Considerations for Antiplatelet Management of Carotid Stenting in the Setting of Mechanical Thrombectomy: A Delphi Consensus Statement

M. Goyal; S. Yoshimura; G. Milot; J. Fiehler; M. Jayaraman; F. Dorn; A. Taylor; J. Liu; F. Albuquerque; M.E. Jensen; R. Nogueira; J.F. Fraser; R. Chapot; L. Thibault; C. Majoie; P. Yang; N. Sakai; D. Kallmes; K. Orlov; A. Arthur; P. Brouwer; J.M. Ospel

doi:10.3174/ajnr.A6888

Abstract

BACKGROUND AND PURPOSE: There are only few data and lack of consensus regarding antiplatelet management for carotid stent placement in the setting of endovascular stroke treatment. We aimed to develop a consensus-based algorithm for antiplatelet management in acute ischemic stroke patients undergoing endovascular treatment and simultaneous emergent carotid stent placement.

MATERIALS AND METHODS: We performed a literature search and a modified Delphi approach used Web-based questionnaires that were sent in several iterations to an international multidisciplinary panel of 19 neurointerventionalists from 7 countries. The first round included open-ended questions and formed the basis for subsequent rounds, in which closed-ended questions were used. Participants continuously received feedback on the results from previous rounds. Consensus was defined as agreement of ≥70% for binary questions and agreement of ≥50% for questions with >2 answer options. The results of the Delphi process were then summarized in a draft manuscript that was circulated among the panel members for feedback.

RESULTS: A total of 5 Delphi rounds were performed. Panel members preferred a single intravenous aspirin bolus or, in jurisdictions in which intravenous aspirin is not available, a glycoprotein IIb/IIIa receptor inhibitor as intraprocedural antiplatelet regimen and a combination therapy of oral aspirin and a P2Y12 inhibitor in the postprocedural period. There was no consensus on the role of platelet function testing in the postprocedural period.

CONCLUSIONS: More and better data on antiplatelet management for carotid stent placement in the setting of endovascular treatment are urgently needed. Panel members preferred intravenous aspirin or, alternatively, a glycoprotein IIb/IIIa receptor inhibitor as an intraprocedural antiplatelet agent, followed by a dual oral regimen of aspirin and a P2Y12 inhibitor in the postprocedural period.

ABBREVIATIONS:

EVT: endovascular treatment
GPIIb/IIIa: glycoprotein IIb/IIIa

Footnotes

Disclosures: Mayank Goyal—UNRELATED: Consultancy: Stryker, Medtronic, Mentice, MicroVention; Grants/Grants Pending: Cerenovus*; Patents (Planned, Pending or Issued): GE Healthcare, Comments: licensing agreement for systems of stroke diagnosis. Shinichi Yoshimura—RELATED: Consulting Fee or Honorarium: Bayer, Sanofi, Otsuka Pharmaceutical, Stryker, Medtronic, Johnson & Johnson, Termo, Medico’s Hirata, Biomedical Solutions, Comments: lecture fee; UNRELATED: Payment for Lectures Including Service on Speakers Bureaus: Boehringer-Ingelheim, Daiichi Sankyo, Bristol-Meyers Squibb, Comments: lecture fee. Jens Fiehler—UNRELATED: Consultancy: Acandis, Cerenovus, Stryker, Medtronic, Penumbra; Grants/Grants Pending: Acandis, Cerenovus, Stryker, Medtronic, Route 92.* Mahesh Jayaraman—UNRELATED: Payment for Lectures Including Service on Speakers Bureaus: Medtronic, Comments: speaking at ISC 2018 on Stroke Systems of Care. Franziska Dorn—UNRELATED: Consultancy: Balt, phenox, Cerus; Payment for Lectures Including Service on Speakers Bureaus: speakers honorary for Cerenovus, Acandis. Allan Taylor—RELATED: Other: limited private practice; UNRELATED: Employment: Groote Schuur Hospital; Expert Testimony: defense and prosecuting attorneys. Raul Nogueira—Other Relationships: RGN reports, consulting fees for advisory roles with Anaconda, Biogen, Cerenovus, Genentech, Imperative Care, Medtronic, phenox, Prolong Pharmaceuticals, Stryker Neurovascular; Stock/Stock Options: advisory roles with Astrocyte, Brainomix, Cerebrotech, Ceretrieve, Corindus Vascular Robotics, Vesalio, Viz-ai, and Perfuze. Justin F. Fraser—UNRELATED: Board Membership: Cerelux LLC, Comments: co-owner of company; Consultancy: Medtronic, Penumbra, Stream Biomedical, Comments: consultant fees; Grants/Grants Pending: American Heart Association and University of Kentucky, Comments: grant support*; Stock/Stock Options: Fawkes Biotechnology, Comments: equity interest ownership. Rene Chapot—UNRELATED: Consultancy: MicroVention, Stryker*; Payment for Development of Educational Presentations: Balt, MicroVention, Siemens.* Charles Majoie—UNRELATED: Grants/Grants Pending: CVON/Dutch Heart Foundation, European Commission, Dutch Health Evaluation Program, TWIN Foundation, Stryker*; Stock/Stock Options: Nico.lab (modest), Comments: a company that focuses on the use of artificial intelligence for medical image analysis. David Kallmes—UNRELATED: Grants/Grants Pending: MicroVention, NeuroSigma, Medtronic, Comments: funding for preclinical research*; Patents (Planned, Pending or Issued): Mayo Clinic, Comments: patent for protection device*; Stock/Stock Options: Marblehead Medical LLC, Superior Medical Experts LLC. Patrick Brouwer—UNRELATED: Consultancy: Cerenovus. Nobuyuki Sakai—UNRELATED: Grants/Grants Pending: Daiichi Sankyo, NeuroVasc, Terumo*; Payment for Lectures Including Service on Speakers Bureaus: Asahi-Intec, Biomedical Solutions. Adam Arthur—UNRELATED: Consultancy: Balt, Johnson & Johnson, Medtronic, MicroVention, Penumbra, Scientia, Siemens, Stryker*; Grants/Grants Pending: Balt, Medtronic, MicroVention, Penumbra, Siemens*; Stock/Stock Options: Azimuth, Bendit, Cerebrotech, EndoStream, Magneto, Marblehead Medical LLC, Neurogami, Serenity, Synchron, TRIAD MEDICAL, Vascular Simulations.* *Money paid to the institution.