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Original research
Tailored antiplatelet therapy in stent assisted coiling for unruptured aneurysms: a nationwide registry study
  1. Jun Seok Koh1,
  2. Gyojun Hwang2,
  3. Jung Cheol Park3,
  4. Chang-Young Lee4,
  5. Joonho Chung5,
  6. Sang-Weon Lee6,
  7. Hyon-Jo Kwon7,
  8. Seong-Rim Kim8,
  9. Dong-Hun Kang9,
  10. Soon Chan Kwon10,
  11. Sung-Tae Kim11,
  12. Chul Hoon Chang12,
  13. Dong-Kyu Jang13,
  14. Jae Hyung Choi14,
  15. Young Woo Kim15,
  16. Bum-Tae Kim16,
  17. Byoung Gook Shin17,
  18. Seung Hoon You18,
  19. Seung Young Chung19,
  20. Junkyeung Ko20,
  21. Tae Gon Kim21,
  22. Seok-Mann Yoon22,
  23. Jong Young Lee23,
  24. Hyun Park24,
  25. Jung Hyun Park25,
  26. Jae-Hoon Cho26,
  27. Hae-Won Koo27,
  28. Jae Hoon Sung28,
  29. Jinnie Rhee29,
  30. Ho Gyun Shin29
  31. for KoNES Registry Investigators
    1. 1Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea (the Republic of)
    2. 2Department of Neurosurgery, Bundang Jesaeng General Hospital, Daejin Medical Center, Seongnam, Gyeonggi, Korea (the Republic of)
    3. 3Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea (the Republic of)
    4. 4Department of Neurosurgery, Keimyung Universtity Dongsan Medical Center, Daegu, Korea (the Republic of)
    5. 5Department of Neurosurgery, Yonsei University Gangnam Severance Hospital, Seoul, Korea (the Republic of)
    6. 6Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Gyeongnam, Korea (the Republic of)
    7. 7Department of Neurosurgery, Regional Cerebrovascular Center, Chungnam National University Hospital, Daejeon, Korea (the Republic of)
    8. 8Department of Neurosurgery, The Catholic University of Korea Bucheon St. Mary's Hospital, Bucheon, Gyeonggi, Korea (the Republic of)
    9. 9Department of Neurosurgery, Kyungpook National University Hospital, Daegu, Korea (the Republic of)
    10. 10Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea (the Republic of)
    11. 11Department of Neurosugery, Inje University Busan Paik Hospital, Busan, Korea (the Republic of)
    12. 12Department of Neurosurgery, Yeungnam University Medical Center, Daegu, Korea (the Republic of)
    13. 13Department of Neurosurgery, Incheon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea (the Republic of)
    14. 14Department of Neurosurgery, Dong-A University Hospital, Busan, Korea (the Republic of)
    15. 15Department of Neurosurgery, The Catholic University of Korea, Uijeongbu St. Mary's Hospital, Uijeongbu, Gyeonggi, Korea (the Republic of)
    16. 16Department of Neurosurgery, Soonchunhyang University, Bucheon Hospital, Bucheon, Gyeonggi, Korea (the Republic of)
    17. 17Department of Neurosurgery, Dongeui Medical Center, Busan, Korea (the Republic of)
    18. 18Department of Neurosurgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Gangwon, Korea (the Republic of)
    19. 19Department of Neurosurgery, Daejeon Eulji University Hospital, Daejeon, Korea (the Republic of)
    20. 20Department of Neurosurgery, Pusan National University Hospital, Busan, Korea (the Republic of)
    21. 21Department of Neurosurgery, CHA Bundang Medical Center, CHA University School of Medine, Seongnam, Gyeonggi, Korea (the Republic of)
    22. 22Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Chungnam, Korea (the Republic of)
    23. 23Department of Neurosurgery, Hallym University Gangdong Sacred Heart hospital, Seoul, Korea (the Republic of)
    24. 24Department of Neurosurgery, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Gyeongnam, Korea (the Republic of)
    25. 25Department of Neurosurgery, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Gyeonggi, Korea (the Republic of)
    26. 26Department of Neurosurgery, Pohang SM Christianity Hospital, Pohang, Gyeongbuk, Korea (the Republic of)
    27. 27Department of Neurosurgery, Inje University Ilsan Paik Hospital, Goyang, Gyeonggi, Korea (the Republic of)
    28. 28Department of Neurosurgery, The Catholic University of Korea, St. Vincent’s Hospital, Suwon, Gyeonggi, Korea (the Republic of)
    29. 29National Evidence-based Healthcare Collaborating Agency, Seoul, Korea (the Republic of)
    1. Correspondence to Dr Gyojun Hwang, Department of Neurosurgery, Bundang Jesaeng General Hospital, Daejin Medical Center, Seongnam, Gyeonggi, Korea (the Republic of); hwang.gyojun.md{at}gmail.com

    Abstract

    Background Antiplatelet therapy, where regimens are tailored based on platelet function testing, has been introduced into neurointerventional surgery. This nationwide registry study evaluated the effect and safety of tailored antiplatelet therapy in stent assisted coiling for unruptured aneurysms compared with conventional therapy using a standard regimen.

    Methods This study enrolled 1686 patients in 44 participating centers who received stent assisted coiling for unruptured aneurysms between January 1, 2019 and December 31, 2019. The standard regimen (aspirin and clopidogrel) was used for all patients in the conventional group (924, 19 centers). The regimen was selected based on platelet function testing (standard regimen for clopidogrel responders; adding cilostazol or replacing clopidogrel with other thienopyridines (ticlopidine, prasugrel, or ticagrelor) for clopidogrel non-responders) in the tailored group (762, 25 centers). The primary outcome was thromboembolic events. Secondary outcomes were bleeding and poor outcomes (increase in modified Rankin Scale score). Outcomes within 30 days after coiling were compared using logistic regression analysis.

    Results The thromboembolic event rate was lower in the tailored group than in the conventional group (30/762 (3.9%) vs 63/924 (6.8%), adjusted OR 0.560, 95% CI 0.359 to 0.875, P=0.001). The bleeding event rate was not different between the study groups (62/762 (8.1%) vs 73/924 (7.9%), adjusted OR 0.790, 95% CI 0.469 to 1.331, P=0.376). Poor outcomes were less frequent in the tailored group (12/762 (1.6%) vs 34 (3.7%), adjusted OR 0.252, 95% CI 0.112 to 0.568, P=0.001).

    Conclusion Tailored antiplatelet therapy in stent assisted coiling for unruptured aneurysms reduced thromboembolic events and poor outcomes without increasing bleeding.

    • Aneurysm
    • Stent

    Data availability statement

    Data are available upon reasonable request. Permission from National Evidence based healthcare Collaborating Agency and Korean NeuroEndovascular Society is required.

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    Data availability statement

    Data are available upon reasonable request. Permission from National Evidence based healthcare Collaborating Agency and Korean NeuroEndovascular Society is required.

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    Footnotes

    • Collaborators KoNES registry investigators: Jun Hyong Ahn, MD, PhD (Department of Neurosurgery, Kangwon National University Hosiptal, School of Medicine, Kangwon National University, Chuncheon); Jun Soo Byun, MD, PhD (Department of Radiology, Seoul Medical Center, Seoul); Chul Hoon Chang, MD (Department of Neurosurgery, Yeungnam University Medical Center, Daegu); In Bok Chang, MD, PhD (Department of Neurosurgery, Hallym University Sacred Heart Hospital, Anyang); Sehun Chang, MD, PhD (Department of Neurosurgery, Daejeon Eulji University Hospital, Daejeon); Jae-Hoon Cho, MD (Department of Neurosurgery, Pohang SM Christianity Hospital, Pohang); Dae Han Choi, MD (Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, Incheon); Jae Hyung Choi, MD, PhD (Department of Neurosurgery, Dong-A University Hospital, Busan); Joonho Chung, MD, PhD (Department of Neurosurgery, Yonsei University Gangnam Severance Hospital, Seoul); Seung Young Chung, MD, PhD (Department of Neurosurgery, Daejeon Eulji University Hospital, Daejeon); Chae-Wook Huh, MD (Department of Neurosurgery, Dongeui Medical Center, Busan); Gyojun Hwang, MD, PhD (Department of Neurosurgery, Bundang Jesaeng General Hospital, Daejin Medical Center, Seongnam); Sung-Kyun Hwang, MD, PhD (Department of Neurosurgery, College of Medicine, Ewha Womans University, Mokdong Hospital, Seoul); Dong-Kyu Jang, MD, PhD, MPH (Department of Neurosurgery, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Incheon); Jin Young Jang, MSN (Department of Neurosurgery, CHA University School of Medicine, Bundang CHA Medical Center, Seongnam); Youngjin Jung, MD (Department of Neurosurgery, Yeungnam University Medical Center, Daegu); Dong-Hun Kang, MD, PhD (Department of Neurosurgery, Kyungpook National University Hospital, Daegu); Bum-Tae Kim, MD, PhD (Department of Neurosurgery, Soonchunhyang University Hospital, Bucheon); Chang Hyeun Kim, MD (Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan); Chang-Hyun Kim, MD (Department of Neurosurgery, Keimyung Universtity Dongsan Medical Center, Daegu); Dae Won Kim, MD, PhD (Department of Neurosurgery, Wonkwang University Hospital, Iksan); Jae Hoon Kim, MD, PhD (Department of Neurosurgery, Nowon Eulji Medical Center, Eulji University, Seoul); Jonghoon Kim, MD, PhD (Department of Neurosurgery, Yeungnam University Medical Center, Daegu); Mi-Kyung Kim, MD (Department of Neurosurgery, Myongji St Mary’s Hospital, Seoul); Seong-Rim Kim, MD, PhD (Department of Neurosurgery, The Catholic University of Korea Bucheon St Mary’s Hospital, Bucheon); So Yeon Kim, MD (Department of Neurosurgery, International St Mary’s Hospital, Catholic Kwandong University, Incheon); Soo Hee Kim, MD (Department of Neurosurgery, Busan Medical Center, Busan); Sung-Tae Kim, MD (Department of Neurosurgery, Inje University Busan Paik Hospital, Busan); Tae Gon Kim, MD, PhD (Department of Neurosurgery, CHA University School of Medicine, Bundang CHA Medical Center, Seongnam); Young Woo Kim, MD, PhD (Department of Neurosurgery, The Catholic University of Korea, Uijeongbu St Mary’s Hospital, Uijeongbu); Junkyeung Ko, MD, PhD (Department of Neurosurgery, Pusan National University Hospital, Busan); Jun Seok Koh, MD, PhD (Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Seoul); Hae-Won Koo, MD (Department of Neurosurgery, Inje University Ilsan Paik Hospital, Goyang); Hyon-Jo Kwon, MD, PhD (Department of Neurosurgery, Regional Cerebrovascular Center, Chungnam National University Hospital, Daejeon); Soon Chan Kwon, MD, PhD (Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan); Chang-Young Lee, MD (Department of Neurosurgery, Keimyung Universtity Dongsan Medical Center, Daegu); Hyung Jin Lee, MD, PhD (Department of Neurosurgery, Catholic University of Korea, Daejeon St Mary’s Hospital, Daejeon); Jong Young Lee, MD, PhD (Department of Neurosurgery, Kangdong Sacred Heart Hospital, Seoul); Sang-Weon Lee, MD, PhD (Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan); Seung Jin Lee, MD (Department of Neurosurgery, Kangwon National University Hosiptal, School of Medicine, Kangwon National University, Chuncheon); Yong Cheol Lim, MD (Department of Neurosurgery, Ajou University School of Medicine, Suwon); Young Seo Lee, MD (Department of Neurosurgery, Good Gang-An Hospital, Busan); Young-Sup Lee, MD (Department of Neurosurgery, Daugu Goodmoring Hospital, Daegu); Taek-Kyun Nam, MD, PhD (Department of Neurosurgery, Chung-Ang University Hospital, Seoul); Jae Sang Oh, MD, PhD (Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan); Hyun Park, MD (Department of Neurosurgery, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju); In Sung Park, MD, PhD (Department of Neurosurgery, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju); Jung Cheol Park, MD, PhD (Department of Neurosurgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul); Jung Hyun Park, MD (Department of Neurosurgery, Hallym University Dongtan Sacred Heart Hospital, Hwaseong); Sang Kyu Park, MD, PhD (Department of Neurosurgery, Yonsei University Gangnam Severance Hospital, Seoul); Sukh Que Park, MD, PhD (Department of Neurosurgery, Soonchunhyang University Hospital, Seoul); Yung Ki Park, MD (Department of Neurosurgery, Uijeongbu Eulji Medical Center, Eulji University, Uijeongbu); Won-Bae Seung, MD, PhD (Department of Neurosurgery, SMG Yeonse Hospital, Changwon); Jae Hyun Shim, MD (Department of Neurosurgery, Park Medical Center, Pyeongtaek); Byoung Gook Shin, MD (Department of Neurosurgery, Dongeui Medical Center, Busan); Hee Sup Shin, MD, PhD (Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Seoul); Wonsoo Son, MD (Department of Neurosurgery, Kyungpook National University Hospital, Daegu); Jae Hoon Sung, MD, PhD (Department of Neurosurgery, The Catholic University of Korea, St Vincent’s Hospital, Suwon); Yusam Won, MD, PhD (Department of Neurosurgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul); Na Rae Yang, MD, PhD (Department of Neurosurgery, College of Medicine, Ewha Womans University, Mokdong Hospital, Seoul); Ho Jun Yi, MD (Department of Neurosurgery, Soonchunhyang University Hospital, Bucheon); Seok-Mann Yoon, MD, PhD (Department of Neurosurgery, Soonchunhyang University, Cheonan Hospital, Cheonan); Seung Hoon You, MD, PhD (Department of Neurosurgery, University of Ulsan College of Medicine, Gangneung Asan Hospital, Gangneung). Outcome adjudication committee: Sook Young Sim, MD, PhD (Department of Neurosurgery, Inje University Ilsan Paik Hospital, Goyang); Keun Young Park, MD, PhD (Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul); Hong Jun Jeon, MD, PhD (Department of Neurosurgery, Kangdong Sacred Heart Hospital, Seoul); Wonki Yoon, MD, PhD (Department of Neurosurgery, Korea University Guro Hospital, Seoul); and Il Young Shin, MD, PhD (Department of Neurosurgery, Hallym University Dongtan Sacred Heart Hospital, Hwaseong).

    • Contributors Guarantors of integrity of entire study: JSK and GH. Study concept and design: GH, JC, S-MY, and B-TK. Data acquisition: all authors. Data analysis: GH, JR, and HGS. Data interpretation: all authors. Drafting manuscript: JSK and GH. Revising manuscript for important intellectual content: all authors. Final approval of the version to be published: all authors. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: all authors.

    • Funding This study was supported by the National Evidence based Healthcare Collaborating Agency (NECA), Republic of Korea (grant No NA19-003/NA20-004).

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.