Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA.
Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA.
World Neurosurg. 2022 Nov;167:e303-e309. doi: 10.1016/j.wneu.2022.08.002. Epub 2022 Aug 7.
Flow diversion of intracranial aneurysms with the pipeline embolization device (PED) may produce angiographically apparent stenosis within the PED, which can lead to secondary ischemic complications. In-stent stenosis can be treated medically with dual antiplatelet therapy (DAPT), but the safety and efficacy of this approach are unknown. In this work, we review the safety and efficacy of DAPT to prevent progression of in-stent stenosis or development of cerebral ischemia.
Clinical and angiographic data from eligible patients were assessed from a prospectively maintained neurointerventional database. Details surrounding in-stent stenosis and DAPT were extracted. Patients were included in this study if in-stent stenosis was detected at any angiographic follow-up and managed with DAPT. The primary efficacy endpoint was lack of angiographic progression of in-stent stenosis or new ipsilateral infarct following initiation of medical therapy.
In total, 23 PED constructs developed in-stent stenosis and were managed with DAPT. Follow-up angiography was available for 19 constructs. Eighty-nine percent (17/19) of PED constructs achieved the primary endpoint of lack of stenosis progression and lack of new ipsilateral ischemic events. Of the 2 PED constructs that failed to achieve the primary endpoint of this study, one demonstrated worsening of in-stent stenosis from 55% to 76% over 16 months, while the other developed ipsilateral ischemic stroke 4 months after detection of in-stent stenosis. In addition, one patient experienced intracranial hemorrhage 9 months after the initiation of DAPT.
Progression of in-stent stenosis and new ipsilateral ischemic events are limited in the presence of DAPT. However, hemorrhagic events related to DAPT may occasionally occur.
颅内动脉瘤血流导向装置（PED）的分流可能会导致 PED 内出现血管造影明显狭窄，从而导致继发性缺血性并发症。支架内狭窄可以用双联抗血小板治疗（DAPT）进行内科治疗，但这种方法的安全性和疗效尚不清楚。在这项工作中，我们回顾了 DAPT 预防支架内狭窄进展或脑缺血发展的安全性和疗效。
从一个前瞻性维护的神经介入数据库评估了符合条件的患者的临床和血管造影数据。提取了支架内狭窄和 DAPT 的详细信息。如果在任何血管造影随访中发现支架内狭窄并采用 DAPT 治疗，患者将被纳入本研究。主要疗效终点是在开始药物治疗后，支架内狭窄无血管造影进展或同侧新梗死。
共 23 个 PED 支架发生支架内狭窄，并采用 DAPT 治疗。19 个支架可进行随访血管造影。89%（17/19）的 PED 支架达到了主要终点，即无狭窄进展和同侧新缺血事件。在本研究未能达到主要终点的 2 个 PED 支架中，1 个支架内狭窄从 55%恶化至 76%，历时 16 个月，另 1 个支架在发现支架内狭窄后 4 个月发生同侧缺血性卒中。此外，1 例患者在开始 DAPT 后 9 个月发生颅内出血。
在 DAPT 存在的情况下，支架内狭窄进展和同侧新缺血事件是有限的。然而，与 DAPT 相关的出血事件偶尔也会发生。
