GP IIB/IIIA Inhibitor Use During Endovascular Intervention€¦ · GP IIB/IIIA Inhibitor Use During...
Transcript of GP IIB/IIIA Inhibitor Use During Endovascular Intervention€¦ · GP IIB/IIIA Inhibitor Use During...
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GP IIB/IIIA Inhibitor Use During GP IIB/IIIA Inhibitor Use During Endovascular InterventionEndovascular Intervention
Jay S. Yadav M.D.
Director, Vascular InterventionDept of Cardiovascular MedicineThe Cleveland Clinic Foundation
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Nothing to Disclose Related to this PresentationNothing to Disclose Related to this Presentation
Name: Jay Yadav, M.D.Jay Yadav, M.D.
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GP IIb/IIIa Receptor Blockade in GP IIb/IIIa Receptor Blockade in Peripheral Vascular Intervention: RationalePeripheral Vascular Intervention: Rationale
◆ Underlying pathophysiology of PVD is atherosclerosis
◆ Plaque rupture (spontaneous or due to vascular intervention) is a
potent stimulus for platelet activation and aggregation
◆ Coagulation system is activated by vessel damage and activated
platelets generate thrombin
◆ Diabetes incidence high in patients with PVD
◆ GP IIb/IIIa inhibitors not associated with increased incidence of ICH
(unlike fibrinolytics)
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GP IIB/IIIA Inhibitor Use GP IIB/IIIA Inhibitor Use During Endovascular During Endovascular InterventionIntervention
◆ Safety◆ Benefit◆ Cost
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Acute Coronary Acute Coronary SyndromesSyndromes
ejt 029–144
The “Hot” VesselThe “Hot” Vessel
MicrovascularMicrovascularObstructionObstruction
1000x1000x5x5x
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Topol EJ. Circulation. 1998;97:211-218.
Intracerebral Hemorrhage Rates in GP Intracerebral Hemorrhage Rates in GP IIb/IIIa Receptor Inhibitor Coronary IIb/IIIa Receptor Inhibitor Coronary Intervention TrialsIntervention Trials
Trial Placebo (%) Inhibitor
(%)
EPIC 0.3 0.3IMPACT 0.1 0.1RESTORE 0.2 0.1CAPTURE 0.0 0.0EPILOG 0.0 0.1
Pooled 0.1 0.1
N
2,0994,0102,1391,2652,792
12,305
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Abciximab in Carotid StentingAbciximab in Carotid StentingKapadia et al , Stroke 2001, 32: 2328-32Kapadia et al , Stroke 2001, 32: 2328-32
Control groupControl groupASA + ADP antagonistASA + ADP antagonist
Abciximab groupAbciximab group ASA + ADP antagonistASA + ADP antagonist
++Abciximab (0.25 mg/kg bolus Abciximab (0.25 mg/kg bolus
± 0.125 mcg/kg/min for 12 0.125 mcg/kg/min for 12 hrs)hrs)
151 patients151 patients159 procedures159 procedures
128 patients128 patients134 procedures134 procedures
23 patients23 patients25 procedures25 procedures
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Procedural EventsProcedural Events Control Abciximab
(n=25) (n=134)Minor strokes 0 1 (0.8%)Major strokes 1 (4%) 0Retinal infarct 0 1 (0.8%) ICH 1 (4%) 0MI 0 0Death 1 (4%) 0Total events 2 (8%) 2 (1.6%)
p=0.05
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30 Day Follow-up: New Events30 Day Follow-up: New Events
Control Abciximab (n=25) (n=134)
Minor strokes 0 0Major strokes 0 0ICH 0 1 (0.8%)MI 0 0Death 2 (8%) 5 (3.7%)Total events 2 (8%) 6 (4.5%)
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All events: 30 daysAll events: 30 days
8%
2.3%
8%
3.7%
Eve
nts
(%)
Eve
nts
(%)
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Severe Aortic Arch Tortuosity with MCA Severe Aortic Arch Tortuosity with MCA embolizationembolization
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PLAQUE PROTRUSION PLAQUE PROTRUSION THROUGH STENT STRUTSTHROUGH STENT STRUTS
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Dethrombosis of Left Anterior Dethrombosis of Left Anterior Descending Coronary Artery with Descending Coronary Artery with AbciximabAbciximab
Initial Angiogram Angiogram Post Abciximab Bolus
Adapted with permission from Rerkpattanapipat P et al. Circulation. 1999;99:2965.
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Combination Therapy in PVDCombination Therapy in PVD
◆ Low Dose Retavase
◆ Full Dose ReoPro
◆ Low Dose, Weight-Adjusted Heparin
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“White” Thrombus “Red” Thrombus
Fibrinolytic ineffectiveFibrinolytic ineffectiveAntiplatelet effectiveAntiplatelet effective
Fibrinolytic effectiveFibrinolytic effectiveAntiplatelet effectiveAntiplatelet effective
Platelet-Rich Thrombus Platelet/Fibrin Thrombus
Platelet Thrombus vs Stabilized Clot
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Abciximab + Urokinase in Peripheral Abciximab + Urokinase in Peripheral Arterial Thrombolysis Arterial Thrombolysis
Tepe G et al. Am J Roentgenol. 1999;172:1343-1346.
Baseline After 1 Hour of TreatmentDigital subtraction angiogram of a right common iliac artery occlusion
Tepe et al
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Abciximab + Reteplase in Abciximab + Reteplase in Chronic SFA Occlusion Chronic SFA Occlusion
Katzen B. Presented at the 11th Annual Symposium of Transcatheter Cardiovascular Therapeutics; September 22, 1999; Washington, DC.
Katzen
Baseline After 2 hours After At 6.5 hours After lysis
6 hours and stent (palpable pulse)
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Major Bleeding at Discharge/Day 7by Abciximab
Note: No incidence of intracranial hemorrhage or stroke among the subjects in the study.
50
9
25
0
15
33
8
33
0
20
0
25
50
75
100
0.1 U/hr 0.2 U/hr 0.5 U/hr 1.0 U/hr Combined
Perc
enta
ge o
f Pat
ient
s
Reteplase Reteplase + abciximab
P=NSP=NS
N 6 6N 6 6 12 1212 12 12 1412 14 12 612 6 36 3836 38
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Patency on 20-hour Angiogram
3342
100
4049
67 64 62
8066
0
20
40
60
80
100
120
0.1 U/hr 0.2 U/hr 0.5 U/hr 1.0 U/hr Combined
Perc
enta
ge o
f Pat
ient
s
Reteplase Reteplase + abciximab
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Distal EmbolizationDistal Embolization(Sufficient to Require Intervention)(Sufficient to Require Intervention)
090302.1 Smith.ppt - On-screen 20
67
25
0
33 31
0 07
175
0
25
50
75
100
0.1 U/hr 0.2 U/hr 0.5 U/hr 1.0 U/hr Combined
Perc
enta
ge o
f Pat
ient
s
Reteplase Reteplase + abciximab
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Case Examples of GP IIB/IIIA Use
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RICAPRE POST
LICAPRE POST
Bilateral Carotid Dissection with Acute StrokeBilateral Carotid Dissection with Acute Stroke
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Middle Cerebral Artrery Middle Cerebral Artrery InterventionIntervention
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Symptomatic Pt with Single Vertebral Symptomatic Pt with Single Vertebral Supplying Entire BrainSupplying Entire Brain
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◆ 83 y.o. woman◆ IRDM x 30 yrs◆ PMHx:
◆ Left CEA◆ S/p CABG◆ Renal artery disease
◆ Aug 01: right femoral-anterior tibial bypass for claudication
◆ Jan 02: bypass thrombectomy for acute leg ischemia
◆ Apr 02: Non-healing ulcer, gangrenous toe, redo femoral-AT bypass
◆ May 02: graft occlusion by U/S
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◆ 64 yo Sx Rica◆ Severe ankylosing spondylitis-
◆ Cannot move neck in any plane◆ Cervical and thoracic spine anteriorly
flexed at 45 degrees◆ Chronic renal insuffic – Cr 4.2◆ Gadolinium
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Case 1Case 1
◆ 59 yo Male w HTN, ↑Chol, Cigs undergoing L Heart Cath
◆ Immediately upon withdrawal of Pigtail Catheter from LV developed Neurological Sx◆ Global Aphasia◆ R Hemianopsia◆ Flacid R Hemiparesis◆ NIHSS=22
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AngiogramAngiogram
◆ Acute Cutoff of L MCA Trunk
• Few Pial Collaterals from ACA to MCA
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Endovascular ApproachEndovascular Approach
◆ 4500U IA Heparin
• 2.3F Microcatheter advanced into MCA over 0.014” Soft Hydrophilic Wire
• 6F MPA1 Guide Inserted into L ICA over 0.035” Glide Wire
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Endovascular ApproachEndovascular Approach
◆ Wire Advanced Through Thrombus for More Support
• Results in Thrombus Migration into MCA Superior Division• 21 min after onset
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Endovascular ApproachEndovascular Approach
◆ Microcatheter is Placed Within Thrombus in Superior Division
• 1 U Retevase Infused over 1 min
• Repeat Angiogram after 5 min Unchanged
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Endovascular ApproachEndovascular Approach
◆ Reopro 1mg Injected Into Thrombus
• Five min Later Partial Recannalization of Superior Division
• Persistent Slow Flow in Distal Branches of Inferior Division and Proximal Superior Division
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Endovascular ApproachEndovascular Approach
◆ Retevase 1U followed by Reopro 5mg (1/4 Bolus) Injected into Sup Division
• 10 min Later Nearly Complete Flow Except for One Distal Branch Occlusion
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OutcomeOutcome
◆ Speech and R Arm Movement Began To Return on the “Table”
• Final Angiogram at 75 min After Onset is Normal
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OutcomeOutcome◆ By Next AM
NIHSS=1◆ CT Normal◆ D/C Day 2- Normal
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CONCLUSIONS – Carotid CONCLUSIONS – Carotid UseUse
◆ GP IIb/IIIa antagonists are safe in carotid stenting
◆ Role with Emboli prevention devices is not clear
◆ Acute stroke / carotid thrombosis
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Conclusions –Carotid UseConclusions –Carotid Use
◆ May Reduce Post Procedure Embolization from Plaque Protruding through Stent Struts
◆ Careful Dosing/Monitoring Critical:◆ 50 u/kg heparin, ACT, PAU◆ Heparin and ACT correlates of ICH
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General Suggestions for General Suggestions for 2b3a in Endovascular 2b3a in Endovascular CasesCases
◆ High Risk for Acute/Sub-acute Thrombosis
◆ Consequence of AT/SAT Catastrophic◆ High Risk of Embolization during or
immediately Post-ProcedureAnd
◆ No Adventitial Wire Perforation
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CONCLUSIONSCONCLUSIONS
◆ Below the Knee◆ Combination with Lytics◆ Inability to Stent◆ Acute Thrombosis◆ Active Embolizers – Shaggy Aorta