Abstract WP1: Intravenous Cangrelor as a Rescue Platelet Inhibitor for Emergent Stenting in Ischemic and Hemorrhagic Stroke

Abstract

Background: Platelet inhibitor loading is commonly used in emergent settings for neurondovascular interventions in which permanent device implantation (eg, a stent or a flow-diverter) is planned. Oral/enteral load of antiplatelets may delay time-sensitive intervention in emergency settings, and intravenous glycoprotein inhibitors have a long half-life making them difficult to reverse should the treatment strategy change or complications (eg, bleeding) occur. Objective: To investigate the safety and utility of Cangrelor, an intravenous P2Y12 receptor inhibitor with immediate onset (within 2 min) and rapid offset (elimination half-life of 3-6 min) of antiplatelet activity for acute stenting in patients with ischemic and hemorrhagic stroke. Methods/Patients: A total of seven patients (at the time of this submission) received intravenous Cangrelor intraprocedurally. Of those, three patients had tandem cervical/intracranial occlusions, necessitating carotid stenting; two underwent intracranial stenting for thrombectomy-resistant intracranial large vessel occlusions, and two had flow-diverting stents for aneurysmal subarachnoid hemorrhage where use of traditional endovascular/microsurgical techniques was deemed suboptimal. In each case, the infusion was started five minutes before the device implantation, after selective access had been obtained and stent placement was imminent. Results: Endovascular device implantation was successful in all patients. P2Y12 inhibition testing was conducted intraprocedurally (5-10 minutes after the bolus dose) and showed adequate platelet inhibiton in all seven cases (PRU 60-151). Upon completion of interventions, all patients underwent head CT which showed no intracranial hemorrhage (or no worsening hemorrhage). The Cangrelor infusion was then terminated and all patients immediately received oral/enteral antiplatelet load. No immediate/early postoperative complications were noted and follow-up (24-96 hours) angiographic or noninvasive imaging confirmed patency of all the implanted devices. Conclusion: Intravenous Cangrelor could serve as a safe and convenient alternative to traditional antiplatelets or glycoprotein inhibitors in emergent neuroendovascular stenting