GPIs Superior for Rescue Treatment after Endovascular Coiling for Cerebral Aneurysm

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Patients who require rescue treatment after receiving endovascular coiling for cerebral aneurysms face higher morbidity and mortality if given thrombolytic agents rather than glycoprotein IIb/IIIa inhibitors (GPIs). The findings, from an observational study, were published online April 18, 2013, ahead of print in Stroke.

Waleed Brinjikji, MD, of the Mayo Clinic (Rochester, MN), and colleagues used the Premier Perspective Database to retrospectively identify nearly 8,000 patients who underwent coiling for either unruptured (n = 3,627) or ruptured (n = 4,204) cerebral aneurysms between November 2005 and December 2011.

Among patients with unruptured aneurysms, 7% required rescue therapy (5.6% GPIs, 0.7% fibrinolytic therapy, and 0.8% both GPIs and fibrinolytics) for thromboembolic complications during their endovascular procedure. Similarly, 8% of patients with ruptured aneurysms needed rescue therapy (5.7% GPIs, 1.6% fibrinolytic therapy, and 0.7% both GPIs and fibrinolytics).

Both patient subsets experienced higher rates of discharge to institutions other than home with fibrinolytic vs. GPI therapy alone. In conjunction with fibrinolytics, patients with unruptured aneurysms had increased aphasia and those with ruptured aneurysms had more ventriculostomy. Several other outcomes also showed trends favoring GPI use (tables 1 and 2).

Table 1. Unruptured Aneurysms

Table 2. Ruptured Aneurysms

Patients who received a combination of GPI and fibrinolytic therapy, meanwhile, also tended to have worse outcomes than those given GPIs alone.

Within the unruptured group, fibrinolytics were more commonly administered at teaching hospitals and to patients not receiving stents (P = 0.04 for both); within the ruptured group, GPIs were more likely to be the therapy of choice at teaching hospitals, though the difference did not reach statistical significance (P = 0.07).

GPIs included abciximab, eptifibatide, and tirofiban, and fibrinolytic therapy consisted of either alteplase, reteplase, tenecteplase, or urokinase.

Results Should Discourage Fibrinolytic Use

Acknowledging the inherent limitations of a database study—such as the lack of details on presenting condition and success of recanalization, for example—the researchers still say that GPIs appear to be “a better option for rescue therapy” based on the current findings.

GPIs have previously been shown to be “relatively safe” in patients with ruptured aneurysms, they note, while thrombolytic agents have been associated with excess bleeding in those with ruptured aneurysms and catastrophic hemorrhage in those with unruptured aneurysms.

“There are few reports on rescue therapy with thrombolytic agents, perhaps because their use has largely been replaced by [GPIs],” Dr. Brinjikji and colleagues write, noting that even so, fibrinolytics have yet to disappear from clinical practice. “Our data confirm the higher risk of morbidity and mortality of thrombolytic agents relative to [GPIs] and might help to discourage continued use of thrombolytic agents for rescue therapy, especially in the setting of subarachnoid hemorrhage.”

 

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Source:
Brinjikji W, McDonald JS, Kallmes DF, et al. Rescue treatment of thromboembolic complications during endovascular treatment of cerebral aneurysms. Stroke. 2013;Epub ahead of print.

 

 

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