J Korean Neurosurg Soc.  2017 Sep;60(5):518-526. 10.3340/jkns.2016.1212.006.

Intra-arterial and Intravenous Tirofiban Infusion for Thromboembolism during Endovascular Coil Embolization of Cerebral Aneurysm

• Kim SH
• Kim TG
• Kong MH

• KMID: 2457958
• DOI: http://doi.org/10.3340/jkns.2016.1212.006

Abstract

OBJECTIVE
Thromboembolism is the one of the most serious complications that can occur during endovascular coil embolization of cerebral aneurysm. We report on the effectiveness and safety of intra-arterial/intravenous (IA/IV) glycoprotein IIb/IIIa inhibitor (tirofiban) infusion for treating thromboembolism during endovascular coil embolization of cerebral aneurysm.
METHODS
We performed a retrospective analysis of 242 patients with ruptured or unruptured cerebral aneurysms (n=264) who underwent endovascular coil embolization from January 2011 to June 2014. Thromboembolism occurred in 20 patients (7.4%), including 14 cases of ruptured aneurysms and 6 cases of unruptured aneurysms. The most common site of aneurysms was the anterior communicating artery (n=8), followed by middle cerebral artery (n=6). When we found an enlarged thromboembolism during coil embolization, we tried to dissolve it using tirofiban administered via IA and IV loading (5 μg/kg, respectively) for 3-5 minutes followed by IV maintenance (0.08 μg/kg/min) for approximately 4-24 hours.
RESULTS
In 4 of 5 patients with total vessel occlusion, the vessel was recanalized to Thrombolysis in Cerebral Infarction Perfusion Scale (TICI) grade 3, and in 1 patient to TICI grade 2a. In 2 patients with partial vessel occlusion and 13 patients with minimal occlusion, the vessel recanalized to TICI grade 3. Irrelevant intracerebral hemorrhage was noted in 1 patient (5%), and thromboemboli-related cerebral infarction developed in 5 patients (25%), of which only 1 (5%) was symptomatic.
CONCLUSION
IA/IV infusion and IV maintenance with tirofiban appear to be an effective rescue treatment for thromboembolism during endovascular coil embolization in patients with ruptured or unruptured cerebral aneurysms.

Keyword

Endovascular coil embolization; Thromboembolism; Tirofiban; Intra-arterial/intravenous infusion

MeSH Terms

Aneurysm
Aneurysm, Ruptured
Arteries
Cerebral Hemorrhage
Cerebral Infarction
Embolization, Therapeutic*
Glycoproteins
Humans
Intracranial Aneurysm*
Middle Cerebral Artery
Perfusion
Retrospective Studies
Thromboembolism*
Glycoproteins

Figure

• 

  Fig. 1 Endovascular coil embolization was performed in a patient with a ruptured left intracerebral artery-anterior choroidal artery aneurysm. The left anterior choroidal artery (black arrows) was highly visible in the working view (A). After completing the coiling, the left anterior choroidal artery was still visible (B). In a follow-up angiogram taken 15 minutes later, the left anterior choroidal artery was not visible (C). Intra-arterial (via the guiding catheter)/intravenous loading was done at the same time with a dose of 5 μg/kg respectively (~80% of the usual recommended dose); tirofiban was maintained intravenously with a dose of 0.08 μg/kg/min (~80% of the usual recommended dose). Thirty minutes later, the flow through the left anterior choroidal artery was noted well (D), and intravenous maintenance therapy continued for approximately 23 hours.

• 

  Fig. 2 Endovascular stent-assisted coil embolization was performed in a patient with a ruptured left anterior communicating artery aneurysm. The left anterior cerebral artery (A1 and A2; black arrows) was highly visible in the working view (A). After stent deployment and completion of coiling, the distal stent marker was noted at the left A2 (arrowhead) (B), and the acute in-stent thrombus and distal flow occlusion were noted in the left A1 (C). An intra-arterial (via the guiding catheter)/intravenous loading dose (5 μg/kg, ~80% of the usual recommended dose) was given at the same time, and tirofiban was maintained intravenously with a dose of 0.08 μg/kg/min (~80% of the usual recommended dose). Thirty minutes later, the flow of the left anterior cerebral artery was noted (D). After administering an oral loading dose of antiplatelets (aspirin 300 mg and clopidogrel 300 mg), intravenous maintenance therapy proceeded for 4 hours and was gradually discontinued.

Reference

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