Endovasküler Yol ile Tedavi Edilmiş Anevrizmalarda Prosedürel Tromboembolik Sonuçların Öngörülebilirliği
Özet
Purpose: Aim of this study was to compare incidental procedurel thromboembolic events occured while beaded stent or flow diverter stent deployment between the first endovascular aneurysm treatment and consecutive endovascular aneurysm treatment based on past medical history, cerebral aneurysm location, thrombocyte reactivity.
Materials and Methods: 320 different patients have been treated by flow diverter stent and beaded stent assited coil embolization since February 2013. Overall 386 EVT procedure were carried out. Apart from initial stent assited EVT procedure, a total of 63 consecutive endovascular aneurysm treatments were also performed in 56 patients. Incidental periprocedural thromboembolic events occurred after stent deployment were subclassified as occlusion in stent, partial occlusion or visible thrombus aggregates in stent and side branch transient ischemia or distal cortical branch emboly. Patient group with incidental thrombotic event during EVT procedure was compared with uncomplicated patient group in terms of past medical history (Major cardiovascular event, hyperlipidemia, hypertension, coagulopathy, history of malignancy, smoking) and preprocedural antiagregation profile. Patients were also divided into two groups as having “proximal aneurysm” and “distal aneurysm” according to internal carotid artery bifurcation and origin of superior cerebellar artery. Patient group with proximal and distal aneurysms were distributed by features of past medical history, preprocedural antiaggregation profile and procedural incidental thromboembolic event prevalence. Furthermore, a group of 56 patient with multiple cerebral aneurysms were ordered into two categories as “initial EVT interventions” and “consecutive EVT interventions”. Those dependent groups were compared with each other according to incidental thromboembolic events during procedure. Moreover, considering aneurysm locations, incidental thromboembolic events after stent deployment were also compared between a group treated by flow diverters and a group treated by beaded intravascular stents. Pearson chi-square test, Yates correction in chi square test and Fischer exact test were used for comparison of categorical variables. Mann Whitney U test were also used for comparison of continuous variables. “p<0,05” was accepted as a mean of statistical significance.
Results: İncidental thromboembolic events occured in 30 (%7,8) patient after stent deployment. Features of past medical histories and thrombocyte inhibition percentage were not different between the thromboembolic group and uncomplicated group. İn case of clopidogrel resistance, despite the antiaggregation by prasugrel, smoking reduced trombocyte inhibition by %3,1 percent. Thromboembolic event prevalence was higher 4,2 times in distally located aneurysms compared to proximal aneurysm (p=0,001). Distal aneurysms treated by flow diverters experienced 4,9 times more thrombotic event than aneurysm treated by beaded intravascular stent (p=0,001). Three thromboembolic events occured in consecutive stent deployment while no thrombotic event detected in initial stent deployment of similar patients (p=0,287).
Conclusion: Repetitive endovascular aneurysm treatments showed no difference in terms of resistance to stent’s intrinsic thrombogenicity effect as compared to inital EVT procedures. İndependent from cardiovascular risks and past medical history, a group of aneurysm located beyond to internal carotid artery bifurcation and basiler apex showed significant risk for occurence of incidental thromboembolic event. Furthermore, using flow diverter stent in aneurysms distal to internal carotid bifurcation and basiler apex exhibited higher incidental thrombotic and ischemic events compared to beaded intravasculer stent.
