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Safety and Tolerability of High-Intensity Anticoagulation with Bivalirudin During Neuroendovascular Procedures

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Abstract

Background

Bivalirudin (Angiomax) is a direct thrombin inhibitor used in interventional cardiology due to its several distinct advantages over heparin, most notably a shorter half-life and a potentially superior safety profile. Bivalirudin is also safe to use in patients with active or remote heparin-induced thrombocytopenia. Our objective was to evaluate the safety and tolerability of high-intensity anticoagulation using bivalirudin during neuroendovascular procedures.

Methods

The bivalirudin dosing regimens reported in the cardiac literature were modified empirically for two different activated clotting time (ACT) target ranges. The low-dose protocol (ACT of 250 to 300 s) was used for embolization procedures and the high-dose protocol (ACT of 300–350) was employed for angioplasty and stent placement. The bivalirudin treated patients were matched for age, gender, and type of procedure with a random sample of patients who underwent neuroendovascular procedures with the standardized heparin protocol. The thromboembolic and hemorrhagic complications were compared between the two groups and bleeding complications were categorized as major (hemorrhage that was intra-cerebral or resulted in Hb decrease ≥ 5 g/dl), minor, or insignificant.

Results

Bivalirudin was used in 30 patients with high-dose and low-dose bivalirudin protocols used in 26 and 4 patients, respectively. These were compared to the 60 control patients who received heparin. There were no bleeding or thromboembolic complications in the bivalirudin treated patients; however one patient reported a transient headache. In patients treated with heparin, one bleeding complication of a groin hematoma was reported. Also one patient was found to have left-arm weakness following the procedure which was attributed to a new small middle cerebral artery ischemic event.

Conclusions

Our data supports that bivalirudin usage is likely a safe alternative to heparin for high-intensity anticoagulation in neuroendovascular procedures. Further studies are required for more definitive comparisons for efficacy and cost-effectiveness between the two agents.

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References

  1. Arora UK, Dhir M. Direct thrombin inhibitors (part 1 of 2). J Invasive Cardiol. 2005;17(1):34–8.

    PubMed  Google Scholar 

  2. Bittl JA. Comparative safety profiles of hirulog and heparin in patients undergoing coronary angioplasty. The Hirulog Angioplasty Study Investigators. Am Heart J. 1995;130(3 Pt 2):658–65.

    Article  PubMed  CAS  Google Scholar 

  3. Ramana RK, Lewis BE. Percutaneous coronary intervention in patients with acute coronary syndrome: focus on bivalirudin. Vasc Health Risk Manag. 2008;4(3):493–505.

    PubMed  CAS  Google Scholar 

  4. Chamberlin JR, Lewis B, Leya F, et al. Successful treatment of heparin-associated thrombocytopenia and thrombosis using Hirulog. Can J Cardiol. 1995;11(6):511–4.

    PubMed  CAS  Google Scholar 

  5. Lincoff AM, Bittl JA, Kleiman NS, et al. Comparison of bivalirudin versus heparin during percutaneous coronary intervention (the Randomized Evaluation of PCI Linking Angiomax to Reduced Clinical Events [REPLACE]-1 trial). Am J Cardiol. 2004;93(9):1092–6.

    Article  PubMed  CAS  Google Scholar 

  6. Bittl JA, Strony J, Brinker JA, et al. Treatment with bivalirudin (Hirulog) as compared with heparin during coronary angioplasty for unstable or postinfarction angina. Hirulog Angioplasty Study Investigators. N Engl J Med. 1995;333(12):764–9.

    Article  PubMed  CAS  Google Scholar 

  7. Georgiadis AL SQ, Suri MFK, Qureshi AI. Adjunct bivalirudin dosing protocol for neuro-endovascular procedures. J Vasc Intervent Neurol. 2008;1(2):50–3.

    Google Scholar 

  8. Cohen DJ, Lincoff AM, Lavelle TA, et al. Economic evaluation of bivalirudin with provisional glycoprotein IIB/IIIA inhibition versus heparin with routine glycoprotein IIB/IIIA inhibition for percutaneous coronary intervention: results from the REPLACE-2 trial. J Am Coll Cardiol. 2004;44(9):1792–800.

    PubMed  CAS  Google Scholar 

  9. Heres EK, Speight K, Benckart D, et al. The clinical onset of heparin is rapid. Anesth Analg. 2001;92(6):1391–5.

    Article  PubMed  CAS  Google Scholar 

  10. Lincoff AM, Bittl JA, Harrington RA, et al. Bivalirudin and provisional glycoprotein IIb/IIIa blockade compared with heparin and planned glycoprotein IIb/IIIa blockade during percutaneous coronary intervention: REPLACE-2 randomized trial. JAMA. 2003;289(7):853–63.

    Article  PubMed  CAS  Google Scholar 

  11. Qureshi AI, Luft AR, Sharma M, et al. Prevention and treatment of thromboembolic and ischemic complications associated with endovascular procedures: part II—clinical aspects and recommendations. Neurosurgery. 2000;46(6):1360–75 (discussion 1375–1366).

    Article  PubMed  CAS  Google Scholar 

  12. Saw J, Bajzer C, Casserly IP, et al. Evaluating the optimal activated clotting time during carotid artery stenting. Am J Cardiol. 2006;97(11):1657–60.

    Article  PubMed  Google Scholar 

  13. Brunton LL, Lazo JS, Parker KL, editors. Goodman & Gilman’s The Pharmacological Basis of Therapeutics. 11th ed. New York: Mc-Graw-Hill Companies; 2006.

    Google Scholar 

  14. Mehran R, Lansky AJ, Witzenbichler B, et al. Bivalirudin in patients undergoing primary angioplasty for acute myocardial infarction (HORIZONS-AMI): 1-year results of a randomised controlled trial. Lancet. 2009;374(9696):1149–59.

    Article  PubMed  Google Scholar 

  15. Feit F, Voeltz MD, Attubato MJ, et al. Predictors and impact of major hemorrhage on mortality following percutaneous coronary intervention from the REPLACE-2 Trial. Am J Cardiol. 2007;100(9):1364–9.

    Article  PubMed  Google Scholar 

  16. Eikelboom JW, Mehta SR, Anand SS, et al. Adverse impact of bleeding on prognosis in patients with acute coronary syndromes. Circulation. 2006;114(8):774–82.

    Article  PubMed  Google Scholar 

  17. Kinnaird TD, Stabile E, Mintz GS, et al. Incidence, predictors, and prognostic implications of bleeding and blood transfusion following percutaneous coronary interventions. Am J Cardiol. 2003;92(8):930–5.

    Article  PubMed  Google Scholar 

  18. Rao SV, Jollis JG, Harrington RA, et al. Relationship of blood transfusion and clinical outcomes in patients with acute coronary syndromes. JAMA. 2004;292(13):1555–62.

    Article  PubMed  CAS  Google Scholar 

  19. Stone GW, Witzenbichler B, Guagliumi G, et al. Bivalirudin during primary PCI in acute myocardial infarction. N Engl J Med. 2008;358(21):2218–30.

    Article  PubMed  CAS  Google Scholar 

  20. Mehran R, Brodie B, Cox DA, et al. The Harmonizing Outcomes with RevasculariZatiON and Stents in Acute Myocardial Infarction (HORIZONS-AMI) Trial: study design and rationale. Am Heart J. 2008;156(1):44–56.

    Article  PubMed  CAS  Google Scholar 

  21. Mehran R, Pocock SJ, Stone GW, et al. Associations of major bleeding and myocardial infarction with the incidence and timing of mortality in patients presenting with non-ST-elevation acute coronary syndromes: a risk model from the ACUITY trial. Eur Heart J. 2009;30(12):1457–66.

    Article  PubMed  Google Scholar 

  22. Bush RL, Lin PH, Mureebe L, et al. Routine bivalirudin use in percutaneous carotid interventions. J Endovasc Ther. 2005;12(4):521–2.

    Article  PubMed  Google Scholar 

  23. Schneider LM, Polena S, Roubin G, et al. Carotid stenting and bivalirudin with and without vascular closure: 3-year analysis of procedural outcomes. Catheter Cardiovasc Interv. 2010;75(3):420–6.

    PubMed  Google Scholar 

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Authors and Affiliations

  1. Zeenat Qureshi Stroke Research Center, University of Minnesota, 12-100 PWB, 516 Delaware St. SE, Minneapolis, MN, 55455, USA

    Ameer E. Hassan, Muhammad Zeeshan Memon, Alexandros L. Georgiadis, Gabriela Vazquez, M. Fareed K. Suri & Adnan I. Qureshi

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  1. Ameer E. Hassan
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  2. Muhammad Zeeshan Memon
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  3. Alexandros L. Georgiadis
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  4. Gabriela Vazquez
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  5. M. Fareed K. Suri
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  6. Adnan I. Qureshi
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Correspondence to Ameer E. Hassan.

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Hassan, A.E., Memon, M.Z., Georgiadis, A.L. et al. Safety and Tolerability of High-Intensity Anticoagulation with Bivalirudin During Neuroendovascular Procedures. Neurocrit Care 15, 96–100 (2011). https://doi.org/10.1007/s12028-010-9421-7

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  • DOI: https://doi.org/10.1007/s12028-010-9421-7

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