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Optimal pediatric dosing of anti-platelet agents for pipeline stent embolization —a case report and review of the literature

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Abstract

Background

Various strategies are emerging for dosing antiplatelet therapies in preparation for pipeline stent embolization in adults. Hyper-response is associated with hemorrhagic complications. Hypo-response is associated with thromboembolic events. Dosing of antiplatelet agents is highly variable, with little consensus among experts for adults–and even more so for children. To date, pipeline stents have been deployed in 11 pediatric patients, ages 4–15. A variety of clopidogrel and aspirin dosing regimens have been used, with response tested in only three patients, who were all therapeutic. Thrombotic events occurred in two patients, neither of whom were tested.

Case

We describe here the first case of a hemorrhagic complication in a hyper-responsive pediatric patient undergoing placement of a pipeline stent.

Discussion

As the use of endovascular therapies requiring dual anti-platelet agents becomes more established, there is an increasing need to develop titration protocols that minimizes the risk of thrombotic and hemorrhagic events.

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References

  1. Goh C, Churilov L, Mitchell P et al (2013) Clopidogrel hyper-response and bleeding risk in neurointerventional procedures. AJNR Am J Neuroradiol 34:721–726

    Article  CAS  PubMed  Google Scholar 

  2. Kashiwazaki D, Kuwayama N, Akioka N et al (2014) The roles and issues of P2Y12 percent inhibition assessed by VerifyNow assay for patients undergoing neurointervention: a prospective study. J Stroke Cerebrovasc Dis 23:1830–1836

    Article  PubMed  Google Scholar 

  3. Delgado Almandoz JE, Crandall BM, Scholz JM et al (2013) Pre-procedure P2Y12 reaction units value predicts perioperative thromboembolic and hemorrhagic complications in patients with cerebral aneurysms treated with the pipeline embolization device. J Neurointerv Surg 5(Suppl 3):iii3–ii10

    Article  PubMed  Google Scholar 

  4. Delgado Almandoz JE, Crandall BM, Scholz JM et al (2014) Last-recorded P2Y12 reaction units value is strongly associated with thromboembolic and hemorrhagic complications occurring up to 6 months after treatment in patients with cerebral aneurysms treated with the pipeline embolization device. AJNR Am J Neuroradiol 35:128–135

    Article  CAS  PubMed  Google Scholar 

  5. Chalouhi N, Zanaty M, Jabbour PM et al (2014) Intracerebral hemorrhage after pipeline embolization: management of antiplatelet agents and the case for point-of-care testing—case reports and review of literature. Clin Neurol Neurosurg 124:21–24

    Article  PubMed  Google Scholar 

  6. Daou B, Starke RM, Chalouhi N et al (2016) P2Y12 reaction units: effect on hemorrhagic and thromboembolic complications in patients with cerebral aneurysms treated with the pipeline embolization device. Neurosurgery 78:27–33

  7. Stone GW, Witzenbichler B, Weisz G et al (2013) Platelet reactivity and clinical outcomes after coronary artery implantation of drug-eluting stents (ADAPT-DES): a prospective multicentre registry study. Lancet 382:614–623

    Article  PubMed  Google Scholar 

  8. Buck ML (2010) Clopidogrel for platelet inhibition in pediatric patients pediatric pharmacotherapy. Pediatr Pharm 16(5). www.medscape.com/viewarticle/723239_10. Accessed November 10, 2015

  9. Li JS, Yow E, Berenzy KY et al (2008) Dosing of clopidogrel for platelet inhibition in infants and young children: primary results of the platelet inhibition in children on clopidogrel (PICOLO) trial. Circulation 117:553–559

    Article  CAS  PubMed  Google Scholar 

  10. Federal Drug Administration (2015) FDA drug safety communication: reduced effectiveness of Plavix (clopidogrel) in patients who are poor metabolizers of the drug. March 12, 2010. www.fda.gov/drugs/drugsafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm203888.htm. Accessed Nov 10

  11. Holmes DR Jr, Dehmer GJ, Kaul S et al (2010) Society for Cardiovascular Angiography and Interventions; Society of Thoracic Surgeons; writing committee members. ACCF/AHA clopidogrel clinical alert: approaches to the FDA "boxed warning": a report of the American College of Cardiology Foundation task force on clinical expert consensus documents and the American Heart Association. Circulation 122:537–557

    Article  PubMed  Google Scholar 

  12. Vasan R, Patel J, Sweeney JM et al (2013) Pediatric intracranial aneurysms: current national trends in patient management and treatment. Childs Nerv Syst 29:451–456

    Article  PubMed  Google Scholar 

  13. Liang J, Bao Y, Zhang H, Wrede KH, Zhi X, Li M et al (2009) The clinical features and treatment of pediatric intracranial aneurysm. Childs Nerv Syst 25:317–324

    Article  PubMed  Google Scholar 

  14. Navarro R, Brown BL, Beier A et al (2015) Flow diversion for complex intracranial aneurysms in young children. J Neurosurg Pediatr 15:276–281

    Article  PubMed  Google Scholar 

  15. Federal Drug Administration (2015) Pipeline™ Embolization device - P100018. Federal drug administration. www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/Recently-ApprovedDevices/ucm252130.htm. Accessed Nov 10

  16. Martin AR, Cruz JP, O'Kelly C et al (2015) Small pipes: preliminary experience with 3-mm or smaller pipeline flow-diverting stents for aneurysm repair prior to regulatory approval. AJNR Am J Neuroradiol 36:557–561

    Article  CAS  PubMed  Google Scholar 

  17. Saatci I, Yavuz K, Ozer C et al (2012) Treatment of intracranial aneurysms using the pipeline flow-diverter embolization device: a single-center experience with long-term follow-up results. AJNR Am J Neuroradiol 33(8):1436–1446

    Article  CAS  PubMed  Google Scholar 

  18. D'Urso PI, Lanzino G, Cloft HJ et al (2011) Flow diversion for intracranial aneurysms. A review. Stroke 42:2363–2368

    Article  PubMed  Google Scholar 

  19. Piano M, Valvassori L, Quilici L et al (2013) Midterm and long-term follow-up of cerebral aneurysms treated with flow diverter devices: a single-center experience. J Neurosurg 118:408–416

    Article  PubMed  Google Scholar 

  20. Munich SA, Tan LA, Keigher KM et al (2014) The pipeline embolization device for the treatment of posterior circulation fusiform aneurysms: lessons learned at a single institution. J Neurosurg 121:1077–1084

    Article  PubMed  Google Scholar 

  21. de Barros FM, Castro RN, Lundquist J et al (2011) The role of the pipeline embolization device for the treatment of dissecting intracranial aneurysms. AJNR Am J Neuroradiol 32:2192–2195

    Article  Google Scholar 

  22. Cinar C, Bozkaya H, Oran I (2013) Endovascular treatment of cranial aneurysms with the pipeline flow-diverting stent: preliminary mid- term results. Diagn Interv Radiol 19:154–164

    PubMed  Google Scholar 

  23. Abla AA, Zaidi HA, Crowley RW et al (2014) Optic chiasm compression from mass effect and thrombus formation following unsuccessful treatment of a giant supraclinoid ICA aneurysm with the pipeline device: open surgical bailout with STA-MCA bypass and parent vessel occlusion. J Neurosurg Pediatr 14:31–37

    Article  PubMed  Google Scholar 

  24. Vargas SA, Diaz C, Herrera DA et al (2015) Intracranial aneurysms in children: the role of stenting and flow-diversion. J Neuroimaging 00:1–5

    Google Scholar 

  25. Zarzecka A, Gory B, Turjman F (2014) Implantation of two flow diverter devices in a child with a giant, fusiform vertebral artery aneurysm: case report. Pediatr Neurol 50:185–187

    Article  PubMed  Google Scholar 

  26. Ryu DS, Hong C-K, Sim YS et al (2010) Anti-platelet drug resistance in the prediction of thromboembolic complications after neurointervention. J Korean Neurosurg Soc 48:319–324

    Article  PubMed  PubMed Central  Google Scholar 

  27. Campo G, Fileti L, de Cesare N et al (2010) Long-term clinical outcome based on aspirin and clopidogrel responsiveness status after elective percutaneous coronary intervention. J Am Coll Cardiol 56:1447–1455

    Article  CAS  PubMed  Google Scholar 

  28. Aradi D, Komocsi A, Vorobcsuk A et al (2010) Prognostic significance of high on-clopidogrel platelet reactivity after percutaneous coronary intervention: systematic review and meta-analysis. Am Heart J 160:543–551

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Neurosurgery, Duke University Hospitals, DUMC Box 3807, Durham, NC, 27701, USA

    Mary In-Ping Huang Cobb, Ali R. Zomorodi, Erik F. Hauck & L. Fernando Gonzalez

  2. Department of Radiology, Division of Interventional Radiology, Duke University Hospitals, Durham, NC, USA

    Tony P. Smith

Authors
  1. Mary In-Ping Huang Cobb
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  2. Ali R. Zomorodi
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  3. Erik F. Hauck
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  4. Tony P. Smith
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  5. L. Fernando Gonzalez
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Corresponding author

Correspondence to Mary In-Ping Huang Cobb.

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The authors declare that they have no conflict of interest.

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Cobb, M.IP.H., Zomorodi, A.R., Hauck, E.F. et al. Optimal pediatric dosing of anti-platelet agents for pipeline stent embolization —a case report and review of the literature. Childs Nerv Syst 33, 685–690 (2017). https://doi.org/10.1007/s00381-016-3311-z

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  • DOI: https://doi.org/10.1007/s00381-016-3311-z

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