Abstract 1122‐000043: Vorapaxar as An Alternative for Ticagrelor Resistance in Neuroendovascular Intervention

Introduction: Perioperative dual‐antiplatelet therapy (DAPT) for flow diversion (FD) limits thromboembolic complications. Practice of DAPT varies across the neuroendovascular field but typically includes aspirin and an ADP receptor antagonist such as clopidogrel, prasugrel, or ticagrelor. Unfortunately, resistance to DAPT medications remains a concern for neuroendovascular intervention, and there is a current lack of standard alternatives for such resistance. The main goal of this abstract is to discuss ticagrelor resistance and to inform possible therapeutic options. Methods: We report a case of vorapaxar treated FD for an intracranial aneurysm in a patient with ticagrelor resistance. FD was deployed for a left internal carotid artery (ICA) blister aneurysm and bilateral ICA dissecting pseudoaneurysms (Figure 1). We also provide a narrative review on previous reports of ticagrelor resistance and associated treatment responses. We used the keywords: “ticagrelor,” “resistance,” “hypo‐response,” “stent thrombosis,” and “aneurysm.” These were implemented in various combinations with Boolean operators in three databases: PubMed, Ovid MEDLINE, and Ovid EMBASE. Results: During a complicated clinical course, the patient had three thromboembolic complications while on DAPT with ticagrelor or prasugrel leading to transition of antiplatelet therapy to vorapaxar. Thromboelastography with platelet mapping (TEG‐PM) routinely demonstrated inadequate platelet inhibition, which was confirmed with platelet function analyzer‐100. Initial TEG‐PM results were 0.0% ADP receptor inhibition and MA‐ADP of 62.2 mm. Repeat angiograms also indicated thromboembolic formation after each of the three events (Figure 1). After introduction of vorapaxar, the patient had adequate platelet inhibition with TEG‐PM results of 49.1% ADP receptor inhibition and MA‐ADP of 48.3 mm. At 84 days follow‐up, the patient was fully recovered with complete occlusion of the aneurysms. In a narrative review of the literature, there were ten previously reported cases of ticagrelor resistance or hypo‐response: three cases in the neuroendovascular literature and seven cases in the cardiovascular literature. Among all of the cases, there was a variability in protocol for treating patients with suggested ticagrelor resistance. All three neuroendovascular cases either employed another ADP receptor antagonist in hopes that the resistance would not generalize or eliminated DAPT altogether and settled for aspirin alone. In some of the cardiovascular cases, ticagrelor was even continued after patients exhibited laboratory evidence of resistance or hypo‐response. Conclusions: Given the paucity of cases describing ticagrelor resistance or hypo‐response in the neuroendovascular and cardiovascular literature, management of DAPT should remain a multifactorial decision depending on the clinical situation. Moreover, we need to consider therapeutic alternatives for cases of resistance such as thrombin receptor antagonists, specifically PAR1 receptor antagonists like vorapaxar. High quality randomized controlled trials are needed to elucidate the safety and efficacy of vorapaxar in neuroendovascular procedures

Evaluation of the Thoracolumbar Injury Classification and Severity (TLICS) Score Over a Two-Year Period at a Level One Trauma Center.

Introduction The use of the Thoracolumbar Injury Classification and Severity Score (TLICS) and other classification systems for guiding the management of traumatic spinal injuries remains controversial. TLICS is one of the few classifications that provides treatment recommendations.We sought to analyze intervention modality selection based on the TLICS scoring system. Methods A retrospective review of patients presenting with traumatic thoracolumbar fractures at a level 1 trauma center over a two-year period was performed. Primary endpoints for comparison analysis included visual analog scale (VAS) scores and Cobb angles during follow-up. Results There were 272 patients with thoracolumbar fractures, of whom 212 had TLICS of ≤3, six with TLICS of 4, and 54 with TLICS of ≥5. Of the 272 total patients, 59 were treated via surgery and 213 via non-surgical conservative methods. The VAS scores significantly decreased from presentation to last follow-up in both surgically treated and conservative groups (p4 conservative group, who had significantly lower Cobb angles at the last follow-up than the TLICS \u3e 4 surgical group (

Vorapaxar as an Alternative for Ticagrelor Resistance in Neuroendovascular Intervention

Background Perioperative dual‐antiplatelet therapy for flow diversion limits thromboembolic complications. However, resistance to dual‐antiplatelet therapy medications remains a concern for neuroendovascular intervention. To date, there is no standardized approach for resistance to ADP receptor antagonists. Methods We report a case of ticagrelor resistance for flow diversion of an intracranial aneurysm treated with vorapaxar, as well as a narrative review of the literature for previous cases of ticagrelor resistance. Results Flow diversion with the Pipeline embolization device was deployed for a left internal carotid artery blister aneurysm and bilateral internal carotid artery dissecting pseudoaneurysms. The patient had 3 thromboembolic complications while on dual‐antiplatelet therapy with ticagrelor or prasugrel, leading to transition of antiplatelet therapy to vorapaxar. At 84 days follow‐up, the patient was fully recovered with complete occlusion of the aneurysms. Conclusion Our case suggests that vorapaxar is a promising alternative for patients with ticagrelor resistance in flow diversion–treated intracranial aneurysms. High‐quality randomized controlled trials are needed to elucidate the safety and efficacy of vorapaxar in neuroendovascular procedures

Managing Disease-Modifying Antirheumatic Drugs (DMARDs) for Patients Undergoing Elective Spine Surgery: A Pilot Survey.

INTRODUCTION: Patients affected by autoimmune pathologies such as rheumatoid arthritis require surgery for various reasons. However, the systemic inflammatory nature of these disease processes often necessitates therapy with disease-modifying antirheumatic drugs (DMARDs). Alteration of these agents in the perioperative period for surgery requires a careful risk-benefit analysis to limit disease flares, infection rates, and secondary revisions. We therefore queried North and South American practices for perioperative management of DMARDs in patients undergoing elective spine surgery. METHODS: An institutional review board-approved pilot survey was disseminated to spine surgeons regarding how they managed DMARDs before, during, and after spine surgery. RESULTS: A total of 47 spine surgeons responded to the survey, 37 of whom were neurosurgeons (78.7%) and 10 orthopedic surgeons (21.3%). Of the respondents, 80.9% were from North America, 72.3% were board-certified, 51.1% practiced in academic institutions, and 66.0% performed 50-150 spine surgeries per year. Most respondents consulted a rheumatologist before continuing or withholding a DMARD in the perioperative period (70.2%). As such, a majority of the spine surgeons in this survey withheld DMARDs at an average of 13.8 days before and 19.6 days after spine surgery. Of the spine surgeons who withheld DMARDs before and after spine surgery, the responses were variable with a trend toward no increased risk of postoperative complications. CONCLUSIONS: Based on the results of this pilot survey, we found a consensus among spine surgeons to withhold DMARDs before and after elective spine surgery

Managing Disease-Modifying Antirheumatic Drugs (DMARDs) for Patients Undergoing Elective Spine Surgery: A Pilot Survey

Introduction: Patients affected by autoimmune pathologies such as rheumatoid arthritis require surgery for various reasons. However, the systemic inflammatory nature of these disease processes often necessitates therapy with disease-modifying antirheumatic drugs (DMARDs). Alteration of these agents in the perioperative period for surgery requires a careful risk-benefit analysis to limit disease flares, infection rates, and secondary revisions. We therefore queried North and South American practices for perioperative management of DMARDs in patients undergoing elective spine surgery. Methods: An institutional review board-approved pilot survey was disseminated to spine surgeons regarding how they managed DMARDs before, during, and after spine surgery. Results: A total of 47 spine surgeons responded to the survey, 37 of whom were neurosurgeons (78.7%) and 10 orthopedic surgeons (21.3%). Of the respondents, 80.9% were from North America, 72.3% were board-certified, 51.1% practiced in academic institutions, and 66.0% performed 50-150 spine surgeries per year. Most respondents consulted a rheumatologist before continuing or withholding a DMARD in the perioperative period (70.2%). As such, a majority of the spine surgeons in this survey withheld DMARDs at an average of 13.8 days before and 19.6 days after spine surgery. Of the spine surgeons who withheld DMARDs before and after spine surgery, the responses were variable with a trend toward no increased risk of postoperative complications. Conclusions: Based on the results of this pilot survey, we found a consensus among spine surgeons to withhold DMARDs before and after elective spine surgery