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Pipeline shield with single antiplatelet therapy in aneurysmal subarachnoid haemorrhage: multicentre experience
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  • Published on:
    Response to Rouchaud
    • Nathan Manning, Neurointerventional Surgeon 1. Institute of Neurological Sciences, Prince of Wales Hospital, Randwick, NSW, Australia. 2. Department of Interventional Neu

    We thank the respondents for providing their case experience and allowing further discussion of this important topic. We would first like to draw attention to specific points in the described case, before discussing some of the more general issues raised.

    The respondents report one of many scenarios in which it may be undesirable to use dual antiplatelet therapy in the elective treatment of intracranial aneurysms with flow diverters. In this case, a 47-year-old woman with an 11 mm left ophthalmic aneurysm harbours a significant aspirin allergy. A single Pipeline Shield device under cover of ticagrelor was used to treat the aneurysm. The patient was well at discharge on postoperative day three but then developed symptomatic stent thrombosis on day 6. We draw attention to three points:

    1) The respondents state that the stent achieved “perfect wall apposition improved with intra-stent balloon angioplasty.” Setting aside the impossibility of improving “perfect wall apposition” with angioplasty, this does allude to the increasingly understood importance of flow diverter wall apposition. [1] However, digital subtraction angiography assess stent apposition poorly. [1] The use of angioplasty suggests that there may have been some initial concern. Moreover, angioplasty itself may contribute to thrombosis if it promotes activation of the extrinsic clotting pathway by disrupting the endothelial layer. The phosphocholine “Shield” layer reduces thrombosis and platelet...

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    Conflict of Interest:
    NWM is a consultant for Medtronic and has received speaker honoraria
  • Published on:
    Alert against the risk of single antiplatelet therapy while using Pipeline Shield flow diverter
    • Aymeric Rouchaud, Interventional neuroradiologist Limoges University Hospital
    • Other Contributors:
      • Suzana Saleme, Interventional neuroradiologist
      • Leonardo Sganzerla, interventional neuroradiologist
      • Charbel Mounayer, Interventional neuroradiologist

    We read with interest the case series by Manning’s et al.[1] using a surface modified flow-diverter stent (Pipeline Flex with Shield Technology, Medtronic Neurovascular, Irvine, California, USA). In this retrospective series, 14 ruptured intracranial aneurysms have been treated in the acute phase after Sub-Arachnoid Hemorrhage (SAH) with the Pipeline shield device under a Single Anti-Platelet Therapy (SAPT). The article concluded the PED-Shield to be safe to use in the acute treatment of ruptured intracranial aneurysms with SAPT.

    However, in this small series, the authors reported one case of total stent occlusion and two cases of platelet aggregation noted on the PED-Shield device requiring to switch from single to dual antiplatelet treatment. Considering those three patients, thrombotic complications have been observed in 21.4 % of cases (3/14) in the acute period. Furthermore, in two cases (14.3 %), the authors reported rebleeding of the culprit aneurysm leading to patient death, pointing out the fact that flow-diverter devices may not immediately prevent the risk of aneurysm rerupture.

    Anti-thrombogenic coating might have an added value in case of very specific aneurysms cases requiring the placement of a stent in the acute phase after rupture. Those specific cases are mainly dissecting or blister aneurysms for which endovascular or even surgical approach are difficult and carry a high risk of morbi-mortality[2][3]. In case of endovascular treatment, rece...

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    Conflict of Interest:
    None declared.