The Study On Application Of Tirofiban In Endovascular Treatment Of Ischemic Cerebrovascular Disease

Platelets play a very important role in the pathogenesis of ischemic cerebrovascular disease.Antiplatelet aggregation therapy is the basic measure for the treatment of ischemic cerebrovascular disease.For patients receiving intravascular treatment for ischemic cerebrovascular disease,the incidence of acute thromboembolism events(TE)remains high despite preoperative antiplatelet therapy,such as aspirin and/or clopidogrel,and intraoperative heparinization.GP ? b/? inhibitors(GPI)is a kind of new antiplatelet aggregation drug,it occupies the platelet GP ? b/?a receptor binding sites,preventing platelet and fibrinogen,inhibit the platelet aggregation induced by a variety of ways.In addition,as another important mechanism of GPI,the competitive inhibition of platelet GP ?b/?a receptor leads to the collapse of acute thrombosis Therefore,GPI can also be used as a remedial treatment for acute intraprocedural stent thrombosis(AIST).In the cardiovascular field,there has been a large number of clinical evidence-based medicine evidence that GPI is efficacy and safety in acute coronary syndrome and percutaneous coronary intervention.In recent years,it has been reported for acute thromboembolism complications during endovascular intervention of ruptured and unruptured aneurysms,and satisfactory results have been achieved by intraarterial superselective injection of GPI.Different from the extensive application of GPI in the intervention of coronary artery and cerebral aneurysm,its application in clinical practice of intravascular treatment of ischemic cerebrovascular disease is still relatively insufficient.At present,most of the studies on GPI in the endovascular treatment of ischemic cerebrovascular disease are retrospective case studies about the application of mechanical thrombectomy for acute ischemic stroke.There are still very few studies no the application of GPI in intervention of non-acute symptomatic intracranial atherosclerotic stenosis/occlusion.We reviewed the data of all patients with non-acute symptomatic intracranial atherosclerotic stenosis/occlusion undergoing endovascular intervention in our hospital to assess the safety and efficacy of intraprocedural GPI tirofiban in such patients.Part? Safety and Efficacy of Tirofiban in Rescue Treatment for Acute Intracranial Intraprocedural Stent ThrombosisBackground and PurposeThe incidence of acute intraprocedural stent thrombosis(AIST)during stenting of intracranial atherosclerotic stenosis(ICAS)has seldom been reported and evidence regarding the treatment of AIST is lacking.We aim to investigate the incidence of AIST during stenting of ICAS in our institute,assess the preliminary efficacy and safety of rescue treatment of tirofiban for these patients.MethodsFrom September 2016 to May 2019,all symptomatic ICAS patients who underwent intracranial stenting in our institute were prospectively registered into this study,of which patients with AIST were retrospectively reviewed to extract baseline characteristics,perioperative management,procedural details,angiographic,and clinical outcomes.Rescue treatment of tirofiban for AIST was assessed by recanalization of the culprit vessel and periprocedural death,hemorrhage,and ischemic stroke.ResultsAcute intraprocedural stent thrombosis developed in 12(6.2%)patients within 30 min after stent placement of 194 patientsThe mean age of treated patients was 60.3 ± 8.3,with the majority(9/12;75%)of the patients being male.The average stenosis degree was 86.1 ± 7.1%.The average length and diameter of the stents were 14.5 ± 4.2 and 3.2 ± 0.5 mm.Of these 12 patients with AIST,3 events occurred with basilar artery(BA)stent placement,4 with V4 segment of the vertebral artery(VA)placement,4 with M1 segment of the middle cerebral artery(MCA)placement,and 1 with ophthalmic internal carotid artery(C6)placement.According to different stents,8 events occurred during the implantation of Wingspan stents,2 occurred during the implantation of Apollo stents,2 events occurred during the implantation of Neuroform EZ stents.All 12 cases were successfully recanalized with modified Thrombolysis In Cerebral Infarction(mTICI)3 and Arterial Occlusive Lesion(AOL)3 after rescue treatment of tirofiban alone.There was no perioperative death or any hemorrhagic complication.Three patients suffered perioperative ischemic stroke.ConclusionsWe observed a non-negligible rate of AIST during intracranial stenting procedures for ICAS.Intra-arterial bolus followed by intravenous tirofiban infusion seems to be efficacious and safe for AIST during stent placement for ICAS,without increasing the rate of hemorrhagic complications and death.However,these findings should be interpreted cautiously because of the aforementioned limitations,and prospective multicenter randomized studies with larger patient number will be required to establish the efficacy and safety of tirofiban.Part ? Tailored Strategies to Treat Thromboembolism Event during Endovascular Recanalization of Non-acute Intracerebral Large Artery OcclusionBackground and Purpose Intracranial large artery occlusion(ILAO)or stenosis is one of the main causes of ischemic stroke in China.In China,the incidence of cerebrovascular disease due to ILAO is higher than in Western countries.And,the majority of patients with non-acute ILAO are refractory to medical treatment due to inadequate collateral circulation.Angioplasty and stenting is a potential treatment option for such patients.However,the introprocedural complications,such as thromboembolism events(TE),are not uncommon,which are the biggest challenge for interventional physicians.The management of thromboembolism events(TE)during endovascular recanalization of non-acute intracerebral large artery occlusion(ILAO)is important in minimizing periprocedural morbidity and mortality.We aimed to present our single-center experience and evaluate the safety and efficacy of the tailored strategies what were adopted.MethodsClinical and radiologic records of 69 consecutive patients who underwent endovascular recanalization of non-acute ILAO at our institution during a 1-year period were reviewed.We identified the cases in which TE occurred during the procedure.The angiography images were reviewed,and treatment strategies were summarized and analyzed.Efficacy outcome was assessed by the target vessel recanalization in the cerebral angiography and measured according to modified Thrombolysis In Cerebral Infarction(mTICI)scale and Arterial Occlusive Lesion(AOL)scale.Safety outcomes were evaluated by any type of intracranial hemorrhage,systemic bleeding or death during hospitalizationResultsOf the 69 patients who underwent endovascular recanalization,63 patients achieved successful recanalization(mTICI 2b-3).6 patients failed recanalization in our study:the guidewire could not traverse the occluded segment in 5 patients,and one patient was forced to stop the operation and transferred to intensive care unit because of ventricular fibrillation after general anesthesia.Of the 63 patients with successful recanalization,4 were identified as suffered from TE,3 patiens suffered from acute intraprocedure stent thrombosis(AIST).1 patient suffered distal thromboembolism due to embolism from unstable thrombus in the occluded segment.The overall rate of TE was 6.3%(4 of 63 patients).AIST developed within 20 minutes after stent placement in all 3 patients(from 10 to 18 minutes),the mean time of thrombus formotion was 13.3±4.2 minutes.The grade of AIST was:1 grade 1,2 grade 2.Thrombus disappeared from 10 to 34 minutes after it was detected,the mean time was 13.3±12.1 minutes.1 patient with distal basilar artery(BA)embolization underwent rescue mechanical thrombectomy with a Solitaire stent.Successful recanalization was achieved in 4(100%)patients with mTICI 2b?3 and AOL 3 after different treatment strategies.No thromboemboli-related(or procedure-related)cerebral infarction developed of the 4 patients.No subarachnoid hemorrhage(SAH),systemic bleeding or death were monitored of the perioperative period(7 days after the operative).Intracerebral hemorrhage occurred in one patient with AIST after intervention.ConclusionsCurrently,no single therapy has consistently proven efficacy in management TE during endovascular recanalization of non-acute ILAO.However,extreme caution shoud be taken in view of the high risk of TE and complexity of the interventional procedure.Timely diagnosis and treatment,while tailored to the specific thromboembolism type and patient,is essential for optimal management and outcomes in this challenging patient population.Part? Safety and Efficacy of Prophylactic Tirofiban Infusion for Acute Intracranial Intraprocedural Stent ThrombosisBackground and PurposePeriprocedural antithrombotic management with glycoprotein ? b/?a(Gp ? b/? a)inhibitors for intracranial artery stenting is still controversial.Acute intraprocedural stent thrombosis(AIST)and periprocedural ischemic events are the major concern in stent angioplasty for intracranial atherosclerotic stenosis(ICAS).Currently,the Gp ? b/?a inhibitors(GPI)tirofiban has shown promise in preventing and treating AIST and thromboembolism event.We aimed to assess the safety and efficacy of tirofiban in stent angioplasty for ICAS in routine clinical practiceMethodsFrom January 2013 to December 2019,consecutive patients treated with endovascular therapy for symptomatic ICAS were identified and dichotomized by whether tirofiban was used.The efficacy and safety outcomes,including periprocedural complications and clinical follow-up outcomes between the 2 groups,were compared by propensity score matching.ResultsA total of 360 patients treated with endovascular intervention for symptomatic severe ICAS were enrolled between January 2016 and December 2019.Twenty-three patients were excluded,including 7 patients with severe ICAS and dissecting aneurysm were treated at the same time,5 patients with intracranial tandem stenosis were treated with more than 2 stents,10 patients receiving treatment for intracranial multi-vessel lesions and 1 patient with intracranial stenting due to restenosis.At last,337 patients were finally included,with 160 in the Tirofiban group and 177 in the non-Tirofiban group.Propensity score matching analysis selected 236 matched patients.One AIST occurred in patients receiving prophylactic tirofiban,while 8 in the non-tirifiban group.The incidence of AIST in the tirofiban group were significantly lower than those in the non-tirofiban group(0.8%vs 6.8%,P=0.039)The periprocedural ischemic events(8.5%vs 5.1%,P=0.424),periprocedural intracranial hemorrhage(4.2%vs 0.8%,P=0.219)and total mortality at the 30-day(3,4%vs 0%,P=0.125)were not statistically different between the two groupsConclusions Compared with conventionally stenting angioplasty without tirofiban,tirofiban prophylactic infusion can effectively lower the incidence of AIST,without increasing the risk of intracranial hemorrhage and 30d death.However,there is no superiority in reducing periprocedura ischemic events.