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Clinical neurology
ORIGINAL RESEARCH
Heterogeneous practice patterns regarding antiplatelet medications for neuroendovascular stenting in the USA: a multicenter survey Ryan W F Faught,1 Sudhakar R Satti,2 Robert W Hurst,3 Bryan A Pukenas,3 Michelle Janine Smith1 ▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/ neurintsurg-2013-010954). 1
Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA 2 Department of Neurointerventional Surgery, Christiana Care Health System, Wilmington, Delaware, USA 3 Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA Correspondence to Dr M J Smith, Department of Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce St, 3rd Floor Silverstein, Philadelphia, PA 19104, USA; michelle.j.smith@ uphs.upenn.edu Received 13 September 2013 Accepted 2 December 2013 Published Online First 3 January 2014
ABSTRACT Background Adequate dual antiplatelet (AP) therapy is imperative when performing neurovascular stenting procedures. Currently, no consensus for the ideal AP regimen exists. Thus the present study aimed to gain a better understanding of real world practice AP patterns by surveying neurointerventional surgeons. Methods Survey links were emailed to 296 neurointerventional surgeons practicing in the USA, asking 51 questions including demographics, stent specific use, AP pre and post-medication, types of APs, point of care (POC) assessment, complications, and outcomes. Data were collected and analyzed using Research Electronic Data Capture (REDCap). Results 74 participants responded; 56.8% were from academic centers. Participants treated an average of 5.5 aneurysms per month. They placed an average of 1.6 intracranial stents and 1.4 cervical stents per month. Mean number of pipeline embolization devices (PEDs) placed per year was 15.2. Heterogeneity existed regarding AP regimens; the most frequent included acetylsalicylic acid (ASA) 325 mg+Plavix 75 mg daily (for 7 days prior) and ASA 325 mg+Plavix 75 mg daily (for 5 days prior) for routine placement of intracranial and cervical stents, respectively. For emergency placement, ASA 325 mg+Plavix 600 mg (at time of surgery) was the most frequently used. 46.8% routinely used POC testing, most frequently VerifyNow (Accumetrics, San Diego, California, USA); the most common threshold determining a non-responder was 80% of the time) to prevent or treat thrombotic complications are listed in table 2. The three most commonly used medications were clopidogrel (93.8%), aspirin 325 mg (81.5%), and aspirin 81 mg (32.3%). Regarding the practice of premedication with AP agents prior to routine placement of a cervical or intracranial stent, the most common regimen was acetylsalicylic acid (ASA) 325 mg+Plavix 75 mg daily (for 7 days prior) (36.5%) and ASA 325 mg+Plavix 75 mg daily (for 5 days prior) (40%), respectively. For emergency placement of both cervical and intracranial stents, the most common practice was ASA 325 mg+Plavix 600 mg (at time of surgery) (64.1% and 50%, respectively) (figure 2). There were multiple other regimens reported, which are described in supplementary appendix B (available online). Maintenance AP medication regimens after placement of cerebrovascular stents are depicted in figure 3. The most common practices for cervical and intracranial stents were ‘other’ and ASA 325 mg daily for life+Plavix 75 mg daily for 3 months, respectively. The other regimens reported by participants are listed in supplementary appendix C (available online). When stopping an AP agent, nine (13.8%) of the respondents tapered the medication prior to discontinuing.
Point of care testing for platelet reactivity—frequency, thresholds, and management changes Regarding the use of POC testing for platelet reactivity, 47 (72.3%) participants responded ‘yes’ to the question, “Does your department use POC platelet aggregation assays such as VerifyNow or P2Y12 to determine the minimal AP dose to achieve inhibition or resistance to a particular AP agent?”, 16 (24.6%) responded ‘no’ and two (3.1%) responded ‘I don’t know’. Of those who responded ‘yes’, additional information pertaining to type and frequency of POC assessment was ascertained (table 3). The most common type of POC test utilized
Table 1
Cerebrovascular stents used per institution
Cerebrovascular stent
No (%)
Neuroform EZ (Stryker) Wingspan stent system (Stryker) Enterprise (Cordis) Pipeline embolization device (eV3/Covidien) RX ACCULINK (Abbott) PRECISE PRO RX (Cordis) Other Xact Carotid Stent (Abbott) (n=5) ‘Ev3, BS coronary’ (n=1) MULTI-LINK MINI VISION coronary stent (Abbott) (n=1) XIENCE V Everolimus eluting coronary stent (Abbott) (n=1) ‘Drug eluding coronary stents’ and Protege RX carotid stent (eV3/ Covidien) (n=1)
67 58 58 62 48 43 9
Faught RWF, et al. J NeuroIntervent Surg 2014;6:774–779. doi:10.1136/neurintsurg-2013-010954
(94.4) (81.7) (81.7) (87.3) (67.6) (60.6) (12.7)
775
Downloaded from http://jnis.bmj.com/ on June 7, 2015 - Published by group.bmj.com
Clinical neurology Table 2 Antiplatelet medications used to prevent or treat thrombotic complications in cerebrovascular stent patients Medication Clopidogrel (Plavix) Aspirin 325 mg (Ecotrin) Aspirin 81 mg (Ecotrin) Abciximab (ReoPro) Eptifibatide (Integrilin) Prasugrel (Effient) Tirofiban (Aggrastat) Ticlopidine (Ticlid) Dipyridamole (Persantine) Other* Ibuprofen (Advil) *Other
Routinely used (No (%))
Ever used (No (%))
61 (93.8) 53 (81.5) 21 (32.3) 14 (21.9) 8 (12.5) 7 (10.8) 4 (6.2) 2 (3.1) 2 (3.1)
62 (95.4) 59 (90.8) 50 (76.9) 54 (83.1) 28 (43.1) 30 (46.2) 12 (18.5) 35 (53.8) 14 (21.5)
2 (3.1) 0 (0.0) Ticagrelor (Brilinta) (n=1) Heparin (Heparin) (n=1)
7 (10.8) 5 (7.7) Ticagrelor (Brilinta) (n=3) Pletal (Cilostazol) (n=2) Heparin (Heparin) (n=1) Aspirin/dipyridamole (Aggrenox) (n=1)
Figure 3 Percentage of respondents who utilized a particular antiplatelet regimen after placement of cervical or intracranial stents. ASA, acetylsalicylic acid.
was the VerifyNow P2Y12 Assay (Accumetrics, San Diego, California, USA) (36, 76.6%), and the most common threshold for determining a non-responder was 220 (n=1). PRU, P2Y12 reaction unit.
agents, such as abciximab. These ‘rescue’ AP medication protocols have been associated with increased hemorrhage rates.15 Furthermore, multiple studies have demonstrated increased complication and hemorrhage rates when placing intracranial stents in patients with acute subarachnoid hemorrhage.6 16 17 The present survey results emphasize the need to focus on determining the safest and most effective AP regimens for intracranial and emergency stenting procedures. Standard practices regarding AP medications for stenting are better defined in the cardiac literature, and most stem from type B level of evidence. The 2011 guidelines from the American College of Cardiology Foundation/American Heart Association/ Society for Cardiovascular Angiography and Interventions for percutaneous coronary intervention describe recommendations for dual AP medication surrounding the placement of coronary stents. Loading patients with ASA and a P2Y12 inhibitor such as clopidogrel, prasugrel (in patients without a stroke and
Clinical neurology
ORIGINAL RESEARCH
Heterogeneous practice patterns regarding antiplatelet medications for neuroendovascular stenting in the USA: a multicenter survey Ryan W F Faught,1 Sudhakar R Satti,2 Robert W Hurst,3 Bryan A Pukenas,3 Michelle Janine Smith1 ▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/ neurintsurg-2013-010954). 1
Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA 2 Department of Neurointerventional Surgery, Christiana Care Health System, Wilmington, Delaware, USA 3 Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA Correspondence to Dr M J Smith, Department of Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce St, 3rd Floor Silverstein, Philadelphia, PA 19104, USA; michelle.j.smith@ uphs.upenn.edu Received 13 September 2013 Accepted 2 December 2013 Published Online First 3 January 2014
ABSTRACT Background Adequate dual antiplatelet (AP) therapy is imperative when performing neurovascular stenting procedures. Currently, no consensus for the ideal AP regimen exists. Thus the present study aimed to gain a better understanding of real world practice AP patterns by surveying neurointerventional surgeons. Methods Survey links were emailed to 296 neurointerventional surgeons practicing in the USA, asking 51 questions including demographics, stent specific use, AP pre and post-medication, types of APs, point of care (POC) assessment, complications, and outcomes. Data were collected and analyzed using Research Electronic Data Capture (REDCap). Results 74 participants responded; 56.8% were from academic centers. Participants treated an average of 5.5 aneurysms per month. They placed an average of 1.6 intracranial stents and 1.4 cervical stents per month. Mean number of pipeline embolization devices (PEDs) placed per year was 15.2. Heterogeneity existed regarding AP regimens; the most frequent included acetylsalicylic acid (ASA) 325 mg+Plavix 75 mg daily (for 7 days prior) and ASA 325 mg+Plavix 75 mg daily (for 5 days prior) for routine placement of intracranial and cervical stents, respectively. For emergency placement, ASA 325 mg+Plavix 600 mg (at time of surgery) was the most frequently used. 46.8% routinely used POC testing, most frequently VerifyNow (Accumetrics, San Diego, California, USA); the most common threshold determining a non-responder was 80% of the time) to prevent or treat thrombotic complications are listed in table 2. The three most commonly used medications were clopidogrel (93.8%), aspirin 325 mg (81.5%), and aspirin 81 mg (32.3%). Regarding the practice of premedication with AP agents prior to routine placement of a cervical or intracranial stent, the most common regimen was acetylsalicylic acid (ASA) 325 mg+Plavix 75 mg daily (for 7 days prior) (36.5%) and ASA 325 mg+Plavix 75 mg daily (for 5 days prior) (40%), respectively. For emergency placement of both cervical and intracranial stents, the most common practice was ASA 325 mg+Plavix 600 mg (at time of surgery) (64.1% and 50%, respectively) (figure 2). There were multiple other regimens reported, which are described in supplementary appendix B (available online). Maintenance AP medication regimens after placement of cerebrovascular stents are depicted in figure 3. The most common practices for cervical and intracranial stents were ‘other’ and ASA 325 mg daily for life+Plavix 75 mg daily for 3 months, respectively. The other regimens reported by participants are listed in supplementary appendix C (available online). When stopping an AP agent, nine (13.8%) of the respondents tapered the medication prior to discontinuing.
Point of care testing for platelet reactivity—frequency, thresholds, and management changes Regarding the use of POC testing for platelet reactivity, 47 (72.3%) participants responded ‘yes’ to the question, “Does your department use POC platelet aggregation assays such as VerifyNow or P2Y12 to determine the minimal AP dose to achieve inhibition or resistance to a particular AP agent?”, 16 (24.6%) responded ‘no’ and two (3.1%) responded ‘I don’t know’. Of those who responded ‘yes’, additional information pertaining to type and frequency of POC assessment was ascertained (table 3). The most common type of POC test utilized
Table 1
Cerebrovascular stents used per institution
Cerebrovascular stent
No (%)
Neuroform EZ (Stryker) Wingspan stent system (Stryker) Enterprise (Cordis) Pipeline embolization device (eV3/Covidien) RX ACCULINK (Abbott) PRECISE PRO RX (Cordis) Other Xact Carotid Stent (Abbott) (n=5) ‘Ev3, BS coronary’ (n=1) MULTI-LINK MINI VISION coronary stent (Abbott) (n=1) XIENCE V Everolimus eluting coronary stent (Abbott) (n=1) ‘Drug eluding coronary stents’ and Protege RX carotid stent (eV3/ Covidien) (n=1)
67 58 58 62 48 43 9
Faught RWF, et al. J NeuroIntervent Surg 2014;6:774–779. doi:10.1136/neurintsurg-2013-010954
(94.4) (81.7) (81.7) (87.3) (67.6) (60.6) (12.7)
775
Downloaded from http://jnis.bmj.com/ on June 7, 2015 - Published by group.bmj.com
Clinical neurology Table 2 Antiplatelet medications used to prevent or treat thrombotic complications in cerebrovascular stent patients Medication Clopidogrel (Plavix) Aspirin 325 mg (Ecotrin) Aspirin 81 mg (Ecotrin) Abciximab (ReoPro) Eptifibatide (Integrilin) Prasugrel (Effient) Tirofiban (Aggrastat) Ticlopidine (Ticlid) Dipyridamole (Persantine) Other* Ibuprofen (Advil) *Other
Routinely used (No (%))
Ever used (No (%))
61 (93.8) 53 (81.5) 21 (32.3) 14 (21.9) 8 (12.5) 7 (10.8) 4 (6.2) 2 (3.1) 2 (3.1)
62 (95.4) 59 (90.8) 50 (76.9) 54 (83.1) 28 (43.1) 30 (46.2) 12 (18.5) 35 (53.8) 14 (21.5)
2 (3.1) 0 (0.0) Ticagrelor (Brilinta) (n=1) Heparin (Heparin) (n=1)
7 (10.8) 5 (7.7) Ticagrelor (Brilinta) (n=3) Pletal (Cilostazol) (n=2) Heparin (Heparin) (n=1) Aspirin/dipyridamole (Aggrenox) (n=1)
Figure 3 Percentage of respondents who utilized a particular antiplatelet regimen after placement of cervical or intracranial stents. ASA, acetylsalicylic acid.
was the VerifyNow P2Y12 Assay (Accumetrics, San Diego, California, USA) (36, 76.6%), and the most common threshold for determining a non-responder was 220 (n=1). PRU, P2Y12 reaction unit.
agents, such as abciximab. These ‘rescue’ AP medication protocols have been associated with increased hemorrhage rates.15 Furthermore, multiple studies have demonstrated increased complication and hemorrhage rates when placing intracranial stents in patients with acute subarachnoid hemorrhage.6 16 17 The present survey results emphasize the need to focus on determining the safest and most effective AP regimens for intracranial and emergency stenting procedures. Standard practices regarding AP medications for stenting are better defined in the cardiac literature, and most stem from type B level of evidence. The 2011 guidelines from the American College of Cardiology Foundation/American Heart Association/ Society for Cardiovascular Angiography and Interventions for percutaneous coronary intervention describe recommendations for dual AP medication surrounding the placement of coronary stents. Loading patients with ASA and a P2Y12 inhibitor such as clopidogrel, prasugrel (in patients without a stroke and
