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Hemorrhagic stroke
Original research
Impact of duration of dual anti-platelet therapy on risk of complications after stent-assisted coiling of unruptured aneurysms
  1. Andrew J Ringer1,
  2. Ricardo A Hanel2,
  3. Ammad A Baig3,
  4. Adnan H Siddiqui4,5,
  5. Demetrius Klee Lopes6,
  6. Guilherme Barros7,
  7. David I Bass7,
  8. Michael R Levitt7,
  9. Christopher C Young7,
  10. Ryan M Naylor8,
  11. Giuseppe Lanzino8,
  12. R Webster Crowley9,
  13. Joseph C Serrone10,
  14. Peter T Kan11,
  15. Mandy J Binning12,
  16. Erol Veznedaroglu12,
  17. Alan Boulos13,
  18. Rabih Tawk14
  19. Endovascular Neurosurgery Research Group (ENRG)
    1. 1Mayfield Clinic, Cincinnati, Ohio, USA
    2. 2Department of Neurosurgery, Lyerly Neurosurgery, Baptist Health, Jacksonville, FL, USA
    3. 3Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
    4. 4Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
    5. 5Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
    6. 6Brain and Spine Institute, Advocate Aurora Health, Park Ridge, Illinois, USA
    7. 7Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
    8. 8Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
    9. 9Neurosurgery, Rush University, Chicago, Illinois, USA
    10. 10Department of Neurological Surgery, Loyola University, Maywood, IL, USA
    11. 11Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
    12. 12Global Neuroscience Institute, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
    13. 13Department of Neurosurgery, Albany Medical Center, Albany, New York, USA
    14. 14Neurosurgery, Mayo Clinic Hospital Jacksonville, Jacksonville, Florida, USA
    1. Correspondence to Dr Andrew J Ringer; editor{at}mayfieldclinic.com

    Abstract

    Background The optimal duration for dual antiplatelet therapy (DAPT) after stent-assisted coiling (SAC) of intracranial aneurysms is unclear. Longer-term therapy may reduce thrombotic complications but increase the risk of bleeding complications.

    Methods A retrospective review of prospectively maintained data at 12 institutions was conducted on patients with unruptured intracranial aneurysms who underwent SAC between January 1, 2016 and December 31, 2020, and were followed ≥6 months postprocedure. The type and duration of DAPT, stent(s) used, outcome, length of follow-up, complication rates, and incidence of significant in-stent stenosis (ISS) were collected.

    Results Of 556 patients reviewed, 450 met all inclusion criteria. Nine patients treated with DAPT <29 days after SAC and 11 treated for 43–89 days were excluded from the final analysis as none completed their prescribed duration of treatment. Eighty patients received short-term DAPT. There were no significant differences in the rate of thrombotic complications during predefined periods of risk in the short, medium, or long-term treatment groups (1/80, 1.3%; 2/188, 1.1%; and 0/162, 0%, respectively). Similarly, no differences were found in the rate of hemorrhagic complications during period of risk in any group (0/80, 0%; 3/188, 1.6%; and 1/162, 0.6%, respectively). Longer duration DAPT did not reduce ISS risk in any group.

    Conclusions Continuing DAPT >42 days after SAC did not reduce the risk of thrombotic complications or in-stent stenosis, although the risk of additional hemorrhagic complications remained low. It may be reasonable to discontinue DAPT after 42 days following non-flow diverting SAC of unruptured intracranial aneurysms.

    • Aneurysm
    • Stent
    • Coil
    • Hemorrhage
    • Platelets

    Data availability statement

    Data are available upon reasonable request. Email corresponding author for data request.

    https://doi.org/10.1136/jnis-2024-021977

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      Data availability statement

      Data are available upon reasonable request. Email corresponding author for data request.

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      Footnotes

      • X @@MayfieldChair, @amdbaig, @cure4stroke, @DrMichaelLevitt, @PeterKa80460001, @BrainSurgeon_MD

      • Collaborators Endovascular Neurosurgery Research Group (ENRG) - Andrew J. Ringer, Ricardo A. Hanel, Ammad Baig, Adnan H. Siddiqui, Demetrius Klee Lopes, Guilherme Barros, David I. Bass, Michael R. Levitt, Christopher C. Young, Ryan M. Naylor, Giuseppe Lanzino, R Webster Crowley, Joseph Serrone, Peter T. Kan, Mandy Binning, Erol Veznedaroglu, Alan Boulos, Rabih Tawk

      • Contributors AJR was responsible for study concept, data collection and aggregation, analysis of the data, and drafting of the manuscript. GL, JCS, and MRL revised the manuscript in collaboration with all the listed authors. All others were responsible for data collection of their respective centers and critical review of the manuscript. AJR is the guarantor.

      • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

      • Competing interests RAH received grants from NIH, Microvention, CNX, Interline Endowment, and Stryker, consulting fees from Medtronic, Cerenous, Balt, Rapid Medical, Stryker, Microvention, Phenox, and Q’Apel, is a Board Member of MIVI, Three Rivers Medical Inc, Shape Medical, eLum, and Corindus, and holds stock options from InNeuroCo, Cerebrotech, eLum, Endostream, Three Rivers Medical Inc., Scientia, Rist, BlinkTBI, Corindus, and NTI. DKL is a consultant for Asahi, Stryker, Corindus, Siemens, and Medtronic, received honoraria from Cerenovus, Medtronic, and Stryker, is on the Advisory Board of INFINITY (trial), received grants from Mentice, has a leadership role with WLNC and Advocate Health and holds stock from Syncron, Three Rivers Inc., Q’apel, VIZ.AI, Methinks, Vastrax, Borvo, BendIT, Collavidence, NDI, Prometheus, NextGen, Galaxy, Global Intervention, and Sim&Cure. AHS is a co-investigator for NIH - 1R01EB030092-01, Project Title: High Speed Angiography at 1000 frames per second, mentor for Brain Aneurysm Foundation Carol W. Harvey Chair of Research, Sharon Epperson Chair of Research, Project Title: A Whole Blood RNA Diagnostic for Unruptured Brain Aneurysm: Risk Assessment Prototype Development and Testing, received consulting fees from Amnis Therapeutics, Apellis Pharmaceuticals, Inc., Asahi Intecc Co Ltd, Boston Scientific, Canon Medical Systems USA, Inc., Cardinal Health 200, LLC, Cerebrotech Medical Systems, Inc., Cerenovus, Contego Medical, Cordis, Corindus, Inc., Endostream Medical, Ltd, FreeOx Biotech, SL, Hyperfine Operations, Inc., Imperative Care, InspireMD, Ltd, Integra, IRRAS AB, Medtronic, MicroVention, Minnetronix Neuro, Inc., Peijia Medical, Penumbra, Piraeus Medical, Inc., Q’Apel Medical, Inc., Rapid Medical, Serenity Medical, Inc., Silk Road Medical, Shockwave Medical, Inc., StimMed, LLC, Stryker Neurovascular, Synchron Australia Pty Ltd, VasSol, Vesalio, Viz.ai, Inc., and WL Gore, holds a patent for a clot retrieval system for removing occlusive clot from a blood vessel, holds stock options of Adona Medical, Inc., Bend IT Technologies, Ltd, BlinkTBI, Inc., Borvo Medical, Inc., Cerebrotech Medical Systems, Inc., CerebrovaKP, Code Zero Medical, Inc., Cognition Medical, Collavidence, Inc., Contego Medical, CVAID Ltd, E8, Inc., Endostream Medical, Ltd, FreeOx Biotech, SL, Galaxy Therapeutics, Inc., Hyperion Surgical, Inc., Imperative Care, Inc., InspireMD, Ltd, Instylla, Inc., Launch NY, Inc., Neurolutions, Inc., NeuroRadial Technologies, Inc. (sold to Medtronic in 2021), Neurovascular Diagnostics, Inc., Peijia Medical, PerFlow Medical, Ltd, Piraeus Medical, Inc., Q’Apel Medical, Inc., QAS.ai, Inc., Radical Catheter Technologies, Inc., Rebound Therapeutics Corp. (purchased 2019 by Integra Lifesciences, Corp), Rist Neurovascular, Inc. (purchased 2020 by Medtronic), Sense Diagnostics, Inc., Serenity Medical, Inc., Silk Road Medical, Sim & Cure, Spinnaker Medical, Inc., StimMed, LLC, Synchron, Inc., Tulavi Therapeutics, Inc., Vastrax, LLC, Viseon, Inc., Whisper Medical, Inc., Willow Medtech, Inc. and is on the National PI/Steering Committees of Cerenovus EXCELLENT and ARISE II Trial, the Medtronic SWIFT PRIME, VANTAGE, EMBOLISE and SWIFT DIRECT Trials, the MicroVention FRED Trial & CONFIDENCE Study, the MUSC POSITIVE Trial, the Penumbra 3D Separator Trial, the COMPASS Trial, the INVEST Trial, the MIVI neuroscience EVAQ Trial, the Rapid Medical SUCCESS Trial, and the InspireMD C-GUARDIANS IDE Pivotal Trial. MRL received a grant from Stryker and Medtronic, consulting fees from Medtronic, Metis Innovative, and Aeaean Advisers, is a member of the DSMB for Arsenal Medical and the editorial board of the Journal of NeuroInterventional Surgery, holds stock options from Proprio, Stroke Diagnostics, Stereotaxis, Fluid Biomed, Hyperion Surgical, and Synchron and received gifts/services from Stryker and Medtronic. GL holds stock options from Superior Medical editors and Nested knowledge. RWC received consulting fees from Medtronic and Microvention. PTK received grants from NIH, Siemens research, the Joe Niekro Foundation, and Medtronic research, consulting fees from Stryker Neurovascular, is a member of the editorial board of the Journal of NeuroInterventional Surgery, and holds stock options from Vena Medical, Deinde, Prometheus, Neurofine, and Vented. No other disclosures were reported.

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