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Neurosurgery:低剂量普拉格雷用于支架辅助弹簧圈栓塞术

2019-01-03 杨中华 脑血管病及重症文献导读

支架辅助弹簧圈(Stent-assisted coil,SAC)栓塞时一项有效的血管内治疗方案,常应用于宽颈、梭型或夹层动脉瘤。支架有助于动脉瘤弹簧圈栓塞,闭塞动脉瘤比单独弹簧圈栓塞更持久。然而,弹簧圈栓塞期间支架增加血栓栓塞事件,缺血性神经系统后遗症更加常见。手术前,大部分患者需要提前使用两种抗血小板药物,比如氯吡格雷和阿司匹林,以降低缺血不良事件的风险。值得注意的是,氯吡格雷的不良反应时缺血性


支架辅助弹簧圈(Stent-assisted coil,SAC)栓塞时一项有效的血管内治疗方案,常应用于宽颈、梭型或夹层动脉瘤。支架有助于动脉瘤弹簧圈栓塞,闭塞动脉瘤比单独弹簧圈栓塞更持久。然而,弹簧圈栓塞期间支架增加血栓栓塞事件,缺血性神经系统后遗症更加常见。手术前,大部分患者需要提前使用两种抗血小板药物,比如氯吡格雷和阿司匹林,以降低缺血不良事件的风险。值得注意的是,氯吡格雷的不良反应时缺血性并发症的危险因素。

最近,三代噻吩并吡啶,普拉格雷,被应用于临床,很多介入科医生血管内治疗颅内动脉瘤时开始使用普拉格雷预防性抗血小板治疗。普拉格雷是新一代 P2Y12腺苷二磷酸受体抑制剂。与氯吡格雷不同,氯吡格雷需要两步过程才具有活性,口服普拉格雷仅需要一步代谢过程就被活化。并且,普拉格雷的大部分代谢产物都具有活性。因此,普拉格雷能够更加迅速和持续地抑制 ADP 诱导血小板聚集,不受年龄、糖尿病、抽烟或肾功能损害的影响。虽然,一些以前的研究报道了弹簧圈栓塞动脉瘤手术前给予普拉格雷的临床结局,但是其预防支架辅助弹簧圈栓塞手术的安全性和有效性尚不清楚。

2018年11月来自韩国的Hyun Ho Choi等在NEUROSURGERY杂志上公布了他们的回顾性研究结果,以验乞未破裂动脉瘤弹簧圈辅助动脉瘤栓塞时给予低剂量普拉格雷(vs 氯吡格雷)作为预防性抗血小板治疗的有效性和安全性。

研究者把患者分为两组:氯吡格雷组和低剂量普拉格雷组。根据医生的意见选择抗血小板治疗方案。已经服用氯吡格雷或普拉格雷者,继续服用这两个药物。在两组中,抗血小板负荷量后6h 抽血,并采用 VerifyNow 评价。测量P2Y12反应单位(P2Y12 reaction unit,PRU)和抑制率评价血小板活性。不良反应者定义为 PRU>285。在氯吡格雷组,手术前一天给予患者双联抗血小板治疗(阿司匹林和氯吡格雷皆300mg 负荷量);手术当天早上给予氯吡格雷75mg 和阿司匹林100mg。不良反应者,额外给予西洛他唑(200mg)。在普拉格雷组,手术前一天给予患者普拉格雷20mg,手术当天早上给予普拉格雷5mg。不良反应者,额外给予普拉格雷10mg。手术后至少维持抗血小板治疗3个月,随后长期阿司匹林治疗。

该研究共纳入了297例患者,311个动脉瘤进行了支架辅助血管内弹簧圈栓塞未破裂颅内动脉瘤。普拉格雷组的 PRU 明显低于氯吡格雷组(132.3 ± 76.9 vs 238.1 ±69.1; P< 0.001);普拉格雷组抑制率也明显高于氯吡格雷组(54.0 ± 26.0% vs 20.8 ± 18.6%; P < 0.001)。普拉格雷组血栓事件发生率明显低于氯吡格雷组(0.9% vs 6.4%; P= 0.01),不过两组出血的并发症比例没有显著性差异(0.5% vs 2.2%; P= 0.22)。在多因素分析中,氯吡格雷是支架辅助弹簧圈栓塞术血栓栓塞的唯一危险因素。

最终作者认为对于支架辅助弹簧圈栓塞的未破裂颅内动脉瘤,采用低剂量普拉格雷作为术前抗血小板治疗是快速、有效和安全的。术前普拉格雷能够显著降低血栓栓塞事件,未增加出血的风险。

原始出处:

Hyun Ho Choi,et al.Antiplatelet Premedication for Stent-Assisted Coil Embolization of Intracranial Aneurysms: Low-Dose Prasugrel vs Clopidogrel.Neurosurgery. 2018 Nov 1;83(5):981-988. doi: 10.1093/neuros/nyx591.

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    2019-04-21 chg121
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    2019-01-15 jyzxjiangqin

    低剂量普拉格雷的治疗。

    0

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    2019-01-05 lsndxfj
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