Antiplatelet Therapy During Emergent Extracranial Internal Carotid Artery Stenting: Comparison of Three Intravenous Antiplatelet Perioperative Strategies.

INTRODUCTION: Guidelines for antiplatelet therapy administration, during emergent stenting for extra-cranial internal carotid artery (EC-ICA) occlusion in the setting of acute ischemic stroke (AIS) are lacking. Different antiplatelet regimen are used in association to endovascular therapy (EVT) for the treatment of EC-ICA lesions. We aimed to compare the clinical and radiological effects of three intravenous antiplatelet agents used during emergent EC-ICA stenting. MATERIAL AND METHODS: Clinical data were collected from January 2015 to December 2019 in a monocentric prospective registry of AIS patients treated by EVT. All patients who underwent emergent EC-ICA stenting were sorted regarding the intravenous antiplatelet agent used during the procedure. RESULTS: Among 218 patients treated by EVT for an EC-ICA occlusion of the anterior circulation during the study period, 70 underwent an emergent stenting of the EC-ICA. 60 were included in the present study, 9 received intravenous (IV) Cangrelor, 8 IV abciximab and 43 Aspirin. The rate of favorable neurological outcome, defined as modified Rankin Scale (mRS) ≤ 2 at three months were better in the Cangrelor and Aspirin groups (66,7% and 58,1%, respectively) than in the Abciximab group (37,5%), as well as, the rate of any intracranial ICH (22,2% and 37,2% vs 62,5%). The rate of acute stent reocclusion was similar between groups. CONCLUSION: When used as a rescue treatment during emergent stenting of EC-ICA, Cangrelor and Aspirin present a better safety profile than Abciximab, with less intracranial hemorrhages and a higher rate of good clinical outcome. Additional studies are needed to confirm these findings.

Effect of Intravenous Abciximab on Coronary Flow Improvement After Re-vascularization in Primary Coronary Intervention and Short Term Impact.

INTRODUCTION: Of recognized fact the importance of early diagnosis and early management of ST-elevation myocardial infarction, to regain a normal or at least adequate coronary flow in the Primary Percutaneous Intervention. Slow or no-reflow is suboptimal myocardial reperfusion, without angiographic evidence of mechanical obstruction. Adenosine, Verapamil and saline flush are manoeuvres proved useful. The resolution of ST-segment is associated with successful revascularization and regarded as a predictor for future events. Glycoprotein IIB/IIIA inhibitors are a group of anti-platelets widely used in acute coronary syndrome. AIM: The aim of the study was to investigate that: uses of intra venous Abciximab, does not improve coronary flow in patients with MI that develop sub optimal flow after primary PCI within 30 minutes, but the improvement need 12 to 24 hour as founded in other studies, and its beneficial effect is related to early improvement in LV function and decrease of re-infarction and re-hospitalization. METHOD: Prospective, case-control study, enrolled fifty patients randomly assigned into two matching groups, first group (25 patients) received an intravenous Abciximab while the second group (25 patients) received intracoronary saline flush. Repeated angiography after 30 minutes, for immediate resultant flow assessment, Electrocardiographic changes resolution, bleeding and death. After a 30 days, a clinical assessment for primary outcome including, death, recurrent Myocardial infarction and Heart failure While the Secondary outcome including stent thrombosis, target vessel revascularization in addition to the primary outcome. RESULT: There was no significant difference in the flow Improvement and ECG resolution between both groups. These findings not affected by the door to balloon time. However, patients with flow improvement had a significant resolution in their ECG. Bleeding propensity and mortality were not significantly affected. Literatures proved the benefit of Abciximab in acute coronary syndrome. CONCLUSION: Both intravenous Abciximab and intracoronary saline flush had comparable effect on coronary flow improvement post primary percutaneous intervention, with minimal variation in the bleeding and in-hospital mortality.

Half bolus dose of intravenous abciximab is safe and effective in the setting of acute stroke endovascular treatment.

BACKGROUND: A stent is often necessary for the treatment of stroke. In such cases,it is essential for the patient to have antiplatelet therapy. There are several methods of antiaggregation, such as oral loading doses of aspirin and clopidogrel, intravenous aspirin, or intravenous glycoprotein IIb/IIIa receptor antagonists, such as abciximab. The aim of this study was to evaluate the incidence of symptomatic intracerebral hematoma (sICH) associated with our antiplatelet protocol: intravenous abciximab bolus at half the dose (0125 mg/kg) at the time of the stenting procedure; oral aspirin (150 mg) and clopidogrel (75 mg) daily added the next day after CT shows no significant hematoma. MATERIALS AND METHODS: Retrospective review of our database of endovascular management of large acute vessel occlusion treated with intravenous abciximab between January 2015 and March 2018. Demographics data, material, drugs, and complications were registered. Fisher tests were used to compare the incidence of sICH in the literature where abciximab 0.25 mg/kg plus maintenance doses are often administrated. RESULTS: Intravenous abciximab was administered to 99 patients. No sICH was observed. According to the European Cooperative Acute Stroke Study Scale, there were 8 cases of hemorrhagic infarction 1, 5 cases of hemorrhagic infarction 2, 4 cases of parenchymal hemorrhage 1, and no cases of parenchymal hemorrhage 2. A comparison between sICH with conventional antiplatelet doses based on the literature showed a statistically significant difference favoring our protocol. CONCLUSION: In the endovascular treatment of acute ischemic stroke, a bolus dose of 0125 mg/kg of abciximab with no maintenance doses, followed by 150 mg of aspirin and 75 mg of clopidogrel orally the next day, is safe and effective.

Intracoronary or intravenous abciximab after aspiration thrombectomy in patients with STEMI undergoing primary percutaneous coronary intervention.

OBJECTIVE: To test whether aspiration thrombectomy with intracoronary (IC) instead of intravenous (IV) administration of abciximab could reduce the no-reflow phenomenon in patients undergoing primary percutaneous intervention (PCI) for ST-elevation myocardial infarction (STEMI). BACKGROUND: Despite recanalisation with PCI, failure to restore microvascular flow may affect the prognosis of patients with STEMI. A combination of aspiration thrombectomy with IC abciximab may improve distal perfusion. METHODS: After aspiration thrombectomy during primary PCI for STEMI, 160 patients were randomly assigned to either an IV or IC abciximab bolus delivered through the aspiration catheter, both followed by a 12-hour IV abciximab infusion. RESULTS: ST-segment resolution ≥ 70% was achieved in 36 of 78 patients with IC versus 30 of 82 patients with IV abciximab (46.1 vs 36.6%, p = 0.368), and partial resolution in 28 of 78 versus 31 of 82 patients (35.9 vs 37.8%, p = 0.368). Postprocedural myocardial blush grade (MBG) 3 was obtained in 62.8 vs 63.4% (p = 0.235) and MBG ≥ 2 in 89.7 vs 81.7% (p = 0.148) of patients given IC and IV abciximab, respectively. There were three deaths in each group (3.8%). Major adverse cardiac events occurred in six of 78 patients given the IC and seven of 82 patients given the IV abciximab bolus (7.6 vs 8.5%, p = 0.410). One stroke occurred in each group, and two patients in the IC and nine in the IV group developed renal failure (2.5 vs 10.9%, p = 0.414). CONCLUSIONS: IC versus IV abciximab did not enhance myocardial reperfusion in non-selected patients with STEMI undergoing primary PCI after aspiration thrombectomy had successfully been performed.

Planned use of GP IIb/IIIa inhibitors is safe and effective during implantation of the Absorb Bioresorbable Vascular Scaffold.

Bioresorbable Vascular Scaffolds (BVS) have the potential for adaptive vessel remodeling, restoration of vasomotion, and late luminal enlargement, thus allowing them to circumvent target lesion failures associated with bare metal stents (BMS) and drug-eluting stents (DES). However, recent data has shown a concerning increase in BVS-associated scaffold thrombosis (ScT) compared to DES. Upfront administration of GP IIb/IIIa inhibitors (GPIs) has shown to reduce early stent thrombosis (ST) compared to standard of care in BMS and DES. Since the use of GPIs was limited in BVS studies, the effect of GPIs on the rate of BVS-associated ScT is largely unknown. This is the first study investigating whether a planned use of GPIs during implantation of the Absorb BVS represents a safe and effective strategy in reducing ScT. In a retrospective chart review of 22 patients undergoing PCI with BVS implantation and planned GPI administration, no acute ScT, in-hospital MACE, or in-hospital major/minor bleeding events were observed. Bleeding reduction strategies such as shorter GPI infusion and radial access were implemented. This study provides valuable preliminary evidence on the benefit and safety in using planned GPI administration to reduce the incidence of ScT after implantation of BVS.

A Randomized Double-Blind Placebo-Controlled Study Comparing Intracoronary Versus Intravenous Abciximab in Patients With ST-Elevation Myocardial Infarction Undergoing Transradial Rescue Percutaneous Coronary Intervention After Failed Thrombolysis.

The risk and benefit ratio of glycoprotein IIb/IIIa inhibitors with dual oral antiplatelet therapy after failed thrombolysis and rescue percutaneous coronary intervention (PCI) is unclear. Using a randomized placebo-controlled, double-blind design, we compared intravenous (IV) and intracoronary (IC) abciximab delivery in 74 patients referred for rescue transradial PCI. The primary angiographic end points were the final thrombolysis in myocardial infarction flow and myocardial blush grades. Secondary end points included acute and 6-month outcomes using angiographic parameters, platelet aggregation parameters, cardiac biomarkers, cardiac magnetic resonance measurements (CMR) and clinical end points. After rescue PCI, normal thrombolysis in myocardial infarction 3 flows were obtained in 70% in the IC group, 48% in the IV group, and 71% in the placebo group, respectively (p = 0.056). Final myocardial blush grades 2 and 3 were obtained in 43% and 39% in the IC group, 48% and 26% in the IV group, and 46% and 42% in the placebo group (p = 0.67), respectively. Acutely, peak release of cardiac biomarkers, necrosis size, myocardial perfusion and no-reflow as assessed by CMR, and clinical end points were similar between the groups and did not suggest a benefit for IC or IV abciximab compared with placebo. There was no increase in bleeding or access site-related complications with abciximab compared with placebo. Clinical, angiographic, and CMR outcomes at 6 months remained comparable between the groups. In patients with ST-elevation myocardial infarction presenting with failed thrombolysis undergoing transradial rescue PCI, IC or IV abciximab had no significant clinical impact.

Impact of Atrial Fibrillation During ST-Segment-Elevation Myocardial Infarction on Infarct Characteristics and Prognosis.

BACKGROUND: Atrial fibrillation (AF) is frequently observed in patients with ST-segment-elevation myocardial infarction and associated with worse clinical outcome. However, the mechanisms for this increased risk are not fully understood. The purpose of this study was to investigate the relationship of the presence of AF to cardiac magnetic resonance (CMR) derived myocardial salvage and damage as well as clinical outcomes. METHODS AND RESULTS: This multicenter CMR study enrolled 786 patients with ST-segment-elevation myocardial infarction. CMR parameters (infarct size, myocardial salvage index, microvascular obstruction, and myocardial function) were assessed 3 (interquartile range [IQR], 2-4) days post-ST-segment-elevation myocardial infarction and compared between patients with or without AF during hospitalization. Major adverse cardiac events were assessed as a composite of all-cause death, reinfarction, and new congestive heart failure at 12 months. AF was documented in 48 (6.1%) patients. There was no significant difference in infarct size (18 [IQR, 9-29]% versus 17 [IQR, 9-25]% of left ventricular mass; P=0.340), myocardial salvage index (51 [IQR, 34-69] versus 51 [IQR, 33-69]; P=0.830), or microvascular obstruction (0.6 [IQR, 0-2.0]% versus 0.0 [IQR, 0-1.8]% of left ventricular mass; P=0.340) between groups. Patients with AF had significantly lower left ventricular (47 [IQR, 34-54]% versus 51 [IQR, 44-58]%; P=0.003) and left atrial (42 [IQR, 17-57]% versus 53 [IQR, 45-59]%; P<0.001) ejection fraction. AF was associated with major adverse cardiac events, even when adjusting for clinical risk factors (odds ratio, 2.48 [95% confidence interval, 1.22-5.03]; P=0.0120) or CMR prognosis markers (odds ratio, 3.77 [95% confidence interval, 1.83-7.79]; P=0.001). CONCLUSIONS: This CMR study found no major differences in myocardial salvage, infarct size, or microvascular damage in patients with ST-segment-elevation myocardial infarction or without AF. AF was, however, associated with cardiac dysfunction and independently related to major adverse cardiac events. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00712101.

In situ administration of abciximab for thrombus resolution during intracranial bypass surgery: case report.

Abciximab is a glycoprotein IIb/IIIa receptor antagonist that functions to prevent platelet aggregation, thus reducing thrombus initiation and propagation. It has been widely used during percutaneous endovascular interventions, such as aneurysm coil embolization, angioplasty, atherectomy, and stent placement, as both a preventative and a salvage therapy. The use of abciximab in cardiac and neurosurgical procedures has been associated with a reduced incidence of ischemic complications and a decreased need for repeated intervention. In these settings, abciximab has been delivered transarterially via a microcatheter or infused intravenously for systemic administration. The authors describe novel in situ delivery of abciximab as an agent to dissolve "white clots," which are composed primarily of platelets, during an intracranial superficial temporal artery to middle cerebral artery bypass in a 28-year-old woman with severe intracranial occlusive disease. Abciximab was able to resolve multiple platelet-based clots after unsuccessful attempts with conventional clot dispersal techniques, such as heparinized saline, tissue plasminogen activator, mechanical passage of a wire through the vessel lumen, and multiple takedowns and re-anastomosis. After abciximab was administered, patency was demonstrated intraoperatively using indocyanine green dye and confirmed postoperatively at 1 and 10 months via CT angiography. The in situ use of abciximab as an agent to disperse a thrombus during intracranial bypass surgery is novel and has not previously been described in the literature, and serves as an additional tool during intracranial vessel bypass surgery.

A comparison of intracoronary treatment strategies for thrombus burden removal during primary percutaneous coronary intervention: a COCTAIL II substudy.

BACKGROUND: Manual thrombus aspiration and local drug delivery of abciximab have been proposed as a strategy to reduce thrombus burden during percutaneous coronary intervention in patients with ST elevation myocardial infarction; however, the effectiveness of these approaches, is uncertain. In this COCTAIL II substudy, we compared the effect of these strategies on prestenting and poststenting thrombus burden assessed by optical coherence tomography. PATIENTS AND METHODS: COCTAIL II trial enrolled patients with ST elevation myocardial infarction randomized to intralesion (IL, by the ClearWay catheter) versus intracoronary (IC, by the guide catheter) abciximab bolus with or without aspiration thrombectomy (AT). The following parameters were used to quantify atherothrombotic burden: thrombus volume (TVol), maximum thrombus area (TA), and thrombus burden (TB). Primary endpoint was the comparison of prestenting TVol after the use of local drug delivery (group IL+IL abciximab plus AT) versus nonlocal drug delivery (group IC abciximab plus AT+IC). RESULTS: The final population consisted of 59 patients undergoing both prestenting and poststenting optical coherence tomography assessment. The amount of thrombus was not significantly different in the groups with local drug delivery of abciximab versus nonlocal drug delivery in both prestenting (TVol: 18.87±26.70 vs. 19.02±18.45; TB: 26.73±12.8 vs. 25.18±13.25; and maximum TA: 59.25±18.84 vs. 53.34±19.30) and poststenting (TVol: 8.46±9.15 vs. 8.05±6.81; TB: 6.68±3.54 vs. 6.24±3.66; and maximum TA: 15.47±7.61 vs. 16.52±11.55) evaluations. A good correlation between thrombus measurements after thrombus removal techniques and intrastent thrombus was observed. CONCLUSION: Either local drug delivery of abciximab or manual thrombus aspiration showed comparable results in terms of prestenting and poststenting thrombus burden removal.