Original Article

Intra-Arterial Use of Abciximab in Thromboembolic Complications Associated with

Cerebral Aneurysm Coiling: The London Ontario Experience

Rafael Martınez-Perez, Stephen P. Lownie, David Pelz

-BACKGROUND: Experience with intra-arterial infusionof abciximab for the treatment of endovascular thromboticcomplications is limited to short case series. Our objectiveis to evaluate the safety and effectiveness of this drug forthe treatment of thromboembolic complications duringaneurysm coiling and to determine the risk factors.

-METHODS: From an aneurysm coiling database, patientstreated with intra-arterial abciximab after having throm-botic complications during the coiling procedure wereselected for analysis. Complications after using abciximabwere categorized as hemorrhage, distal migration of thethrombus, and aneurysm recanalization.

-RESULTS: Fourteen coiling patients sustained a throm-boembolic complication and were treated using intra-arterial infusion of abciximab and were subjected tofurther analysis. The age range was 48e76 years. Threepatients were male. Seven patients had subarachnoidhemorrhage. Only complete recanalization was associatedwith clinical improvement, but this occurred in only 4 pa-tients (28.5%). Partial or complete recanalization occurredin 13 patients (93%). Eight patients (57%) had complicationsderived from the infusion. Three patients had aneurysmrecanalization, 3 patients had distal migration of thethrombus and 1 patient had a hemorrhagic complication.Eight patients demonstrated acute infarcts related to the

Key words- Abciximab- Coiling- Complications- Endovascular- Reopro- Stroke- Thromboembolic

Abbreviations and AcronymsCT: Computed tomographyDSA: Digital substraction angiographyDWI: Diffusion-weighted imageIA: Intra-arterialIV: IntravenousMRA: Magnetic resonance angiogramMRI: Magnetic resonance imaging

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occluded vessel, whereas 7 patients made a good func-tional recovery.

-CONCLUSION: Successful recanalization of a vesseloccluded by thrombus formation during aneurysm coilingusing abciximab (Reopro) infusion is less than optimal.There are risks related to abciximab, including bleedingand aneurysm recanalization.

INTRODUCTION

hromboembolic complications during endovascularaneurysm coiling range in frequency from 6.7% to 28%1,2;

Tthey are the most common cause of periprocedural

morbidity associated with the endovascular treatment of cerebralaneurysms.3 Acute management of this type of complication hasrisks, such as hemorrhage from an unsecured cerebral aneurysmor hemorrhage within a new infarct. Possible treatments includemechanical thrombectomy and the use of thrombolytic drugs,including urokinase,4 tissue plasminogen activator (tPA),5 andGPII/IIIb inhibitors.6,7

Abciximab is a GPII/IIIb inhibitor, reported to be effective indissolving hyperacute thrombi when used intravenously.7

Experience with intra-arterial (IA) abciximab is, however, limitedto a few small case series, with potential selection bias. Theprevious literature has reported high rates of success, but better

mRS: modified Rankin scoreSAH: Subarachnoid hemorrhageTICI: Thrombolysis in cerebral infarctiontPA: Tissue plasminogen activator

Departments of Clinical Neurological Sciences and Medical Imaging, Schulich School ofMedicine and Dentistry, Western University, London, Ontario, Canada

To whom correspondence should be addressed: Rafael Martínez-Pérez, M.D.[E-mail: rafa11safin@hotmail.com]

Citation: World Neurosurg. (2017) 100:342-350.http://dx.doi.org/10.1016/j.wneu.2017.01.023

Journal homepage: www.WORLDNEUROSURGERY.org

Available online: www.sciencedirect.com

1878-8750/$ - see front matter ª 2017 Elsevier Inc. All rights reserved.

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RAFAEL MARTÍNEZ-PÉREZ ET AL. INTRA-ARTERIAL USE OF ABCIXIMAB IN CEREBROVASCULAR PROCEDURES

delineation of complication rates, and related factors should befurther reviewed. In this article, we review our experience with IAabciximab and try to clarify the benefits versus the risks.

METHODS

Study PopulationFrom a prospectively maintained database of 240 coiled patientstreated between January 2012 and January 2016, 14 patients wereselected for analysis according to the following criteria: 1) patientswith a brain saccular aneurysm treated with coil embolization; 2)use of IA abciximab after having a thrombotic complication duringcoiling procedure; 3) availability of digital subtraction angiography(DSA) before and after abciximab infusion; 4) availability ofpostprocedural computed tomography (CT) or magnetic reso-nance imaging (MRI) with diffusion-weighted imaging (DWI)scan.Angiographic and endovascular procedures: diagnostic cerebral

angiography of each aneurysm was discussed with a vascularneurosurgeon and a neurointerventional radiologist to decide thebest therapeutic alternative (surgical clipping vs. endovascularcoiling). Criteria favoring endovascular coiling were saccularruptured aneurysm, presence of vasospasm, location within pos-terior location, dome-to-neck ratio greater than 1.5, age greaterthan 65 years, and calcification of the aneurysm neck visualized onthe CT scan. A balloon-assisted coiling procedure was performedwhen the dome-to-neck ratio was less than 1.5, and the procedurewas still favorable for endovascular coiling.Administration of IA abciximab was always considered after

having a thromboembolic complication following an endovascularcoiling procedure. When an intraprocedural vessel rupturehappened or when the aneurysm ruptured previously to coildeployment, IA infusion of abciximab was avoided. Further con-servative management was considered when the thrombus for-mation was not sufficient to produce a considerable delay on flowor to produce significant impairment in the patient after checkingwith a neurologic examination.

IA Abciximab Infusion ProcedureIn all patients, intravenous (IV) heparin was routinely given tomaintain ACT between 200 and 300 seconds during the pro-cedure; this was not reversed after the administration of abcix-imab. After a thromboembolic complication was confirmed byDSA, a microcatheter was navigated to the proximal end of theblood clot, and the IA abciximab infusion was started. The rateand dosage of IA infusion followed the recommendations ofFiorella et al.6 The abciximab, diluted in saline to 0.2 mg/mL,was administered as a bolus of 2e5 mg over a period of 2minutes. After each bolus was administered, controlangiography was performed through the guiding catheter toassess the progress of thrombolysis. In cases of thrombuspersistence or progression, further IA administration wasperformed until reaching a maximum dose of 0.25 mg/kgabciximab. Infusion was stopped if the patient washemodynamically unstable or any complications occurred.When concurrent IV infusion was performed, the drug wasdiluted in 0.9% normal saline, and infusion was continued for12 hours at a rate of 0.125 mg/kg/min. The total doses of IA

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abciximab and use of any other antifibrinolytic drugs wererecorded. When coadjutant IV infusion of heparin wasperformed, unfractionated heparin was infused over a periodof 12e24 hours to maintain partial thromboplastin time doubleof the baseline. Within the period of January 2012 toDecember 2013, there was not a strict protocol regarding theconcomitant use of IV heparin or abciximab (patients 5,7,8,10and 13). The decision was made by consensus betweenintensive care physician and endovascular surgeon. Overall,concomitant use of IV anticoagulants or antiplatelets wasavoided in those patients with subarachnoid hemorrhage(SAH). Our current practice is to avoid the IV injection ofabciximab and the use of other fibrinolytics as much aspossible in all patients, given the higher risk of havinghemorrhagic complications.4 Our protocol does not includepretreatment with antiplatelets before intervention whenendovascular coiling is planned.

Radiological AssessmentThromboembolic complication was confirmed on DSA. It wasdefined as anterograde flow disturbance, such as a complete oc-clusion or a delayed flow into the distal vessels, produced bygradual progression of a thrombus. Angiographic recanalizationwas classified according to thrombolysis in cerebral infarction(TICI) score8 as follows: complete recanalization (TICI 3), partialrecanalization (TICI 1 and 2), or no changes in distal flow (TICI0). New hemorrhage or progression of a previous hemorrhagicevent, distal thrombus migration and aneurysm recanalizationwere considered as complications of the infusion. Distalmigration of the thrombus was considered as a flow delay orcomplete occlusion of a distal segment of the same parentartery after a complete or partial recanalization. The state of theaneurysm after abciximab infusion was also analyzed in thepostprocedure DSA. An increase of contrast filling withinthe aneurysm in a comparison of angiography before abciximabinfusion angiogram was considered to represent aneurysmrecanalization.All patients had post-coiling MRI and magnetic resonance

angiography (MRA) as a routine follow-up. A new hyperintenselesion on DWI was considered an acute ischemic stroke. Wedifferentiated between significant or nonsignificant stroke as fol-lows: if the volume of diffusion restriction was greater than 10 mL;was responsible for new neurologic deficits post after coiling; andwas related with the vessel previously occluded during thethrombotic complication. MRA was used to assess the post-coilingstate of the aneurysm according to the Raymond Roy occlusionclass.9 Contrast extravasation on DSA during the infusion, andprogression of a previous hemorrhage on the post-coiling MRIor CT were considered to be hemorrhagic complications.

Clinical Follow-UpThe first physical examinations after coiling of all patients wererecorded. All patients were assessed at 6 months after the pro-cedure, according to the modified Rankin Scale (mRS).10

ComplicationsUndesirable events that were directly related to the infusion pro-cedure, including rupture of the aneurysm or hemorrhagic

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complication, distal migration of the thrombus and recanalizationof the aneurysm were considered complications of the abciximabinfusion.

Statistical AnalysisAbciximab dose was considered a quantitative variable. Quali-tative variables considered were the following: “completerecanalization” (complete vs. partial or no recanalization),“partial recanalization” (partial and complete recanalization vs.non-recanalization), “complications” (present or absent),“rebleeding” after abciximab infusion (present or absent),“aneurysm sac recanalization” (yes or no), significant “infarctionin the MRI post procedure” (present or absent) and “good clin-ical outcome” (mRS <2).Qualitative variables, including “complete recanalization,”

“partial recanalization,” “presence of complications,” “rebleed-ing,” “recanalization of the aneurysm,” presence of significant“infarction in the MRI post procedure,” and “good clinicaloutcome” were compared among groups regarding their age (>65years old), sex (male or female), location of the aneurysm treated(anterior vs. posterior circulation), presence of SAH at time oftreatment and IV coadministration of another antiplatelet orfibrinolytic drug, such as heparin or abciximab, using the Fisherexact test.To compare the qualitative variables “partial recanalization” and

“complete recanalization” with “significant infarction in the MRI”and with “good clinical outcome,” a Fisher exact test wasperformed.A dose of IA abciximab (quantitative variable) was also

compared with the following qualitative variables: “completerecanalization,” “partial recanalization,” “presence of anycomplication,” “rebleeding,” “aneurysm sac recanalization,”“infarction in the MRI,” and “good clinical outcome.” Testingcomparison, in this case, was done using Kruskal-Wallis test. Atwo-tailed P < 0.05 was considered significant, and all tests werecalculated using SPSS version 22.

RESULTS

The incidence of thrombotic complications in our series was 7.9%(19 of 240 cases). Five patients did not receive IA abciximab andwere not included in further analysis. Of these, 3 patients hadsmall thrombotic formations that did not limit the distal flowand did not have clinical implications for the patients, and in2 patients the thrombosis occurred in the presence of a rupturedaneurysm before any coil was deployed. Finally, the analysisincluded 14 patients using IA infusion of abciximab. Threepatients were men, and 11 patients were women. The age rangewas 48e76 years, with an average of 56.5. Seven patients had SAH,7 patients had an unruptured aneurysm. The summary of theresults is shown in Table 1.Thirteen (93%) patients had at least partial recanalization, and

28.5% experienced complete recanalization of the parent vesselwith restoration of normal flow. Eight (57%) patients had acomplication from the infusion. No complication derived from theuse of abciximab was directly associated with death or severedisability (mRS of 5 or 6). Regarding complications, 3 patients hadaneurysm recanalization, 4 patients had distal migration of the

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thrombus, and 1 patient had a hemorrhagic complication. Noadditional bleeding was seen in the patients with rupturedaneurysms.In the postoperative MRI examinations, 6 patients did not have

significant infarct related to the vessel initially occluded. In 8patients, DWI lesions were found related to the artery that wasoccluded. The MRA demonstrated recanalization of the targetvessel in all cases. The aneurysm was completely occluded (Ray-mond Roy occlusion class 1) in 3 cases; in 7 there was some fillingof the neck (Raymond Roy occlusion class 2) and in 4 there was atleast some partial filling of the aneurysm dome (Raymond Royocclusion class 3).One patient died on the fourth postoperative day because of

complications derived from the SAH, 5 patients had completerecovery (mRS ¼ 0), 6 had slight or moderate disability (mRS ¼ 2or 3), and 1 patient had severe disability (mRS ¼ 5).Qualitative variables, including age greater than 65 years, sex,

SAH presentation, and coadjuvant administration of IV drug, didnot demonstrate statistical significant association with recanali-zation (partial or complete), complication rates, infarction inpostprocedure MRI or clinical status at follow-up.Three patients were treated with abciximab after developing

thromboembolic complications during treatment of an aneurysmin posterior circulation. The location in the posterior circulationwas significantly related to the lower rate of infarction seen in theMRI after the procedure (0% vs. 91%; P ¼ 0.011).All the patients with a thrombotic complication in the posterior

circulation recovered completely (mRS ¼ 0; 100% mRS <2),whereas only 3 of the 11 patients with thromboembolic compli-cation occurring in the anterior circulation had an mRS less than 2at follow up. However, this relation lacks statistical signification(P ¼ 0.055). Location of the aneurysm did not show significantassociation with vessel recanalization or complications (P ¼ 0.9and P ¼ 0.76, respectively).Complete recanalization of the parent vessel was associated

with good clinical outcome (100% vs. 27%, P ¼ 0.05), but therewas not a significant association with infarction on MRI(P ¼ 0.67). On the other hand, partial recanalization did not showsignificant association with clinical outcome nor infarction on theMRI (P ¼ 0.57 and P ¼ 0.71, respectively).Higher doses of IA abciximab were associated with higher rates

of aneurysmal recanalization (P ¼ 0.038), but did not show betterrecanalization rates, partial (P ¼ 0.42) or complete (P ¼ 0.36).

DISCUSSION

To date, reports of the use of abciximab has been restricted tosmall case series6,11-14 and have suggested a low risk of compli-cation. Our larger case series found an unexpected highercomplication rate and a lower rate of procedural success than hasbeen previously reported.Previous experience with the use of IA abciximab infusion is

summarized in Table 2. Successful recanalization rates in theliterature range between 80% and 100%. A potential question isthe definition of successful recanalization, which is oftensubjective without clear thresholds. Satisfactory improvement offlow in our series occurred in 13 of 14 patients, althoughcomplete recanalization with restoration of normal flow was

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Table 1. Patients with Thrombotic Complications During Coiling of Cerebral Aneurysm, Treated with Intra-arterial Abciximab

Age (years) SexIA Abcximab

(mg) AneurysmCoadjuvant IV

Infusion Recanalization Complication MRI MRI - (RROC)mRS at

Follow-Up

53 Female 10 (e) Acom, 10 mm None Complete Rupture and bleeding Left MCA and watershed stroke foci.Rebleeding

2 2

61 Female 7 (R) Acom, 12 mm None None None Left ACA infarct 1 2

70 Female 10 (R) Acom, 11 mm None Complete None No significative infarct 2 0

61 Female 5 (e) Basilar, 14 mm None Partial Recanalization of aneurysm No infarct 3 0

51 Male 7 (e) Acom, 9 mm None Complete Distal thrombus No significative infarct 2 0

50 Female 17 (e) Basilar, 7 mm None Complete None No infarct 1 0

60 Female 9 (e) Basilar, 6 mm IV abcximab Partial None No infarct 2 0

49 Male 9 (R) MCA, 7 mm IV abciximab Partial Distal thrombus Multiple infarcts and petechial transformation 3 5

47 Female 10 (e) MCA, 8 mm None Partial None Multiple right small infarcts 2 0

55 Female 8 (R) Acom, 5 mm IV abciximab/heparin Partial Distal thrombus Infarct left ACA territory 1 3

50 Female 10 (R) Acom, 6 mm None Partial Distal thrombus Infarct Left Parietal, progression of the SAH 1 3

76 Male 6 (R) Acom, 8 mm None Partial Recanalization of aneurysm Left frontal and left parietal infarct 3 6

48 Female 8 (R) MCA, 10 mm Heparin Partial None No infarct 2 3

61 Female 8 (R) Acom, 7 mm None Partial Recanalization of aneurysm Caudate nucleus infarct 2 2

IA, intra-arterial; IV, intravenous; MRI, magnetic resonance imaging; RROC, Raymond Roy occlusion class; mRS, modified Rankin Score; (e), elective/unruptured; (R), ruptured/SAH; NR, not reported; SAH, subarachnoid hemorrhage; ACom,anterior communicating artery; ACA, anterior cerebral artery; MCA, middle cerebral artery.

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Table 2. Experience of Use of Intrarterial Abciximab

Investigation Work Use NRate of Success in Terms

of Recanalization Dose of Infusion Complication

Park et al., 200817 — n ¼ 32 (R 16; nr 16) 100%53% Complete47% Partial

5e15 mg 1% hemorrhage

Song et al., 20043 — n ¼ 7 (R 4; nr 3) 86%57% Complete28% Partial

5 mg 0.14% hemorrhage (1 SAH)

Fiorella et al., 20046 Coiling and AVM cases, IV and tPAwas also administered

n ¼ 3 (R 3) 100% Complete 3.5e10 mg 0% hemorrhage, 40% cortical infarcts

Mounayer et al., 200312 n ¼ 13 (R 4; nr 9) 100%92% Complete8% Partial

4e10 mg 0% hemorrhage, 8% distal embolization (stroke)

Kwon et al., 200211 Urokinasealso administered

n ¼ 2 (R 1; nr 1) 100% 4e5 mg 0%

Aggour et al., 201014 IA, followed by a IV infusion for12 hours, 6 patients tPA

n ¼ 23 (R 11; nr 12) 73.9% of at least partial recanalization56.6% complete recanalization

5 mg/minmaximum; 0.25 mg/kg

0% hemorrhagic complications

Jones et al., 200813 IA, followed by IV infusionfor 12 hours

n ¼ 15 (R 12; nr 3) TICI 0 (13.3%)TICI 1e2 (46%)TICI 3 (40%)

0.25 mg/kg 0% intracranial bleeding, 6% digestive bleeding

Walsh et al., 201116 Study included patients treated withIA and IV; IA during coiling ¼ 4.

n ¼ 4 (R 2; nr 2) NR (75% distal migration of thrombus) NR 25% intracranial hemorrhage, 75% distalmigration of thrombus

R, ruptured; nr, not ruptured; SAH, subarachnoid hemorrhage; IV, intravenous; tPA, tissue plasminogen activator; IA, intra-arterial; NR, not reported; AVM, arteriovenous malformation; TICI, thrombolysis in cerebral infarction.

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Figure 1. A 55-year-old female patient with a nonruptured anteriorcommunicating aneurysm. (A) Cerebral angiogram, left internal carotidartery (ICA) injection. Anteroposterior projection shows complete suddenocclusion of the ipsilateral A1 (arrow) during coiling of the anteriorcommunicating aneurysm. (B) Cerebral angiogram after intra-arterialinfusion of 10 mg of abciximab. Mild improvement of distal flow and faintopacification of main trunk of the anterior cerebral artery (arrowheads), but

without filling of the whole tree of the anterior cerebral artery (ACA)(thrombolysis in cerebral infarction score ¼ 1). (C) Magnetic resonanceimaging, axial T2 diffusion, performed 36 hours later demonstrated acuteinfarct (asterisk) in the ACA territory. The patient experienced right legparalysis, and she was discharged home after 2 weeks. Modified Rankinscore at 6 months was 3.

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RAFAEL MARTÍNEZ-PÉREZ ET AL. INTRA-ARTERIAL USE OF ABCIXIMAB IN CEREBROVASCULAR PROCEDURES

seen in only 4 cases. Moreover, we found the correlation betweenDSA, MRI findings, and neurologic impairment to be imperfect,leading to uncertainty about the real value of the flowimprovement demonstrated after the IA abciximab infusion onDSA. In fact, up to 25% of patients in our series with completerecanalization and 77.7% of those with partial recanalization stilldemonstrated significant infarcts in the territory of the initiallyoccluded vessel. Only when the recanalization of the parentvessel was complete was there a significant correlation withbetter neurologic outcomes. This result might be a littlediscouraging, considering our current study, in which completerecanalization was achieved in only 28.5% of cases. This ratedoes not differ significantly with most recent investigations.13,14,17

At this point, it is interesting to remark that we found a closerelation with the location of the aneurysm treated in the posteriorcirculation and better clinical outcomes and a lower rate ofinfarction. This association has never been reported in neuro-endovascular cases treated with IA abciximab. Previous studieshave suggested that recanalization response after tPA infusion isworse in patients with posterior circulation strokes.15 This findinghas been explained by the difference in the clot composition, asthe rate of cardioembolic strokes is higher in the middlecerebral artery.18 We hypothesize that our differences in clinicaland radiologic outcomes between anterior and posteriorcirculation are due more to hemodynamic factors, as theetiology of the clot is the same in both posterior and anteriorcirculation.More than 50% of the cases suffered complications, including

hemorrhage, distal migration of the thrombus with obstruction ofother important branches and recanalization of the aneurysm.To our knowledge, this study is the first to assess the post-

coiling state of the aneurysm after IA abciximab infusion on the

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basis of MRA findings. Aneurysm recanalization was seen in 3 ofour patients (Figure 1), and it is closely related to the dose of IAabciximab administered; however, increasing doses did notmean higher recanalization rates or better clinical outcomes.Despite the fact that none of these recanalized aneurysms rebledafter IA abciximab infusion, we believe that abciximab shouldbe used with caution in patients with ruptured aneurysms, andwith due consideration of other factors such as packingdensity19 and platelet count.17

Two studies report cases of hemorrhagic complications in pa-tients with ruptured aneurysms. These authors considered thepresence of a ruptured aneurysm to be a relative contraindicationto the use of abciximab. We only observed one hemorrhagiccomplication, and it occurred in a patient with a ruptured aneu-rysm. It may, however, be difficult to differentiate betweenbleeding causing by the use of abciximab and a rerupture of theaneurysm. Gentric20 reported an incidence of hemorrhagiccomplications of 9.5%, but only one quarter of them wereclinically relevant.Apart from the setting of ruptured aneurysm, other factors

believed to be associated with hemorrhagic complication includeconcurrent IV administration of urokinase, or another anti-fibrinolytic,4 and thrombocytopenia.17 We could not demonstratethis relationship, but the power of our study might be limitedby the small number of the sample. Early in our experience, IVheparin was administered for 24 hours after IA infusion ofabciximab in 2 patients. There was no hemorrhagiccomplication and no aneurysm recanalization. Similarly, 2 of ourpatients received concurrent IV injection of abciximab, with nonew hemorrhage. Our current practice is to avoid the IVinjection of abciximab and the use of other fibrinolytics. IAinfusion of other GPIIb/IIIa inhibitors, such as eptifibatide and

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Figure 2. A 61-year-old female patient with a rupturedanterior communicating aneurysm. (A) Cerebralangiogram, anteroposterior (AP) left internal carotidartery (ICA) injection. After deployment of first 3 coils, athrombus formation besides the coil mass (arrow)produces complete occlusion of left A2, seen as a lackof distal flow in the ipsilateral anterior cerebral artery(arrowheads). (B) Cerebral angiogram, AP left ICA after8 mg of IA abciximab achieved partial recanalization

with improvement of filling in distal A2 (arrowheads).There was persistent flow delay and permanent “snowdot” (arrow) adjacent to the coil mass, protruding intothe parent vessel. (C and D) Twenty-fourehourpostprocedure magnetic resonance imaging andangiography. (C) Axial T1 gadolinium. Recanalization ofpart of the neck, measuring 6 mm in maximumdiameter (arrow). (D) Axial diffusion. Ipsilateral leftcaudate nucleus infarct (asterisk).

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RAFAEL MARTÍNEZ-PÉREZ ET AL. INTRA-ARTERIAL USE OF ABCIXIMAB IN CEREBROVASCULAR PROCEDURES

tirofiban, have been proposed as an alternative to abciximab fortreating thromboembolic complications duringneuroendovascular procedures.21 Although some studies haveshown lower rates of rebleeding and thrombocytopenia,22 thereis still not enough evidence to justify their use.21

Distal migration of the thrombus is a complication notcommonly addressed by other authors. Mounayer12 reported 1patient with distal embolism causing a stroke in a series of 13patients treated with IA abciximab. Walsh et al.16 observed thatthis complication was common in his series.16 The incidence ofthis complication was also high in our experience, as up to onequarter of our patients demonstrated obstruction of flow in adistal vessel, with 3 of the 4 cases developing significant infarcton MRI (Figure 2).We believe that the use of IA abciximab should be considered

on an individual basis. Factors to consider include the clinicalcondition, the presence of concomitant hemorrhage, which vesselis occluded, the potential for collateral circulation, and risk factorsfor bleeding, including doses of abciximab and treatment withother blood thinners. Although the current study has some po-tential limitations, including a small number of cases and the lackof a reliable comparison group, our results are not as encouragingas previously described. We demonstrate, on a scientific merit, therole of some risk factors in relation to the prognosis and

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complication rates of using IA abciximab for thromboemboliccomplications after aneurysm coiling.

CONCLUSION

In our experience, the use of IA abciximab for treatment of acutethrombotic complications during aneurysm coiling is moderatelysuccessful for restoration of blood flow in an occluded vessel.The complication rate using IA abciximab is higher than pre-

viously reported. Aside from the well-known risk of bleeding,there is also an increasing risk of stroke on post-procedural DWI,even when recanalization on MRA is achieved. Greater doses of IAabciximab are associated with higher rates of aneurysm recanali-zation, without demonstrating a clear improvement in outcome orreperfusion. Patients with thromboembolic complications inposterior circulation treated with abciximab have better radiologicand clinical outcomes than do those occurring in the anteriorcirculation. The use of IA abciximab should be individualized andlimited in patients with complication risk factors.

ACKNOWLEDGMENTS

The authors thank Catherine Carlisle for her support, strength,and cooperation and for being the soul of this department, and theWriting Support Centre at Western University for help in editingthis manuscript.

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ORIGINAL ARTICLE

RAFAEL MARTÍNEZ-PÉREZ ET AL. INTRA-ARTERIAL USE OF ABCIXIMAB IN CEREBROVASCULAR PROCEDURES

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Conflict of interest statement: The authors declare that thearticle content was composed in the absence of anycommercial or financial relationships that could be construedas a potential conflict of interest. Dr Martinez-Perezobtained his scholarship from the “Fundacion Alfonso Martin

WORLD NEUROSURGERY, http://

Escudero, Madrid, Spain” to do his fellowship at WesternUniversity.

Received 8 November 2016; accepted 6 January 2017

Citation: World Neurosurg. (2017) 100:342-350.http://dx.doi.org/10.1016/j.wneu.2017.01.023

Journal homepage: www.WORLDNEUROSURGERY.org

Available online: www.sciencedirect.com

1878-8750/$ - see front matter ª 2017 Elsevier Inc. Allrights reserved.

dx.doi.org/10.1016/j.wneu.2017.01.023

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