Ticagrelor versus clopidogrel dual antiplatelet therapy for unruptured intracranial aneurysms treated with flowdiverter.

BACKGROUND AND PURPOSE: Antiplatelet therapy (APT) is a key element limiting the risk of thromboembolic events (TEE) in neuroendovascular procedures, including aneurysm treatment with flowdiverter. Clopidogrel combined with aspirin is the mostly reported dual APT (DAPT). However, resistance phenomenon and intraindividual efficacy fluctuation are identified limitations. In recent years, ticagrelor has been increasingly used in this indication. We compared these two DAPT regimens for intracranial aneurysm treated with flowdiverter. METHODS: We conducted a multicentric retrospective study from prospectively maintained databases in two high volume centers extracting consecutive patients presenting unruptured intracranial aneurysm treated with flowdiverter and receiving DAPT (May 2015 to December 2019).  Two groups were compared according to their DAPT regimen: "ticagrelor+aspirin" and "clopidogrel+aspirin". Clopidogrel group was systematically checked with platelet test inhibition before endovascular procedure. The primary endpoint was composite, defined as any thrombo-embolic event (TEE) or major hemorrhagic event occurring the first 6 months during and after embolization RESULTS: 260 patients met our inclusion criteria. Baseline patients and aneurysms characteristics were comparable between groups, except for aneurysm location, median size and pre-treatment modified Rankin scale. No significant difference was observed regarding the primary composite outcome: 11.5% (12/104) in the ticagrelor group versus 10.9% (17/156) in the clopidogrel group (p = 1.000). There was also no significant difference in secondary outcomes including TEE (10.5 vs 9.0%; p = 0.673), major hemorrhage (0.9 vs 1.2%; p = 0.651) and clinical outcome (at least 1-point mRS worsening during follow up: 6.7% vs 8.3%; p = 0.813). CONCLUSION: First-line DAPT with ticagrelor+aspirin seems as safe and effective as clopidogrel+aspirin regimen.

MRI Outcomes Achieved by Simple Flow Blockage Technique in Symptomatic Carotid Artery Stenosis Stenting.

In this study, we aimed to determine the frequency and clinical impact of new ischemic lesions detected with diffusion-weighted-imaging-MRI (DWI-MRI) as well as the clinical outcomes after carotid artery stenting (CAS) using the simple flow blockage technique (SFB). This is a retrospective study with data extraction from a monocentric prospective clinical registry (from 2017 to 2019) of consecutive patients admitted for symptomatic cervical ICA stenosis or web. Herein, patients benefited from DWI-MRI before and within 48 h of CAS for symptomatic ICA stenosis or web. The primary endpoint was the frequency of new DWI-MRI ischemic lesions and the secondary (composite) endpoint was the rate of mortality, symptomatic stroke or acute coronary syndrome within 30 days of the procedure. All of the 82 CAS procedures were successfully performed. Among the 33 patients (40.2%) with new DWI-MRI ischemic lesions, 30 patients were asymptomatic (90.9%). Irregular carotid plaque surface with (n = 13, 44.8%) or without ulceration (n = 12, 60.0%) was associated with higher rates of new DWI-MRI lesions by comparison to patients with a regular plaque (n = 7, 25%) (p = 0.048) using the univariate analysis. Less than half of this CAS cohort using the SFB technique had new ischemic lesions detected with DWI-MRI. Among these patients, more than 90% were asymptomatic. Irregularity of the plaque seems to increase the risk of peri-procedural DWI-MRI lesions.

Angiographic Patterns and Outcomes Achieved by Proximal Balloon Occlusion in Symptomatic Carotid Artery Stenosis Stenting.

BACKGROUND AND PURPOSE: The best embolic protection strategy has not yet been established for carotid artery stenting (CAS). This article reports a new simplified approach using a balloon guide catheter inspired by stroke therapy, in patients harboring a symptomatic ICA atherosclerotic stenosis or web. In addition, the three angiographic patterns and clinical outcomes associated with this technique, called the simple flow blockage (SFB) technique are described. MATERIAL AND METHODS: This was a retrospective study with data extraction from a monocentric prospective clinical registry of consecutive patients admitted for symptomatic ICA stenosis or web. The primary study outcome (composite endpoint) was the rate of occurrence of death, symptomatic stroke or acute coronary syndrome within 30 days of the intervention. RESULTS: In this study 75 symptomatic patients with >50% carotid artery atherosclerotic stenosis or web were included. All procedures were successfully performed. The composite endpoint occurred in 3 patients (4.0%, 95% confidence interval, CI, 0.0-11.3): 1 had symptomatic ischemic stroke, 1 had reperfusion syndrome with symptomatic intracranial hemorrhage and 1 had acute coronary syndrome. After proximal balloon inflation three angiographic patterns were observed: complete contrast column stagnation in the ICA (38.7%), retrograde washout of the ICA from the intracranial circulation towards the external carotid artery (35.5%) and antegrade washout of contrast medium towards the intracranial circulation (25.8%). The median procedure length was 40 min. New asymptomatic ischemic lesions were observed in 22.5% on DWI-MRI. CONCLUSION: The SFB technique enables fast and safe procedures in CAS. A favorable angiographic pattern after proximal balloon inflation was observed in 74.2% of cases.