Procedural eptifibatide administration as an alternative to preprocedural dual antiplatelet therapy for patients undergoing flow diversion procedures: case series and review of the literature.

Abstract

Pretreatment with dual antiplatelet agents (DAPT) has been standard practice for patients undergoing aneurysm treatment with flow diversion (FD). Rates of periprocedural diffusion lesions observed after FD procedures remain high (>50%). We assessed the feasibility of intraprocedural eptifibatide as an alternative to standard preprocedural DAPT. Consecutive patients undergoing FD procedures underwent postprocedural MRI. Patients were pretreated with aspirin and administered a single IV heparin dose (3000-5000 U) after arterial access. Immediately following flow diverter placement, patients were administered eptifibatide. After the procedure, patients were loaded with a P2Y12 inhibitor and then maintained on DAPT. MRI was performed within 72 hours of all procedures. Of 50 consecutive patients undergoing FD procedures, 10 (20%) had one or more postprocedural diffusion lesions. No angiographically evident thromboembolic events were encountered, and no patients had clinically evident periprocedural ischemic or hemorrhagic events. Univariate logistic regression showed that a higher fluoroscopy dose was associated with an increased risk of diffusion lesions (OR 5.05, 95% CI 1.20 to 29.39, P=0.026). Switching P2Y12 agents was associated with a reduced risk (OR 0.09, 95% CI 0.00 to 0.77, P=0.023). A comparison with the available literature (eight studies, 426 patients, 63.8% rate of diffusion lesions) indicated a significantly lower rate of diffusion lesions with the eptifibatide protocol (OR 0.14, 95% CI 0.07 to 0.29, P<0.001). Intraprocedural eptifibatide may be an acceptable alternative to preprocedural DAPT to achieve platelet inhibition for FD procedures. This protocol did not result in peripheral or neurological hemorrhagic complications and was associated with a very low incidence of post-procedure diffusion lesions.