Stent-assistedcoil embolization (SACE) has facilitated the treatment of wide-necked and other complex cerebral aneurysms by improving aneurysm neck coverage, preventing coil herniation into the parent artery, and keeping its patency. Stent use brings up concerns about thrombus formation and subsequent cerebral infarction. Dual antiplatelet therapy (DAPT) with clopidogrel and aspirin helps to prevent thromboembolic complications, but resistance or variable responsiveness to clopidogrel may increase the risk of ischemic events.1
Prasugrel, a new-generation P2Y12adenosine diphosphate receptor antagonist, is activated by a single-step process and provides more consistent and effective platelet inhibition.2Recent studies have reported the safety and efficacy of a low-dose prasugrel regimen (20 mg for loading and 5 mg for maintenance) during the periprocedural period in patients undergoing endovascular treatment for cerebral aneurysms.3–5However, these studies have limitations in providing follow-up data after SACE with the use of prasugrel. Additional studies are needed on several issues, including the safety and effectiveness of prasugrel during the extended follow-up period, associated complications, and clinical events related to the antiplatelet regimen changes from DAPT to single antiplatelet medication and from thienopyridines to aspirin.
The purpose of the present study was to investigate the safety and efficacy of a low-dose prasugrel regimen during the long-term follow-up period beyond 1 month after SACE.
开云体育世界杯赔率
Study Population and Data Collection
Between November 2014 and August 2018, 396 consecutive patients with unruptured intracranial aneurysms were treated with SACE under a prasugrel regimen at our institution. Patient-related variables included sex, age, body weight, BMI, hypertension, diabetes mellitus, hyperlipidemia, alcohol consumption, smoking, and retreatment after recanalization. Laboratory features included hematocrit, platelet count, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, triglycerides, and platelet function assay results using the VerifyNow system (Accumetrics). Hypertension, diabetes mellitus, and hyperlipidemia were defined if they were currently administered or diagnosed. Alcohol consumption and smoking were defined if they were maintained from the time of SACE to the follow-up period. Angiographic features included aneurysm size and location and stent types. Therapeutic alternatives for treatment were discussed by the cerebrovascular team with multidisciplinary deliberation.
Informed consent for the procedure was obtained from each patient and their respective family members. This study was conducted after obtaining approval from the institutional review board according to principles outlined in the Declaration of Helsinki, and the need for informed consent for the research was waived because of the retrospective nature of the investigation.
Antiplatelet Medication and Endovascular Procedure
A loading dose of dual antiplatelet medication (20 mg of prasugrel and 300 mg of aspirin) was administered the day before the procedure, and an additional 5 mg of prasugrel and 100 mg of aspirin were given the morning of the procedure day. Whole blood was obtained 6 hours after loading of antiplatelet medication, and the VerifyNow P2Y12assay was used to evaluate platelet reactivity. In poor responders with higher residual platelet reactivity (P2Y12reactivity unit [PRU] values greater than 285), an additional 10 mg of prasugrel was given.3DAPT (5 mg of prasugrel and 100 mg of aspirin) was recommended for at least 1 month after the SACE procedure and maintained for 3 months if possible, followed by lifelong maintenance on aspirin, except for patients with internal carotid artery lesions. For the latter, antiplatelet medication was terminated 1.5 years after SACE, if not contraindicated. The antiplatelet therapy regimen was adjusted according to procedural characteristics, underlying disease and related medications, adverse drug reactions, and patient compliance.
Most endovascular procedures were conducted under general anesthesia. A bolus of unfractionated heparin (3000 IU) was given intravenously after placement of the femoral arterial sheath and bolstered thereafter at hourly intervals (1000 IU); the activated clotting time was monitored. Coil placement was continued until the aneurysm was satisfactorily obliterated, and the appropriate devices were chosen at the operators’ discretion. We used the stents for SACE as follows: LVIS (MicroVention), Enterprise (Cerenovus), Atlas (Stryker), and Neuroform (Boston Scientific).
Outpatient visits were performed at 1, 3, and 6 months during the first 6 months after SACE, after which they were scheduled according to prescription adjustment and the angiography follow-up schedule. We instructed patients to contact the neurointerventional team by telephone or to visit the emergency department if any neurological symptoms related to the treatment developed.
Delayed ischemic events were defined as clinically recognized neurological symptoms associated with the treated vascular territory at least 1 month after treatment. When this event occurred, CT and/or MRI, including diffusion-weighted protocols, were performed to confirm hemorrhagic and ischemic lesions. Diagnosis of cerebral infarction was determined according to the presence of relevant ischemic lesions.
Statistical Analysis
Categorical data were summarized as frequencies, and continuous variables were presented as means ± SDs. Chi-square and Fisher’s exact tests or unpaired t-tests were used to analyze categorical and continuous variables, respectively. Univariate analysis was conducted to determine the risk factors for thromboembolic complications, and a multivariate model that included variables with p values < 0.20 was used. The results of the binary logistic regression model were reported as ORs, 95% CIs, and p values. A 2-tailed p value < 0.05 was considered statistically significant. The Kaplan-Meier product-limit method and the log-rank test served to estimate cumulative survival without thromboembolic complications. All statistical analyses were performed using IBM SPSS (version 26, IBM Corp.) and MedCalc software (version 19.5).
Results
Baseline Characteristics
Of the 396 patients, 278 were female (70.2%). The mean age was 58.1 ± 10.3 years (range 14–81 years). The baseline characteristics of patients were as follows: 199 patients (50.3%) had hypertension, 39 (9.8%) had diabetes mellitus, 203 (51.3%) had hyperlipidemia, 116 (29.3%) consumed alcohol, and 68 (17.2%) were smokers. For 79 patients (19.9%), SACE was performed as a secondary treatment for recanalization after coil embolization procedures. The mean maximum aneurysm diameter was 6.2 ± 3.1 mm (range 2.1–43.0 mm). The most frequent stents were the LVIS (n = 244, 61.6%), followed by Enterprise (n = 121, 30.6%), Atlas (n = 22, 5.6%), and Neuroform (n = 9, 2.3%). Baseline characteristics are detailed inTable 1。
Baseline characteristics of patients, laboratory data, and aneurysms
| Variable | Value |
|---|---|
| No. of patients | 396 |
| Mean age, yrs | 58.1 ± 10.3 |
| Mean body weight, kg | 63.0 ± 11.2 |
| Mean BMI | 24.8 ± 3.5 |
| Female sex | 278 (70.2) |
| Mean duration of dual antiplatelet medication (PSG & aspirin), mos | 3.2 ± 1.1 |
| Medical & social history | |
| Hypertension | 199 (50.3) |
| Diabetes mellitus | 39 (9.8) |
| Hyperlipidemia | 203 (51.3) |
| Alcohol use | 116 (29.3) |
| Smoker | 68 (17.2) |
| Mean lab values | |
| Hematocrit, % | 39.7 ± 4.2 |
| Platelet count, ×103/µL | 240.1 ± 63.3 |
| HDL, mg/dL | 57.2 ± 25.0 |
| LDL, mg/dL | 107.1 ± 32.4 |
| Triglycerides, mg/dL | 121.0 ± 66.6 |
| Aneurysm data | |
| Mean max aneurysm diameter, mm | 6.2 ± 3.1 |
| Location | |
| ICA | 170 (42.9) |
| ACA | 99 (25.0) |
| MCA | 64 (16.2) |
| PC | 63 (15.9) |
| Repeat embolization | 79 (19.9) |
| Stent type | |
| LVIS | 244 (61.6) |
| Enterprise | 121 (30.6) |
| Atlas | 22 (5.6) |
| Neuroform | 9 (2.3) |
| Mean VerifyNow platelet function test values | |
| Base | 279.9 ± 42.5 |
| % inhibition | 54.9 ± 27.6 |
| PRU | 125.6 ± 78.1 |
| Mean follow-up, mos | 24.6 ± 11.3 |
ACA = anterior cerebral artery; ICA = internal carotid artery; MCA = middle cerebral artery; PC = posterior circulation; PSG = prasugrel.
Values are presented as the number of patients (%) or mean ± SD.
After the SACE procedure, prasugrel medication was maintained for 1 month in 25 patients (6.3%), for 3 months in 334 (84.3%) patients, and for 6 months or longer in 37 (9.3%) patients.
Follow-Up Results
In this cohort, cerebral infarction occurred in 1 patient (0.3%, 95% CI 0%–1.8%) beyond 1 month after SACE. No patient developed intracranial or other critical hemorrhage. Overall, delayed ischemic events occurred in 14 patients (3.5%) during the mean follow-up period of 24.6 ± 11.3 months (range 5–58 months). Motor transient ischemic attacks (TIAs) were the most frequent symptoms (n = 9), followed by visual TIAs (n = 2), a sensory TIA (n = 1), memory disturbance (n = 2), and both motor and sensory TIAs (n = 1). Only 1 patient (0.3%) showed positive relevant ischemic lesions on MRI (case 1). This patient reported recurrent right-sided motor weakness, and MRI showed an acute focal infarction in the left caudate and corona radiata. All patients had temporary symptoms and fully recovered. The other 13 patients did not demonstrate ischemic lesions on MRI, and their symptoms were transient.
当时的事件,11个患者塔基•ng aspirin only. The other patients were taking aspirin and prasugrel (n = 1), clopidogrel only (n = 1), and prasugrel only (n = 1). The intervals between prasugrel discontinuation and events were less than 1 month in 7 patients, 1 month in 4 patients, and 3 months in 1 patient (Table 2,Fig. 1). Regarding the duration of prasugrel medication, delayed ischemic events occurred in 0%, 4.2%, and 0% of patients in the 1-month group, 1- to 3-month group, and 3- to 6-month group, respectively.
缺血性ev延迟患者的临床资料ents
| Case No. | Antiplatelet Agent Before Event (mos)* | Location | PRU/% Inhibition | Stent Type | Symptom | Interval From Coiling to Event, mos | Interval From Stopped PSG to Event, mos | Antiplatelet Medication After Event (mos) | mRS Grade |
|---|---|---|---|---|---|---|---|---|---|
| 1 | PSG/ASA (1) → PSG (2) →ASA | MCA | 38/82% | Enterprise | Motor TIA | 4 | 1 | CPG/ASA | 0 |
| 2 | PSG (3) →ASA | ICA | 203/34% | LVIS | Motor TIA | 3 | <1 | CPG | 0 |
| 3 | PSG (3) →ASA | ACA | 265/19% | LVIS | Motor TIA | 3 | <1 | CPG | 0 |
| 4 | PSG | ICA | 223/5% | Enterprise | Visual TIA | 1 | w/ PSG | PSG(2) → CPG (8) → ASA | 0 |
| 5 | PSG (3) →ASA | MCA | 117/60% | LVIS | Motor TIA | 3 | <1 | CPG | 0 |
| 6 | PSG/ASA (1) → PSG (2) →CPG | MCA | 23/91% | LVIS | Memory disturbance & sensory TIA | 4 | 1 | CPG/ASA (15) → CPG | 0 |
| 7 | PSG (3) →ASA | ICA | 194/11% | LVIS | Motor TIA | 3 | <1 | CPG/ASA (5) → CPG (30) → none | 0 |
| 8 | PSG/ASA (1) → PSG (2) →ASA | MCA | 176/20% | LVIS | Motor TIA | 3 | <1 | CPG/ASA (1) → CPG | 0 |
| 9 | PSG/ASA (3) →ASA | ACA | 149/31% | LVIS | Motor TIA | 3 | <1 | CPG (15) → ASA | 0 |
| 10 | PSG/ASA (3) →ASA | PC | 115/62% | Atlas | Motor & sensory TIA | 6 | 3 | CPG/ASA (6) → ASA | 0 |
| 11 | PSG/ASA (1) → PSG (2) →ASA | ICA | 112/67% | Enterprise | Visual TIA | 3 | <1 | CPG (21) → none | 0 |
| 12 | PSG/ASA | ACA | 344/0% | LVIS | Memory disturbance | 1 | w/ PSG | CPG (9) → ASA | 0 |
| 13 | PSG/ASA (1) → PSG (2) →ASA | ICA | 31/89% | LVIS | Motor TIA | 4 | 1 | CPG/ASA (10) → CPG | 0 |
| 14 | PSG/ASA (1) → PSG (2) →ASA | ICA | 49/81% | Atlas | Motor TIA | 4 | 1 | CPG (6) → ASA | 0 |
ASA = aspirin; CPG = clopidogrel; mRS = modified Rankin Scale; → = progression of medication.
Boldface type indicates the antiplatelet medication being used when symptoms occurred.
延迟分配SACE后缺血性事件。Left:Duration from coiling to events.Right:Duration from discontinued prasugrel (PSG) to events.
Risk Factor Analysis for Delayed Ischemic Events
The risk factors for delayed ischemic events were evaluated using the following variables: sex, age, body weight, BMI, hypertension, diabetes mellitus, hyperlipidemia, smoking, alcohol, hematocrit, platelets, HDL cholesterol, LDL cholesterol, triglycerides, PRU, LVIS stent, posterior circulation, maximum aneurysm size, and repeat treatment. When we compared variables between patients with and without delayed ischemic events, no significant differences were found (Table 3). Multivariate regression analysis did not provide risk factors correlated with delayed ischemic events (Table 4).
Patient characteristics with and without delayed ischemic events during the follow-up period
| Variable | No Ischemic Event (n = 382) | Any Ischemic Event (n = 14) | p Value |
|---|---|---|---|
| Mean age, yrs | 58.2 ± 10.3 | 55.1 ± 9.5 | 0.265 |
| Mean body weight, kg | 63.0 ± 11.2 | 63.9 ± 10.2 | 0.758 |
| Mean BMI | 24.8 ± 3.6 | 24.6 ± 3.0 | 0.834 |
| Female sex | 269 (70.4) | 9 (64.3) | 0.622 |
| Medical & social history | |||
| Hypertension | 195 (51.0) | 4 (28.6) | 0.111 |
| Diabetes mellitus | 38 (9.9) | 1 (7.1) | 1.000 |
| Hyperlipidemia | 194 (50.8) | 9 (64.3) | 0.321 |
| Alcohol use | 111 (29.1) | 5 (35.7) | 0.591 |
| Smoker | 64 (16.8) | 4 (28.6) | 0.274 |
| Mean lab values | |||
| Hematocrit, % | 39.7 ± 4.2 | 39.9 ± 4.0 | 0.873 |
| Platelet count, ×103/µL | 240.0 ± 64.4 | 239.4 ± 41.2 | 0.972 |
| HDL, mg/dL | 57.5 ± 25.3 | 48.6 ± 11.3 | 0.195 |
| LDL, mg/dL | 106.7 ± 32.6 | 116.7 ± 27.1 | 0.257 |
| Triglycerides, mg/dL | 120.1 ± 66.3 | 144.3 ± 73.7 | 0.183 |
| Aneurysm data | |||
| Mean max aneurysm diameter, mm | 5.8 ± 4.6 | 4.7 ± 2.0 | 0.372 |
| Location | 0.540 | ||
| ICA* | 164 (42.9) | 6 (42.9) | |
| ACA | 96 (25.1) | 3 (21.4) | |
| MCA | 60 (15.7) | 4 (28.6) | |
| PC | 62 (16.2) | 1 (7.1) | |
| Repeat embolization | 77 (20.2) | 2 (14.3) | 0.745 |
| LVIS stent | 235 (61.55) | 9 (64.3) | 0.834 |
| Mean VerifyNow platelet function test values | |||
| Base | 280.2 ± 42.4 | 271.1 ± 45.9 | 0.431 |
| % inhibition | 55.2 ± 27.4 | 46.6 ± 32.9 | 0.251 |
| PRU | 124.8 ± 77.4 | 145.6 ± 95.3 | 0.329 |
| Mean follow-up, mos | 24.6 ± 11.2 | 22.8 ± 9.8 | 0.541 |
Values are presented as the number of patients (%) or mean ± SD unless specified otherwise.
Internal carotid artery aneurysms included posterior communication artery, anterior choroidal artery, ophthalmic artery, and paraclinoid location aneurysms.
Analysis of risk factors of delayed ischemic events of SACE
| Variable | Univariate Analysis | Multivariate Analysis | ||
|---|---|---|---|---|
| OR (95% CI) | p Value | OR (95% CI) | p Value | |
| Female sex | 0.756 (0.248–2.306) | 0.623 | ||
| Age | 0.973 (0.928–1.021) | 0.265 | ||
| Body weight | 1.007 (0.962–1.055) | 0.757 | ||
| BMI | 0.984 (0.843–1.147) | 0.833 | ||
| Hypertension | 0.384 (0.118 - -1.244) | 0.111 | 2.621 (0.802–8.562) | 0.111 |
| Diabetes mellitus | 0.696 (0.089–5.471) | 0.731 | ||
| Hyperlipidemia | 1.744 (0.574–5.301) | 0.327 | ||
| Smoking | 1.987 (0.605–6.534) | 0.258 | ||
| Alcohol | 1.356 (0.445–4.138) | 0.529 | ||
| Hematocrit | 1.011 (0.888–1.150) | 0.873 | ||
| Platelet | 1.000 (0.991–1.008) | 0.967 | ||
| HDL cholesterol | 0.964 (0.925–1.004) | 0.080 | 0.968 (0.927–1.010) | 0.133 |
| LDL cholesterol | 1.009 (0.993–1.025) | 0.257 | ||
| Triglycerides | 1.004 (0.998 - -1.010) | 0.189 | 1.002 (0.995–1.008) | 0.613 |
| PRU | 1.003 (0.997–1.010) | 0.330 | ||
| LVIS stent | 1.126 (0.370–3.425) | 0.834 | ||
| Posterior circulation | 0.397 (0.051–3.090) | 0.378 | ||
| Max aneurysm size | 0.820 (0.609–1.104) | 0.190 | ||
| Repeat treatment | 0.660 (0.145–3.011) | 0.592 | ||
Kaplan-Meier estimates of cumulative survival without delayed ischemic events during 36 months after coil embolization are shown inFig. 2。使用生存率较,累积发生率of delayed ischemic events shown by duration of prasugrel maintenance (1 month vs 3 months, p = 0.299; 3 months vs 6 months, p = 0.213) were not significantly different (Fig. 3).
Kaplan-Meier estimates of cumulative survival without delayed ischemic events during 36 months after SACE.
Kaplan-Meier estimates of cumulative survival without delayed ischemic events during 36 months after SACE.Left:One month versus 3 months of prasugrel maintenance.Right:Three months versus 6 months of prasugrel maintenance.
Discussion
This study outlines the benefits of low-dose prasugrel maintenance after SACE. Of the 396 patients who underwent SACEs, delayed ischemic events occurred in 3.5% (95% CI 2.1%–5.9%), and only 1 patient (0.3%, 95% CI 0%–1.8%) showed diffusion-restrictive lesions. Moreover, hemorrhagic events did not occur during the follow-up period, and all patients recovered well without permanent neurological deficits.
In cardiology practice, the standard prasugrel protocol (60-mg loading dose and 10-mg maintenance dose [abbreviated as 60/10]) suggested that prasugrel improved the effectiveness of reducing thromboembolic complications compared with clopidogrel.6,7Despite the significant reduction in rates of ischemic events, an increased risk of major bleeding, including fatal bleeding, was reported in patients on the 10-mg daily maintenance dose, especially in patients ≥ 75 years, with a weight < 60 kg, or with a history of ischemic stroke.6Therefore, a lower maintenance dose (5 mg daily) was recommended to minimize their bleeding risk.8In the neurointerventional field, a 60/10-mg prasugrel regimen was also associated with higher hemorrhagic rates in comparison with clopidogrel.9Therefore, a low-dose prasugrel regimen with loading dose of 20 mg of prasugrel (corresponding to one-third the dose in the TRITON-TIMI 38 trial) the day before a procedure and a maintenance dose of 5 mg of prasugrel (half of the trial dose6) the morning of the procedure was applied in subsequent studies, and this regimen showed effective reductions of thromboembolic events and acceptable hemorrhagic complication rates.4,5In a previous study comparing a low-dose prasugrel regimen and a clopidogrel-based tailored regimen for patients undergoing stent-assisted treatment for aneurysms,3the study also demonstrated less frequent thromboembolic events in the prasugrel group (0.9% vs 6.4%, p = 0.01).
Delayed thromboembolic and hemorrhagic complications have been other important concerns of SACE. Reports of low-dose prasugrel medication in the neurovascular field have only included initial complications; there have been no reports on whether the initial effects of low-dose prasugrel lasted during the maintenance period, whether it could be safely switched to a single medication, and whether there were no additional hemorrhagic complications. We believe that this study demonstrates the efficacy and safety of the low-dose prasugrel maintenance regimen. At our institution, we recommend DAPT (5 mg of prasugrel and 100 mg of aspirin) for at least 1 month after the SACE procedure, with maintenance at this dose for 3 months if possible. Variable antiplatelet regimens were used in patients depending on procedural thromboembolic complications, underlying diseases, prior antiplatelet agent use, side effects, and adherence during the follow-up period. Among the various prescriptions, the low-dose prasugrel regimen prevented thromboembolic complications effectively in this study, without the occurrence of hemorrhagic complications. Notably, this study shows a low complication rate, like that in previous studies (Table 5).12–14,18,19Although the antiplatelet protocol and the definition of delayed ischemic events were various in these studies, the results of the present study showed effective prevention of ischemic events.
Summary of clinical outcomes of antiplatelet medication after SACE
| Authors & Year | No. of Cases | Delayed Ischemic Event Definition | Antiplatelet Protocol | No. of Patients (%) | ||
|---|---|---|---|---|---|---|
| Stroke | Transient Ischemic Event | Total Ischemic Events | ||||
| Lee et al., 201319 | 261 | 2 wks postprocedure | 75 mg CPG & 100 mg ASA for ≥1 mo, 100 mg ASA for ≥1 yr | 11 (4.2) | 0 (0) | 11 (4.2) |
| Rossen et al., 201212 | 121 | Follow-up ≥3 mos after CPG discontinuation | 75 mg CPG & 81 mg ASA daily for 6 wks followed by 325 mg ASA daily indefinitely | 6 (5) | 0 (0) | 6 (5) |
| Hwang et al., 201413 | 395 | 1 mo postprocedure | 75 mg CPG & 100 mg ASA for ≥3 mos, 100 mg ASA for ≥1 yr | 7 (1.8) | 7 (1.8) | 14 (3.5) |
| Song et al., 201518 | 125 | 1 mo postprocedure | 75 mg CPG 100 mg ASA for ≥6 mos followed by 75 mg CPG or 100 mg ASA | 10 (7.9) | 0 (0) | 10 (7.9) |
| Kim et al., 201814 | 507 | 1 mo postprocedure | 75 mg CPG & 100 mg ASA for various durations depending on yr of procedure | 9 (1.8) | 16 (3.1) | 25 (4.9) |
| Present series | 396 | 1 mo postprocedure | 5 mg PSG & 100 mg ASA for ≥1 mo after procedure followed by 325 mg ASA daily indefinitely | 1 (0.2) | 13 (3.3) | 14 (3.5) |
Although DAPT with clopidogrel and aspirin has been a widely accepted prophylactic regimen in patients undergoing SACE,10the duration of DAPT after SACE has been heterogeneous. There is no widely accepted consensus of the ideal time point of shifting to a single antiplatelet medication. In patients with percutaneous coronary intervention for stable angina, DAPT is recommended for 6 months in patients without risk of the occurrence of life-threatening bleeding, and 3-month DAPT is recommended in patients with a higher risk of life-threatening bleeding.8In the neurointerventional field, cessation of DAPT was correlated with thromboembolic complications after SACE, and ischemic events also occurred immediately after shifting to aspirin only within 2 months.11–14Prolonged DAPT showed inconsistent effectiveness for the prevention of thromboembolic complications,13,14and it was associated with a high risk of bleeding.13–17In a survey by Faught et al.,10the most common duration of DAPT after placement of a cervical or intracranial stent was 3 months, followed by 6 months. In the present study, since patients with 6 months of prasugrel maintenance did not experience delayed ischemic events, the longer period of prasugrel maintenance might be favored unless the patient demonstrates a tendency to bruise easily or has other hemorrhagic problems. In our analysis, delayed ischemic events occurred in 0%, 4.2%, and 0% of the patients in the 1-month group, 1- to 3-month group, and 3- to 6-month group, respectively. The majority (84.4%) of patients belonged to the second group, which made the statistical analyses suboptimal. Additional data and studies are needed to make evidence-based statements.
There are critical limitations to the present study. No consistent antiplatelet regimen was used, and heterogeneous regimens were prescribed to the patients during follow-up, according to their various clinical situations. As a result, an optimal antiplatelet medication protocol could not be determined in the current study. Large, prospective, and randomized clinical trials are needed to determine the optimal antiplatelet medication protocol for reducing the incidence of thromboembolic and hemorrhagic complications following neuroendovascular procedures.
Conclusions
Maintenance with low-dose prasugrel was found to be safe and effective in patients treated with SACEs. Transient ischemic events most likely occurred within 2 months of ceasing prasugrel medication.
Disclosures
The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
Author Contributions
Conception and design: Kang, Choi, K Kim, JE Kim. Acquisition of data: Kang, Choi, HS Lee, SH Lee, K Kim, Cho. Analysis and interpretation of data: Kang, Choi. Drafting the article: Kang, Choi. Critically revising the article: Kang, Choi, Cho. Reviewed submitted version of manuscript: Kang, HS Lee, Cho. Approved the final version of the manuscript on behalf of all authors: Kang. Statistical analysis: Kang, Choi. Administrative/technical/material support: Kang, Choi, HS Lee, Cho, JE Kim. Study supervision: Kang, HS Lee, K Kim, Cho, JE Kim.
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17 ↑
BittlJA,BaberU,BradleySM,WijeysunderaDN。Duration of dual antiplatelet therapy: a systematic review for the 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines。Circulation。2016;134(10):e156–e178。
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18 ↑
SongJ,YeonJY,KimJS,HongSC,KimKH,JeonP。Delayed thromboembolic events more than 30 days after self expandable intracranial stent-assisted embolization of unruptured intracranial aneurysms。Clin Neurol Neurosurg。2015;135:73–78。
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19 ↑
LeeSJ,ChoYD,KangHS,Kim我,HanMH。Coil embolization using the self-expandable closed-cell stent for intracranial saccular aneurysm: a single-center experience of 289 consecutive aneurysms。Clin Radiol。2013;68(3):256–263。
