Effect of antiplatelet therapy and platelet function testing on hemorrhagic and thrombotic complications in patients with cerebral aneurysms treated with the pipeline embolization device: a review and meta-analysis.
OBJECTIVE
The pipeline embolization device (PED) necessitates dual antiplatelet therapy (APT) to decrease thrombotic complications while possibly increasing bleeding risks. The role of APT dose, duration, and response in patients with hemorrhagic and thromboembolic events warrants further analysis.


METHODS
A PubMed and Google Scholar search from 2009 to 2014 was performed using the following search terms individually or in combination: pipeline embolization device, aneurysm(s), and flow diversion, excluding other flow diverters. Review of the bibliographies of the retrieved articles yielded 19 single and multicenter studies. A statistical meta-analysis between aspirin (ASA) dose (low dose ≤160 mg, high dose ≥300 mg), loading doses of APT agents, post-PED APT regimens, and platelet function testing (PFT) with hemorrhagic or thrombotic complications was performed.


RESULTS
ASA therapy for ≤6 months post-PED was associated with increased hemorrhagic events. High dose ASA ≤6 months post-PED was associated with fewer thrombotic events compared with low dose ASA. Post-PED clopidogrel for ≤6 months demonstrated an increased incidence of symptomatic thrombotic events. Loading doses of ASA plus clopidogrel demonstrated a decreased incidence of permanent symptomatic hemorrhagic events. PFT did not show a statistically significant relationship with symptomatic hemorrhagic or thrombotic complications.


CONCLUSIONS
High dose ASA >6 months is associated with fewer permanent thrombotic and hemorrhagic events. Clopidogrel therapy ≤6 months is associated with higher rates of thrombotic events. Loading doses of ASA and clopidogrel were associated with a decreased incidence of hemorrhagic events. PFT did not have any significant association with symptomatic events.
Departments of Neurosurgery and Radiology, The Emory Clinic, Atlanta, Georgia, USA.
Susana L
SL
Skukalek
Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.
Anne M
AM
Winkler
Department of Biostatistics and Bioinformatics, Emory Rollins School of Public Health, Atlanta, Georgia, USA.
Jian
J
Kang
Departments of Radiology and Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA.
Jacques E
JE
Dion
Departments of Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA.
C Michael
CM
Cawley
Departments of Neurology and Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA.
Adam
A
Webb
Department of Neurosurgery, The University of Texas at Houston, Houston, Texas, USA.
Mark J
MJ
Dannenbaum
Department of Neurosurgery, Tripler Army Medical Center, Honolulu, Hawaii, USA.
Albert J
AJ
Schuette
Emory University Hospital, Atlanta, Georgia, USA.
Bill
B
Asbury
Departments of Radiology and Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA.
Frank C
FC
Tong
D002543:Cerebral Hemorrhage / Q000139:chemically induced*; D004621:Embolization, Therapeutic / Q000295:instrumentation* / Q000379:methods; D006801:Humans; D002532:Intracranial Aneurysm / Q000188:drug therapy / Q000628:therapy*; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage / Q000009:adverse effects*; D010979:Platelet Function Tests; D013923:Thromboembolism / Q000139:chemically induced*
D010975:Platelet Aggregation Inhibitors
Aneurysm; Complication; Flow Diverter