Intimal injury during CAS may lead to collagen exposure with subsequent activation of procoagulant factors with the end result of a platelet-rich thrombus formation. In some instances, thrombus formation may cause occlusion of a cerebral blood vessel with subsequent ischemic stroke. Interventionalists utilize GP IIb/IIIa inhibition during CAS either therapeutically to treat acute in-stent thrombosis or preventatively to reduce the risk of periprocedural thrombus formation. Few reports suggested that the use of GP IIb/IIIa inhibitors alone or in combination with intra-arterial thrombolysis may lead to successful revascularization of an acutely thrombosed stent during CAS (Tong et al., 2000
; Steiner-Boker et al., 2004
). In a retrospective review of 254 CAS procedures, Green et al. identified two patients with witnessed thromboembolic events occurred intra-operatively. In both patients, the thrombotic events occurred during the initial passage of the filter wire through the proximal lesion. Nevertheless, both patients were successfully treated with intra-arterial urokinase and intravenous GP IIb/IIIa inhibitor (abciximab; Green et al., 2005
). Adjunctive use of GP IIb/IIIa inhibitors during interventional procedures has been shown to decrease the risk of periprocedural ischemic events (Qureshi et al., 2004
; Dumont et al., 2012
). Most of these data were abstracted from the cardiology literature, which has shown that the adjunctive use of GP IIb/IIIa inhibitors in the setting of percutaneous coronary intervention significantly reduces the rates of 30-day mortality and myocardial Infarction, as well as reduces the need for repeat revascularization procedures (Labinaz et al., 2007
; Winchester et al., 2011
). These beneficial effects were achieved at an increased risk of thrombocytopenia and minor bleeding.
In our study, we found a low risk of ICH and groin hematoma associated with the use of eptifibatide during CAS. The overall rate of ICH in our cohort (1.2%) is compatible with previous reports which ranged between 0.36 and 4.1% (Cheung et al., 2003
; Moulakakis et al., 2009
). None of the 14 patients with acute stroke and treated with eptifibatide during CAS had ICH. There has been contradicting safety data regarding the use of GP IIb/IIIa inhibitors during CAS (Qureshi et al., 2002
; Chan et al., 2005
; Kramer et al., 2007
; Zahn et al., 2007
) however, most of these studies were focused on abciximab during CAS. Kapadia et al. evaluated 151 patients with CAS, 128 of those had been prophylactically treated with abciximab while the rest of cohort was treated with intravenous heparin. At 30-days, the thromboembolic rates were significantly less in the abciximab group (1.6 versus 8%) with one patient developed ICH in the abciximab group (Kapadia et al., 2001
). The authors suggested a relative safety of abciximab during CAS. On the contrary, Wholey et al. shown higher rates of thromboembolic events (6 versus 2.4%) as well as hemorrhages in abciximab group compared to intravenous heparin. Two of four neurologically related deaths in the abciximab group were due to large ICH compared to no hemorrhages in the heparin group (Wholey et al., 2003
). These observations led the authors to conclude relative risks associated with the use of GP IIb/IIIa inhibitors during CAS. A recent change in focus to the use of eptifibatide during cardiac interventional procedures has been noted by neurointerventionalists (Mahmoudi et al., 2011
). Eptifibatide has a shorter life span compared to abciximab and hence, may have a better safety profile. The safety and efficacy of eptifibatide was assessed in a small sample of CAS patients treated with high-dose eptifibatide administered as intravenous bolus followed by continuous infusion over 20–24
h post-operatively (Qureshi et al., 2004
; Dumont et al., 2012
). Again the authors suggested eptifibatide was safe to use during CAS. Besides the absent risk of ICH in our eptifibatide group, no mortality was reported despite the fact that more than half of our patients had CAS performed urgently.
This study is limited by the small sample of those who were treated with eptifibatide during CAS, thus may have led to a selection bias. In addition, the use of eptifibatide in our series was not uniform, i.e., eptifibatide was given for therapeutic and preventative purposes. Regardless, this study suggests the relative safety of eptifibatide use during CAS when performed electively or urgently. Risk-benefit assessment in large prospective studies or national registry would be useful.