogrel [n=1]) and two institutions reported practitioner dependent practices. Most institutions assessed clopidogrel responsiveness (77%). All but one institution assessed clopidogrel responsiveness by P2Y12 assay. Just under half of centers reported ticagrelor as the primary alternative in clopidogrel non-responders (48%). When ticagrelor was used, 21 of the 33 centers used low-dose aspirin as recommended by the ticagrelor approved FDA labeling.
Conclusion Dual antiplatelet therapy with aspirin and clopidogrel appears to be standard of care in this setting based on our survey. About half of the responders use ticagrelor in cases where clopidogrel resistance is suspected. Large randomized controlled trials are needed to evaluate the safety and efficacy of ticagrelor in this setting.
Disclosures S. Farrokh: None. K. Owusu: None. L. Rivera Lara: None. K. Nault: None. B. Spoelhof: None. F. Hui: None.
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