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  • Procedural complexity independent of P2Y12 reaction unit (PRU) values is associated with acute in situ thrombosis in Pipeline flow diversion of cerebral aneurysms

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Original article
Procedural complexity independent of P2Y12 reaction unit (PRU) values is associated with acute in situ thrombosis in Pipeline flow diversion of cerebral aneurysms
  1. Bowen Jiang1,
  2. Matthew T Bender1,
  3. Erick M Westbroek1,
  4. Jessica K Campos1,
  5. Li-Mei Lin2,
  6. Risheng Xu1,
  7. Rafael J Tamargo1,
  8. Judy Huang1,
  9. Geoffrey P Colby3,
  10. Alexander L Coon1
  1. 1 Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
  2. 2 Department of Neurosurgery, University of California, Irvine School of Medicine, Orange, California, USA
  3. 3 Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA
  1. Correspondence to Dr Alexander L Coon; acoon2{at}jhmi.edu

Abstract

Background Acute in situ thrombosis is an ischaemic phenomenon during Pipeline embolisation device (PED) procedures with potentially high morbidity and mortality. There is controversy regarding the role of platelet function testing with P2Y12 assay as a predictor of intraprocedural thromboembolic events. There is limited knowledge on whether procedural complexity influences these events.

Methods Data were collected retrospectively on 742 consecutive PED cases at a single institution. Patients with intraprocedural acute thrombosis were compared with patients without these events.

Results A cohort of 37 PED cases with acute in situ thrombosis (mean age 53.8 years, mean aneurysm size 8.4 mm) was matched with a cohort of 705 PED cases without intraprocedural thromboembolic events (mean age 56.4 years, mean aneurysm size 6.9 mm). All patients with in situ thrombosis received intra-arterial and/or intravenous abciximab. The two groups were evenly matched in patient demographics, previous treatment/subarachnoid hemorrhage (SAH) and aneurysm location. There was no statistical difference in postprocedural P2Y12 reaction unit (PRU) values between the two groups, with a mean of 156 in the in situ thrombosis group vs 148 in the control group (p=0.5894). Presence of cervical carotid tortuosity, high cavernous internal carotid artery grade, need for multiple PED and vasospasm were not significantly different between the two groups. The in situ thrombosis group had statistically significant longer fluoroscopy time (60.4 vs 38.4 min, p<0.0001), higher radiation exposure (3476 vs 2160 mGy, p<0.0001), higher rates of adjunctive coiling (24.3% vs 8.37%, p=0.0010) and higher utilisation of balloon angioplasty (37.8% vs 12.2%, p<0.0001). Clinically, the in situ thrombosis cohort had higher incidence of major and minor stroke, intracerebral haemorrhage and length of stay.

Conclusions Predictors of procedural complexity (higher radiation exposure, longer fluoroscopy time, adjunctive coiling and need for balloon angioplasty) are associated with acute thrombotic events during PED placement, independent of PRU values.

  • aneurysm
  • endovascular
  • flow diversion
  • pipeline embolization device
  • abciximab

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/svn-2018-000150

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    Footnotes

    • Contributors BJ, GPC, L-ML, MTB, EMW and JKC drafted the manuscript and critically revised the manuscript for important intellectual content. MTB, JKC, RX and BJ assisted with the data collection and analysis. GPC and ALC performed treatment procedures and assisted in critically revising the manuscript. ALC, JH and RJT crucially reviewed the important intellectual content of the manuscript. ALC performed treatment procedures and critically revised the important intellectual content. All authors read and approved the final manuscript.

    • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests ALC is a proctor for the Woven EndoBridge (WEB) device (Sequent Medical, Aliso Viejo, California), a proctor for the Surpass device (Stryker Neurovascular, Fremont, California) and a consultant for Stryker Neurovascular, a proctor for the Pipeline embolisation device (Medtronic Neurovascular, Irvine, California) and a consultant for Medtronic, and a proctor for the FRED device (MicroVention, Tustin, California) and a consultant for MicroVention. GPC is a proctor for the Pipeline embolisation device and consultant for Stryker Neurovascular. L-ML is a proctor for the Pipeline embolisation device (Medtronic Neurovascular, Irvine, California), a consultant for MicroVention and participates in clinical trial for Stryker.

    • Patient consent Not required.

    • Ethics approval Hopkins IRB.

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

    • Data sharing statement There are no additional unpublished data from this study.