Endothelin receptor antagonist improves donor lung function in an ex vivo perfusion system.

BACKGROUND: A lung transplant is the last resort treatment for many patients with advanced lung disease. The majority of donated lungs come from donors following brain death (BD). The endothelin axis is upregulated in the blood and lung of the donor after BD resulting in systemic inflammation, lung damage and poor lung graft outcomes in the recipient. Tezosentan (endothelin receptor blocker) improves the pulmonary haemodynamic profile; however, it induces adverse effects on other organs at high doses. Application of ex vivo lung perfusion (EVLP) allows the development of organ-specific hormone resuscitation, to maximise and optimise the donor pool. Therefore, we investigate whether the combination of EVLP and tezosentan administration could improve the quality of donor lungs in a clinically relevant 6-h ovine model of brain stem death (BSD). METHODS: After 6 h of BSD, lungs obtained from 12 sheep were divided into two groups, control and tezosentan-treated group, and cannulated for EVLP. The lungs were monitored for 6 h and lung perfusate and tissue samples were processed and analysed. Blood gas variables were measured in perfusate samples as well as total proteins and pro-inflammatory biomarkers, IL-6 and IL-8. Lung tissues were collected at the end of EVLP experiments for histology analysis and wet-dry weight ratio (a measure of oedema). RESULTS: Our results showed a significant improvement in gas exchange [elevated partial pressure of oxygen (P = 0.02) and reduced partial pressure of carbon dioxide (P = 0.03)] in tezosentan-treated lungs compared to controls. However, the lungs hematoxylin-eosin staining histology results showed minimum lung injuries and there was no difference between both control and tezosentan-treated lungs. Similarly, IL-6 and IL-8 levels in lung perfusate showed no difference between control and tezosentan-treated lungs throughout the EVLP. Histological and tissue analysis showed a non-significant reduction in wet/dry weight ratio in tezosentan-treated lung tissues (P = 0.09) when compared to control. CONCLUSIONS: These data indicate that administration of tezosentan could improve pulmonary gas exchange during EVLP.

Neural network imaging to characterize brain injury in cardiac procedures: the emerging utility of connectomics.

Cognitive dysfunction is a poorly understood but potentially devastating complication of cardiac surgery. Clinically meaningful assessment of cognitive changes after surgery is problematic because of the absence of a means to obtain reproducible, objective, and quantitative measures of the neural disturbances that cause altered brain function. By using both structural and functional connectivity magnetic resonance imaging data to construct a map of the inter-regional connections within the brain, connectomics has the potential to increase the specificity and sensitivity of perioperative neurological assessment, permitting rational individualized assessment and improvement of surgical techniques.

Hydrodynamic evaluation of aortic cardiopulmonary bypass cannulae using particle image velocimetry.

The high velocity jet from aortic arterial cannulae used during cardiopulmonary bypass potentially causes a "sandblasting" injury to the aorta, increasing the possibility of embolisation of atheromatous plaque. We investigated a range of commonly available dispersion and non-dispersion cannulae, using particle image velocimetry. The maximum velocity of the exit jet was assessed 20 and 40 mm from the cannula tip at flow rates of 3 and 5 L/min. The dispersion cannulae had lower maximum velocities compared to the non-dispersion cannulae. Dispersion cannulae had fan-shaped exit profiles and maximum velocities ranged from 0.63 to 1.52 m/s when measured at 20 mm and 5 L/min. Non-dispersion cannulae had maximum velocities ranging from 1.52 to 3.06 m/s at 20 mm and 5 L/min, with corresponding narrow velocity profiles. This study highlights the importance of understanding the hydrodynamic performance of these cannulae as it may help in selecting the most appropriate cannula to minimize the risk of thromboembolic events or aortic injury.

Protocol guided bleeding management improves cardiac surgery patient outcomes.

BACKGROUND AND OBJECTIVES: Excessive bleeding is a risk associated with cardiac surgery. Treatment invariably requires transfusion of blood products; however, the transfusion itself may contribute to postoperative sequelae. Our objective was to analyse a quality initiative designed to provide an evidenced-based approach to bleeding management. MATERIALS AND METHODS: A retrospective analysis compared blood product transfusion and patient outcomes 15 months before and after implementation of a bleeding management protocol. The protocol incorporated point-of-care coagulation testing (POCCT) with ROTEM and Multiplate to diagnose the cause of bleeding and monitor treatment. RESULTS: Use of the protocol led to decreases in the incidence of transfusion of PRBCs (47·3% vs. 32·4%; P < 0·0001), FFP (26·9% vs. 7·3%; P < 0·0001) and platelets (36·1% vs. 13·5%; P < 0·0001). During the intra-operative period, the percentage of patients receiving cryoprecipitate increased (2·7% vs. 5·1%; P = 0·002), as did the number of units transfused (248 vs. 692; P < 0·0001). The proportion of patients who received tranexamic acid increased (13·7% to 68·2%; P < 0·0001). There were reductions in re-exploration for bleeding (5·6% vs. 3·4; P = 0·01), superficial chest wound (3·3% vs. 1·4%; P = 0·002), leg wound infection (4·6% vs. 2·0%; P < 0·0001) and a 12% reduction in mean length of stay from operation to discharge (95%: 9-16%, P < 0·0001). Acquisition cost of blood products decreased by $1 029 118 in the 15-month period with the protocol. CONCLUSIONS: The implementation of a bleeding management protocol supported by POCCT in a cardiac surgery programme was associated with significant reductions in the transfusion of allogeneic blood products, improved outcomes and reduced cost.

A comprehensive ovine model of blood transfusion.

BACKGROUND: The growing awareness of transfusion-associated morbidity and mortality necessitates investigations into the underlying mechanisms. Small animals have been the dominant transfusion model but have associated limitations. This study aimed to develop a comprehensive large animal (ovine) model of transfusion encompassing: blood collection, processing and storage, compatibility testing right through to post-transfusion outcomes. MATERIALS AND METHODS: Two units of blood were collected from each of 12 adult male Merino sheep and processed into 24 ovine-packed red blood cell (PRBC) units. Baseline haematological parameters of ovine blood and PRBC cells were analysed. Biochemical changes in ovine PRBCs were characterized during the 42-day storage period. Immunological compatibility of the blood was confirmed with sera from potential recipient sheep, using a saline and albumin agglutination cross-match. Following confirmation of compatibility, each recipient sheep (n = 12) was transfused with two units of ovine PRBC. RESULTS: Procedures for collecting, processing, cross-matching and transfusing ovine blood were established. Although ovine red blood cells are smaller and higher in number, their mean cell haemoglobin concentration is similar to human red blood cells. Ovine PRBC showed improved storage properties in saline-adenine-glucose-mannitol (SAG-M) compared with previous human PRBC studies. Seventy-six compatibility tests were performed and 17·1% were incompatible. Only cross-match compatible ovine PRBC were transfused and no adverse reactions were observed. CONCLUSION: These findings demonstrate the utility of the ovine model for future blood transfusion studies and highlight the importance of compatibility testing in animal models involving homologous transfusions.

Transfusion of packed red blood cells reduces selenium levels and increases lipid peroxidation in an in vivo ovine model.

BACKGROUND: Oxidative stress from surgery or critically illness has been shown to adversely contribute to morbidity and mortality. Recent studies record that oxidative stress is heightened following packed red blood cell (PRBC) transfusions and that products of oxidative stress accumulate as the PRBC ages. However, there are no studies that investigate if transfusion of aged PRBC actually increases the recipient's oxidative stress profile more than fresh PRBC. OBJECTIVE: To compare the effect of fresh vs aged PRBC transfusions on the recipient's oxidative stress using an ovine model. MATERIALS AND METHODS: Male sheep were transfused with either fresh (n = 6) or aged (n = 6) ovine PRBC, and serial blood samples taken. Plasma samples were analysed for lipid peroxidation using the thiobarbituric acid reactive substances (TBARS) assay. This served as an indicator of oxidative injury. Antioxidant function and trace element levels were also measured. RESULTS: Like human PRBC, the ovine PRBC had negligible selenium levels. Irrespective of age, PRBC transfusion was associated with reduced selenium levels and antioxidant function, which correlated with increased markers of lipid peroxidation. CONCLUSION: Transfusion of selenium poor PRBC can dilute selenium levels and compromise glutathione peroxidase antioxidant activity and thereby allow lipid peroxidation. As there was no evidence that aged PRBC induced more severe oxidative injury this suggests that selenium dilution is a key underlying mechanism. Further studies are needed to assess the impact of transfusion-related oxidative stress in massive transfusions.

Cardiac surgery in indigenous Australians: early onset cardiac disease with follow-up challenges.

OBJECTIVE: To review the risk factors, complications and follow-up of Indigenous patients post cardiac surgery. METHODS: This was a retrospective study of Indigenous patients who underwent cardiac surgery at an Australian tertiary hospital between 2002 and 2009. Patients' medical notes were reviewed and data collected and analysed. RESULTS: There were 220 Indigenous patients who had cardiac surgery. Non-elective surgery was performed in 45.0% (99/220). A history of smoking was reported by 76.8% (169/220). The most common operation was coronary artery bypass grafting with a mean age of 55 years. Of the 71 valve operations, 31.0% had rheumatic heart disease. Mechanical valves were given to 56.3% (40/71) of patients with a mean age of 45 years. The rate of peri-operative bleeding requiring blood transfusion or reoperation was 8.6% (19/220) and 28-day mortality was 0.45% (1/220). Of the patients with mechanical valves, 10.0% (4/40) did not present for outpatient review. Late anticoagulation related complications were haemorrhagic stroke 7.5% (3/40) and ischaemic bowel 2.5% (1/40). Late mortality was 9.5% (21/220). Late anticoagulation related deaths were in 1.8% (4/220), of whom 0.9% (2/220) had mechanical valves. CONCLUSIONS: The mean age of 52 years at which Indigenous patients have cardiac surgery is significantly low compared to non-Indigenous patients. Indigenous patients have multiple risk factors for cardiac disease and with a large number requiring emergency surgery. Although surgical outcome in the short term is favourable, a large number of patients are lost to follow-up. The use of mechanical valve and warfarin should be individualised. Strategic post-operative follow-up mechanisms are needed to address these issues.

Stored blood transfusion induces transient pulmonary arterial hypertension without impairing coagulation in an ovine model of nontraumatic haemorrhage.

BACKGROUND AND OBJECTIVES: Transfusion of blood products in particular older products is associated with patient morbidity. Previously, we demonstrated a higher incidence of acute lung injury in lipopolysaccharide-treated sheep transfused with stored blood products. As transfusion following haemorrhage is more common, we aimed to determine whether a 'first hit' of isolated haemorrhage would precipitate similar detrimental effects following transfusion and also disrupt haemostasis. MATERIALS AND METHODS: Anaesthetized sheep had 33% of their total blood volume collected into Leukotrap bags (Pall Medical), which were processed into packed red blood cells and cross-matched for transfusion into other sheep. After 30 mins, the sheep were resuscitated with either: fresh (<5 days old) or stored (35-42 days old) ovine blood followed by 4% albumin to replacement volume, albumin alone or normal saline alone and monitored for 4 h. RESULTS: The first hit of haemorrhage precipitated substantial decreases in mean arterial pressure however haemostasis was preserved. Transfusion of stored ovine blood induced (1) transient pulmonary arterial hypertension but no oedema and (2) reduced fibrinogen levels more than fresh blood, but neither induced coagulopathy. Thus, transfusion of stored blood affected pulmonary function even in the absence of overt organ injury. CONCLUSION: The fact that stored blood transfusions: (1) did not induce acute lung injury in contrast to previous lipopolysaccharide-primed animal models identifies the 'first hit' as an important determinant of the severity of transfusion-mediated injury; (2) impaired pulmonary dynamics verifies the sensitivity and vulnerability of the pulmonary system to injury.

Is hyperoxaemia helping or hurting patients during extracorporeal membrane oxygenation? Review of a complex problem.

Extracorporeal membrane oxygenation (ECMO) facilitates organ support in patients with refractory cardiorespiratory failure whilst disease-modifying treatments can be administered. Improvements to the ECMO process have resulted in its increased utilisation. However, iatrogenic injuries remain, with bleeding and thrombosis the most significant concerns. Many factors contribute to the formation of thrombi, with the hyperoxaemia experienced during ECMO a potential contributor. Outside of ECMO, emerging evidence associates hyperoxaemia with increased mortality. Currently, no universal definition of hyperoxaemia exists, a gap in clinical standards that may impact patient outcomes. Hyperoxaemia has the potential to induce platelet activation, aggregation and, subsequently, thrombosis through markedly increasing the production of reactive oxygen species. There are minimal data in the current literature that explore the relationship between ECMO-induced hyperoxaemia and the production of reactive oxygen species - a putative link towards pathology. Furthermore, there is limited research directly linking hyperoxaemia and platelet activation. These are areas that warrant investigation as definitive data regarding the nascence of these pathological processes may delineate and define the relative risk of supranormal oxygen tension. These data could then assist in defining optimal oxygenation practice, reducing the risks associated with extracorporeal support.

Current intraoperative storage and handling practices of autologous bypass conduit: A survey of the royal australasian college of surgeons.

During bypass surgery for peripheral arterial occlusive disease and ischaemic heart disease, autologous graft conduit including great saphenous veins and radial arteries are frequently stored in solution. Endothelial damage adversely affects the performance and patency of autologous bypass grafts, and intraoperative graft storage solutions have been shown to influence this process. The distribution of storage solutions currently used amongst Cardiothoracic and Vascular Surgeons from Australia and New Zealand is not well defined in the literature. The aim of this study was to determine current practices regarding autologous graft storage and handling amongst this cohort of surgeons, and discuss their potential relevance in the context of early graft failure. From this survey, the most frequently used storage solutions were heparinized saline for great saphenous veins, and pH-buffered solutions for radial arteries. Duration of storage was 30-45 min for almost half of respondents, although responses to this question were limited. Further research is required to investigate whether ischaemic endothelial injury generates a prothrombotic state, whether different storage media can alter this state, and whether this is directly associated with clinical outcomes of interest such as early graft failure.

Brain stem death induces pro-inflammatory cytokine production and cardiac dysfunction in sheep model.

INTRODUCTION: Organs procured following brain stem death (BSD) are the main source of organ grafts for transplantation. However, BSD is associated with inflammatory responses that may damage the organ and affect both the quantity and quality of organs available for transplant. Therefore, we aimed to investigate plasma and bronchoalveolar lavage (BAL) pro-inflammatory cytokine profiles and cardiovascular physiology in a clinically relevant 6-h ovine model of BSD. METHODS: Twelve healthy female sheep (37-42 Kg) were anaesthetized and mechanically ventilated prior to undergoing BSD induction and then monitored for 6 h. Plasma and BAL endothelin-1 and cytokines (IL-1ß, 6, 8 and tumour necrosis factor alpha (TNF-α)) were assessed by ELISA. Differential white blood cell counts were performed. Cardiac function during BSD was also examined using echocardiography, and cardiac biomarkers (A-type natriuretic peptide and troponin I were measured in plasma. RESULTS: Plasma concentrations big ET-1, IL-6, IL-8, TNF-α and BAL IL-8 were significantly (p < 0.01) increased over baseline at 6 h post-BSD. Increased numbers of neutrophils were observed in the whole blood (3.1 × 109 cells/L [95% confidence interval (CI) 2.06-4.14] vs. 6 × 109 cells/L [95%CI 3.92-7.97]; p < 0.01) and BAL (4.5 × 109 cells/L [95%CI 0.41-9.41] vs. 26 [95%CI 12.29-39.80]; p = 0.03) after 6 h of BSD induction vs baseline. A significant increase in ANP production (20.28 pM [95%CI 16.18-24.37] vs. 78.68 pM [95%CI 53.16-104.21]; p < 0.0001) and cTnI release (0.039 ng/mL vs. 4.26 [95%CI 2.69-5.83] ng/mL; p < 0.0001), associated with a significant reduction in heart contractile function, were observed between baseline and 6 h. CONCLUSIONS: BSD induced systemic pro-inflammatory responses, characterized by increased neutrophil infiltration and cytokine production in the circulation and BAL fluid, and associated with reduced heart contractile function in ovine model of BSD.

Neutrophil antibody diagnostics and screening: review of the classical versus the emerging.

BACKGROUND AND OBJECTIVES Severe transfusion-related acute lung injury (TRALI) events have been linked to donor-derived neutrophil antibodies. The journey to developing mass donor neutrophil antibody screening platforms is challenged by the fragility of neutrophils and their unique-specific antigenic characteristics. MATERIAL AND METHODS This article critically evaluates the capabilities and potential of five emerging antibody screening platforms designed to detect neutrophil reactive antibodies relevant to TRALI. They are compared with established neutrophil serological methods. RESULTS Data from two recombinant antigen platforms and a method using human neutrophil antigens-expressing KY cells indicated high specificity. Two mixed cellular flow cytometric assays have the advantage of presenting native conformation of the human polymorphonuclear neutrophil antigenic epitopes. CONCLUSIONS To date, the number and specificity of test sera applied to each platform is small. This needs to be substantially increased and further rigorous serological evaluation is yet needed to compare the sensitivity and specificity limits of each new platform with classical methods. With a limited world supply of TRALI-relevant test sera, a collaborative effort of laboratories with neutrophil and TRALI investigation expertise is required.

A novel in vivo ovine model of transfusion-related acute lung injury (TRALI).

BACKGROUND AND OBJECTIVES: Even with the introduction of specific risk-reduction strategies, transfusion-related acute lung injury (TRALI) continues to be a leading cause of transfusion-related morbidity and mortality. Existing small animal models have not yet investigated TRALI resulting from the infusion of heat-treated supernatant from whole blood platelet concentrates. In this study, our objective was the development of a novel in vivo two-event model of TRALI in sheep. MATERIALS AND METHODS: Lipopolysaccharide (LPS; 15 µg/kg) as a first event, modelled clinical infection. Transfusion (estimated at 10% of total blood volume) of heat-treated pooled supernatant from date-of-expire human whole blood platelet concentrates (d5-PLT-S/N) was used as a second event. TRALI was defined by both hypoxaemia that developed either during the transfusion or within two hours of its completion and post-mortem histological evidence of pulmonary oedema. RESULTS: LPS infusion did not cause lung injury itself, but did result in decreased circulating levels of lymphocytes and neutrophils with evidence of the latter becoming sequestered in the lungs. Sheep that received LPS (first event) followed by d5-PLT-S/N (second event) displayed decreased pulmonary compliance, decreased end tidal CO(2) and increased arterial partial pressure of CO(2) relative to control sheep, and 80% of these sheep developed TRALI. CONCLUSIONS: This novel ovine two-event TRALI model presents a new tool for the investigation of TRALI pathogenesis. It represents the first description of an in vivo large animal model of TRALI and the first description of TRALI caused by transfusion with heat-treated pooled supernatant from human whole blood platelet concentrates.

Oxygen delivery through high-flow nasal cannulae increase end-expiratory lung volume and reduce respiratory rate in post-cardiac surgical patients.

BACKGROUND: High-flow nasal cannulae (HFNCs) create positive oropharyngeal airway pressure, but it is unclear how their use affects lung volume. Electrical impedance tomography allows the assessment of changes in lung volume by measuring changes in lung impedance. Primary objectives were to investigate the effects of HFNC on airway pressure (P(aw)) and end-expiratory lung volume (EELV) and to identify any correlation between the two. Secondary objectives were to investigate the effects of HFNC on respiratory rate, dyspnoea, tidal volume, and oxygenation; and the interaction between BMI and EELV. METHODS: Twenty patients prescribed HFNC post-cardiac surgery were investigated. Impedance measures, P(aw), ratio, respiratory rate, and modified Borg scores were recorded first on low-flow oxygen and then on HFNC. RESULTS: A strong and significant correlation existed between P(aw) and end-expiratory lung impedance (EELI) (r=0.7, P<0.001). Compared with low-flow oxygen, HFNC significantly increased EELI by 25.6% [95% confidence interval (CI) 24.3, 26.9] and P(aw) by 3.0 cm H(2)O (95% CI 2.4, 3.7). Respiratory rate reduced by 3.4 bpm (95% CI 1.7, 5.2) with HFNC use, tidal impedance variation increased by 10.5% (95% CI 6.1, 18.3), and ratio improved by 30.6 mm Hg (95% CI 17.9, 43.3). A trend towards HFNC improving subjective dyspnoea scoring (P=0.023) was found. Increases in EELI were significantly influenced by BMI, with larger increases associated with higher BMIs (P<0.001). CONCLUSIONS: This study suggests that HFNCs reduce respiratory rate and improve oxygenation by increasing both EELV and tidal volume and are most beneficial in patients with higher BMIs.

Scurvy: historically a plague of the sailor that remains a consideration in the modern intensive care unit.

We report the case of the case of a 56 year old female with sepsis on a background of rheumatoid arthritis and steroid use manifesting with overt clinical features of scurvy. Ascorbic acid assays were able to demonstrate severe deficiency and confirm a diagnosis of scurvy. Clinical resolution of signs and symptoms following commencement of vitamin C replacement was rapid. The intensivist and dietitian need to consider this diagnosis even in the first world setting, particularly in the presence of sepsis, inflammatory conditions, steroid use and importantly malnutrition.

Randomised controlled trial of oxygen therapy and high-flow nasal therapy in African children with pneumonia.

PURPOSE: The life-saving role of oxygen therapy in African children with severe pneumonia is not yet established. METHODS: The open-label fractional-factorial COAST trial randomised eligible Ugandan and Kenyan children aged > 28 days with severe pneumonia and severe hypoxaemia stratum (SpO2 < 80%) to high-flow nasal therapy (HFNT) or low-flow oxygen (LFO: standard care) and hypoxaemia stratum (SpO2 80-91%) to HFNT or LFO (liberal strategies) or permissive hypoxaemia (ratio 1:1:2). Children with cyanotic heart disease, chronic lung disease or > 3 h receipt of oxygen were excluded. The primary endpoint was 48 h mortality; secondary endpoints included mortality or neurocognitive sequelae at 28 days. RESULTS: The trial was stopped early after enrolling 1852/4200 children, including 388 in the severe hypoxaemia stratum (median 7 months; median SpO2 75%) randomised to HFNT (n = 194) or LFO (n = 194) and 1454 in the hypoxaemia stratum (median 9 months; median SpO2 88%) randomised to HFNT (n = 363) vs LFO (n = 364) vs permissive hypoxaemia (n = 727). Per-protocol 15% of patients in the permissive hypoxaemia group received oxygen (when SpO2 < 80%). In the severe hypoxaemia stratum, 48-h mortality was 9.3% for HFNT vs. 13.4% for LFO groups. In the hypoxaemia stratum, 48-h mortality was 1.1% for HFNT vs. 2.5% LFO and 1.4% for permissive hypoxaemia. In the hypoxaemia stratum, adjusted odds ratio for 48-h mortality in liberal vs permissive comparison was 1.16 (0.49-2.74; p = 0.73); HFNT vs LFO comparison was 0.60 (0.33-1.06; p = 0.08). Strata-specific 28 day mortality rates were, respectively: 18.6, 23.4 and 3.3, 4.1, 3.9%. Neurocognitive sequelae were rare. CONCLUSIONS: Respiratory support with HFNT showing potential benefit should prompt further trials.

Excellent cardiac surgical outcomes in paediatric indigenous patients, but follow-up difficulties.

BACKGROUND: Indigenous Australians' infant mortality is three times that of non-Indigenous Australians. Indigenous children's mortality from rheumatic heart disease is 17-21 times that of non-Indigenous male and female children, respectively. No studies have looked specifically at the operative outcomes of cardiac surgery in paediatric Indigenous patients in Australia and little is known about their follow-up. AIMS: To describe operative outcomes of all Indigenous paediatric cardiac surgical patients at a single Australian tertiary hospital and assess their follow-up. METHODS: Database review of retrospectively collected data of all Indigenous paediatric patients who had cardiac surgery performed at The Prince Charles Hospital, Brisbane between 2002 and 2009 (112 patients, 123 operations). Follow-up was assessed by chart review and time to first post-discharge echocardiogram recorded in the hospital database. RESULTS: Eighty-one percent of operations were congenital heart disease related and 19% of operations were rheumatic heart disease related. Common co-morbidities included respiratory (9.7%) and renal dysfunction (0.8%). Common complications were, bleeding/tamponade 4.1%, cardiac arrest 4.1% and new atrial arrhythmia 2.4%. Mortality was 1% for congenital operations and 4.4% for rheumatic operations. Only 33% of patients had follow-up within eight weeks documented through letters or chart entry. Only 77.5% of patients had a documented follow-up echocardiogram. DISCUSSION: Operative outcome in Indigenous paediatric patients is similar to that found in the global literature. The follow-up for such an excellent surgical outcome has been disappointing. A coordinated action within and between health, health related and social institutions with sufficient resources will assist.

Antiplatelet Management for Stent-Assisted Coiling and Flow Diversion of Ruptured Intracranial Aneurysms: A DELPHI Consensus Statement.

BACKGROUND AND PURPOSE: There is a paucity of data regarding antiplatelet management strategies in the setting of stent-assisted coiling/flow diversion for ruptured intracranial aneurysms. This study aimed to identify current challenges in antiplatelet management during stent-assisted coiling/flow diversion for ruptured intracranial aneurysms and to outline possible antiplatelet management strategies. MATERIALS AND METHODS: The modified DELPHI approach with an on-line questionnaire was sent in several iterations to an international, multidisciplinary panel of 15 neurointerventionalists. The first round consisted of open-ended questions, followed by closed-ended questions in the subsequent rounds. Responses were analyzed in an anonymous fashion and summarized in the final manuscript draft. The statement received endorsement from the World Federation of Interventional and Therapeutic Neuroradiology, the Japanese Society for Neuroendovascular Therapy, and the Chinese Neurosurgical Society. RESULTS: Data were collected from December 9, 2019, to March 13, 2020. Panel members achieved consensus that platelet function testing may not be necessary and that antiplatelet management for stent-assisted coiling and flow diversion of ruptured intracranial aneurysms can follow the same principles. Preprocedural placement of a ventricular drain was thought to be beneficial in cases with a high risk of hydrocephalus. A periprocedural dual, intravenous, antiplatelet regimen with aspirin and a glycoprotein IIb/IIIa inhibitor was preferred as a standard approach. The panel agreed that intravenous medication can be converted to oral aspirin and an oral P2Y12 inhibitor within 24 hours after the procedure. CONCLUSIONS: More and better data on antiplatelet management of patients with ruptured intracranial aneurysms undergoing stent-assisted coiling or flow diversion are urgently needed. Panel members in this DELPHI consensus study preferred a periprocedural dual-antiplatelet regimen with aspirin and a glycoprotein IIb/IIIa inhibitor.

Considerations for Antiplatelet Management of Carotid Stenting in the Setting of Mechanical Thrombectomy: A Delphi Consensus Statement.

BACKGROUND AND PURPOSE: There are only few data and lack of consensus regarding antiplatelet management for carotid stent placement in the setting of endovascular stroke treatment. We aimed to develop a consensus-based algorithm for antiplatelet management in acute ischemic stroke patients undergoing endovascular treatment and simultaneous emergent carotid stent placement. MATERIALS AND METHODS: We performed a literature search and a modified Delphi approach used Web-based questionnaires that were sent in several iterations to an international multidisciplinary panel of 19 neurointerventionalists from 7 countries. The first round included open-ended questions and formed the basis for subsequent rounds, in which closed-ended questions were used. Participants continuously received feedback on the results from previous rounds. Consensus was defined as agreement of ≥70% for binary questions and agreement of ≥50% for questions with >2 answer options. The results of the Delphi process were then summarized in a draft manuscript that was circulated among the panel members for feedback. RESULTS: A total of 5 Delphi rounds were performed. Panel members preferred a single intravenous aspirin bolus or, in jurisdictions in which intravenous aspirin is not available, a glycoprotein IIb/IIIa receptor inhibitor as intraprocedural antiplatelet regimen and a combination therapy of oral aspirin and a P2Y12 inhibitor in the postprocedural period. There was no consensus on the role of platelet function testing in the postprocedural period. CONCLUSIONS: More and better data on antiplatelet management for carotid stent placement in the setting of endovascular treatment are urgently needed. Panel members preferred intravenous aspirin or, alternatively, a glycoprotein IIb/IIIa receptor inhibitor as an intraprocedural antiplatelet agent, followed by a dual oral regimen of aspirin and a P2Y12 inhibitor in the postprocedural period.