Top

Published in:

20-11-2023 | Thrombosis | Original Article

Feasibility and safety values of activated clotting time–guided systemic heparinization in coil embolization for unruptured intracranial aneurysms

Authors: Hyuk Jang, Byung-Rae Cho, Dong-Kyu Jang, Dong-Sub Kim

Published in: Acta Neurochirurgica | Issue 12/2023

Abstract

Objective

This study aimed to evaluate the feasibility and safety values of activated clotting time (ACT)–guided systemic heparinization in reducing periprocedural thrombosis and bleeding complications during coil embolization of unruptured intracranial aneurysms.

Methods

A total of 228 procedures performed on 213 patients between 2016 and 2021 were included in the retrospective analysis. The target ACT was set at 250 s. Logistic regression was performed to assess predictors for the occurrence of thrombosis and bleeding. Receiver operating characteristic (ROC) analyses were employed to determine the optimal cut-off values for ACT, heparinization, and procedure time.

Results

Most (85.1%) of procedures were stent-assisted embolization. The mean baseline ACT was 128.8 ± 45.7 s. The mean ACT at 20 min after the initial intravenous heparin loading of 78.2 ± 18.8 IU/kg was 185 ± 46.4 s. The mean peak ACT was 255.6 ± 63.8 s with 51.3% (117 cases) achieving the target ACT level. Peak ACT was associated with symptomatic thrombosis (OR per second, 1.008; 95% CI, 1.000–1.016; P = 0.035) (cut-off value, 275 s; area under ROC (AUROC), 0.7624). Total administered heparin dose per body weight was negatively associated with symptomatic thrombosis (OR per IU/kg, 0.972; 95% CI, 0.949–0995; P = 0.018) (cut-off value, 294 IU/kg; AUROC, 0.7426) but positively associated with significant bleeding (OR, 1.008 per IU/kg; 95% CI, 1.005–1.012; P <0 .001) (cut-off value, 242 IU/kg; AUROC, 0.7391). Procedure time was significantly associated with symptomatic thrombosis (OR per minute, 1.05; 95% CI, 1.017–1.084; P value = 0.002) (cut-off value, 158 min; area under ROC, 0.8338).

Conclusion

This study demonstrated that ACT-guided systemic heparinization was feasible to achieve the target ACT value and proposes probable safety thresholds to prevent periprocedural complications through reducing procedure time during coil embolization of unruptured intracranial aneurysms in the stent era.

Almekhlafi MA, Al Sultan AS, Kuczynski AM, Brinjikji W, Menon BK, Hill MD, Goyal M (2020) Antiplatelet therapy for prevention of thromboembolic complications in coiling-only procedures for unruptured brain aneurysms. J Neurointerv Surg 12:298–302. https://doi.org/10.1136/neurintsurg-2019-015173CrossRefPubMed

Bendszus M, Koltzenburg M, Bartsch AJ, Goldbrunner R, Gunthner-Lengsfeld T, Weilbach FX, Roosen K, Toyka KV, Solymosi L (2004) Heparin and air filters reduce embolic events caused by intra-arterial cerebral angiography: a prospective, randomized trial. Circulation 110:2210–2215. https://doi.org/10.1161/01.CIR.0000144301.82391.85CrossRefPubMed

Bertrand OF, Larose E, Rodés-Cabau J, Rinfret S, Déry JP, Bagur R, Gleeton O, Nguyen CM, Proulx G, De Larochellière R, Poirier P, Costerousse O, Roy L (2010) Incidence, range, and clinical effect of hemoglobin changes within 24 hours after transradial coronary stenting. Am J Cardiol 106:155–161. https://doi.org/10.1016/j.amjcard.2010.03.013CrossRefPubMed

Bittl JA, Strony J, Brinker JA, Ahmed WH, Meckel CR, Chaitman BR, Maraganore J, Deutsch E, Adelman B (1995) Treatment with bivalirudin (Hirulog) as compared with heparin during coronary angioplasty for unstable or postinfarction angina. Hirulog Angioplasty Study Investigators. N Engl J Med 333:764–769. https://doi.org/10.1056/NEJM199509213331204CrossRefPubMed

Bond KM, Brinjikji W, Murad MH, Kallmes DF, Cloft HJ, Lanzino G (2017) Diffusion-weighted imaging-detected ischemic lesions following endovascular treatment of cerebral aneurysms: a systematic review and meta-analysis. AJNR Am J Neuroradiol 38:304–309. https://doi.org/10.3174/ajnr.A4989CrossRefPubMedPubMedCentral

Bracard S, Barbier C, Derelle AL, Anxionnat R (2013) Endovascular treatment of aneurisms: pre, intra and post operative management. Eur J Radiol 82:1633–1637. https://doi.org/10.1016/j.ejrad.2013.02.012CrossRefPubMed

Brener SJ, Moliterno DJ, Lincoff AM, Steinhubl SR, Wolski KE, Topol EJ (2004) Relationship between activated clotting time and ischemic or hemorrhagic complications: analysis of 4 recent randomized clinical trials of percutaneous coronary intervention. Circulation 110:994–998. https://doi.org/10.1161/01.CIR.0000139868.53594.24CrossRefPubMed

Castellan L, Causin F, Danieli D, Perini S (2003) Carotid stenting with filter protection. Correlation of ACT values with angiographic and histopathologic findings. Neuroradiol J = Journal de neuroradiologie 30:103–108

Choi J, Koo Y, Whang K, Cho S, Kim J (2021) Safety of heparin loading during endovascular embolization in patients with aneurysmal subarachnoid hemorrhage. Clin Neurol Neurosurg 201:106453. https://doi.org/10.1016/j.clineuro.2020.106453CrossRefPubMed

10.

Doganer O, Wiersema AM, Pierie M, Blankensteijn JD, Yeung KK, Jongkind V (2021) More effective anticoagulation during non-cardiac arterial procedures using activated clotting time guided heparin administration. Ann Vasc Surg 76:378–388. https://doi.org/10.1016/j.avsg.2021.04.023CrossRefPubMed

11.

Dutsch A, Graesser C, Voll F, Novacek S, Eggerstedt R, Armbruster NL, Laugwitz KL, Cassese S, Schunkert H, Ndrepepa G, Kastrati A, Kessler T, Sager HB (2022) Association of in-hospital hemoglobin drop with decreased myocardial salvage and increased long-term mortality in patients with acute ST-segment-elevation myocardial infarction. J Am Heart Assoc 11:e024857. https://doi.org/10.1161/jaha.121.024857CrossRefPubMedPubMedCentral

12.

Ferguson JJ, Dougherty KG, Gaos CM, Bush HS, Marsh KC, Leachman DR (1994) Relation between procedural activated coagulation time and outcome after percutaneous transluminal coronary angioplasty. J Am Coll Cardiol 23:1061–1065. https://doi.org/10.1016/0735-1097(94)90590-8CrossRefPubMed

13.

Fuchs S, Kornowski R, Teplitsky I, Brosh D, Lev E, Vaknin-Assa H, Ben-Dor I, Iakobishvili Z, Rechavia E, Battler A, Assali A (2009) Major bleeding complicating contemporary primary percutaneous coronary interventions-incidence, predictors, and prognostic implications. Cardiovascular Revascularization Medicine: Including Molecular Interventions 10:88–93. https://doi.org/10.1016/j.carrev.2008.08.001CrossRefPubMed

14.

Hirsh J, Anand SS, Halperin JL, Fuster V, American Heart A (2001) AHA Scientific Statement: Guide to anticoagulant therapy: heparin: a statement for healthcare professionals from the American Heart Association. Arterioscler Thromb Vasc Biol 21:E9–E9. https://doi.org/10.1161/hq0701.093520CrossRefPubMed

15.

Jiang WJ, Wang YJ, Du B, Wang SX, Wang GH, Jin M, Dai JP (2004) Stenting of symptomatic M1 stenosis of middle cerebral artery: an initial experience of 40 patients. Stroke 35:1375–1380. https://doi.org/10.1161/01.STR.0000128018.57526.3aCrossRefPubMed

16.

Kessler IM, Mounayer C, Piotin M, Spelle L, Vanzin JR, Moret J (2005) The use of balloon-expandable stents in the management of intracranial arterial diseases: a 5-year single-center experience. AJNR Am J Neuroradiol 26:2342–2348PubMedPubMedCentral

17.

Kim DJ, Lee BH, Kim DI, Shim WH, Jeon P, Lee TH (2005) Stent-assisted angioplasty of symptomatic intracranial vertebrobasilar artery stenosis: feasibility and follow-up results. AJNR Am J Neuroradiol 26:1381–1388PubMedPubMedCentral

18.

Knight CJ, Panesar M, Wilson DJ, Patrineli A, Chronos N, Wright C, Clarke D, Patel D, Fox K, Goodall AH (1998) Increased platelet responsiveness following coronary stenting. Heparin as a possible aetiological factor in stent thrombosis. Eur Heart J 19:1239–1248. https://doi.org/10.1053/euhj.1998.1047CrossRefPubMed

19.

Koh JS, Hwang G, Park JC, Lee CY, Chung J, Lee SW, Kwon HJ, Kim SR, Kang DH, Kwon SC, Kim ST, Chang CH, Jang DK, Choi JH, Kim YW, Kim BT, Shin BG, You SH, Chung SY et al (2023) Tailored antiplatelet therapy in stent assisted coiling for unruptured aneurysms: a nationwide registry study. J Neurointerv Surg. https://doi.org/10.1136/jnis-2022-019571

20.

Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS Jr, Nnacheta LC et al (2022) 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 145:e4–e17. https://doi.org/10.1161/CIR.0000000000001039CrossRefPubMed

21.

Lee SH, Jang MU, Kang J, Kim YJ, Kim C, Sohn JH, Yang J, Jeon JP, Cho Y, Choi HJ (2018) Impact of reducing the procedure time on thromboembolism after coil embolization of cerebral aneurysms. Front Neurol 9:1125. https://doi.org/10.3389/fneur.2018.01125CrossRefPubMedPubMedCentral

22.

Levy EI, Boulos AS, Guterman LR (2002) Stent-assisted endoluminal revascularization for the treatment of intracranial atherosclerotic disease. Neurol Res 24:337–346. https://doi.org/10.1179/016164102101200113CrossRefPubMed

23.

Lim Fat MJ, Al-Hazzaa M, Bussiere M, dos Santos MP, Lesiuk H, Lum C (2013) Heparin dosing is associated with diffusion weighted imaging lesion load following aneurysm coiling. J Neurointerv Surg 5:366–370. https://doi.org/10.1136/neurintsurg-2011-010225CrossRefPubMed

24.

Lylyk P, Cohen JE, Ceratto R, Ferrario A, Miranda C (2002) Endovascular reconstruction of intracranial arteries by stent placement and combined techniques. J Neurosurg 97:1306–1313. https://doi.org/10.3171/jns.2002.97.6.1306CrossRefPubMed

25.

Mascelli MA, Kleiman NS, Marciniak SJ Jr, Damaraju L, Weisman HF, Jordan RE (2000) Therapeutic heparin concentrations augment platelet reactivity: implications for the pharmacologic assessment of the glycoprotein IIb/IIIa antagonist abciximab. Am Heart J 139:696–703. https://doi.org/10.1016/s0002-8703(00)90050-4CrossRefPubMed

26.

Mascitelli JR, Moyle H, Oermann EK, Polykarpou MF, Patel AA, Doshi AH, Gologorsky Y, Bederson JB, Patel AB (2015) An update to the Raymond-Roy Occlusion Classification of intracranial aneurysms treated with coil embolization. J Neurointerv Surg 7:496–502. https://doi.org/10.1136/neurintsurg-2014-011258CrossRefPubMed

27.

McGarry TF Jr, Gottlieb RS, Morganroth J, Zelenkofske SL, Kasparian H, Duca PR, Lester RM, Kreulen TH (1992) The relationship of anticoagulation level and complications after successful percutaneous transluminal coronary angioplasty. Am Heart J 123:1445–1451. https://doi.org/10.1016/0002-8703(92)90793-uCrossRefPubMed

28.

Mo L, Yue J, Yu W, Liu X, Tan C, Peng W, Ding X, Chen L (2022) Diffusion-weighted imaging lesions after endovascular treatment of cerebral aneurysms: a network meta-analysis. Front Surg 9:964191. https://doi.org/10.3389/fsurg.2022.964191CrossRefPubMed

29.

Morabia A (1986) Heparin doses and major bleedings. Lancet 1:1278–1279. https://doi.org/10.1016/s0140-6736(86)91421-2CrossRefPubMed

30.

Mottillo S, Filion KB, Joseph L, Eisenberg MJ (2017) Defining optimal activated clotting time for percutaneous coronary intervention: a systematic review and Bayesian meta-regression. Catheter Cardiovasc Interv 89:351–366. https://doi.org/10.1002/ccd.26652CrossRefPubMed

31.

Narins CR, Hillegass WB Jr, Nelson CL, Tcheng JE, Harrington RA, Phillips HR, Stack RS, Califf RM (1996) Relation between activated clotting time during angioplasty and abrupt closure. Circulation 93:667–671. https://doi.org/10.1161/01.cir.93.4.667CrossRefPubMed

32.

O'Gara PT, Kushner FG, Ascheim DD, Casey DE Jr, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE et al (2013) 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 127:e362–e425. https://doi.org/10.1161/CIR.0b013e3182742cf6CrossRefPubMed

33.

Oshita J, Sakamoto S, Matsushige T, Okazaki T, Ishii D, Kawano R, Kurisu K (2019) Factors other than body weight predicting heparin loading to acquire optimal activated clotting time in endovascular neurointerventions. Clin Neurol Neurosurg 184:105422. https://doi.org/10.1016/j.clineuro.2019.105422CrossRefPubMed

34.

Park JC, Lee DH, Kim JK, Ahn JS, Kwun BD, Kim DY, Choi CG (2016) Microembolism after endovascular coiling of unruptured cerebral aneurysms: incidence and risk factors. J Neurosurg 124:777–783. https://doi.org/10.3171/2015.3.Jns142835CrossRefPubMed

35.

Scharf J, Dempfle CE (2012) Anticoagulation in neurointerventions: basic pharmacology and pathophysiology, current status, practical advice. Clin Neuroradiol 22:3–13. https://doi.org/10.1007/s00062-012-0133-6CrossRefPubMed

36.

Wiersema AM, Roosendaal LC, Koelemaij MJW, Tijssen JGP, van Dieren S, Blankensteijn JD, Debus ES, Middeldorp S, Heyligers JMM, Fokma YS, Reijnen M, Jongkind V (2021) ACTION-1: study protocol for a randomised controlled trial on ACT-guided heparinization during open abdominal aortic aneurysm repair. Trials 22:639. https://doi.org/10.1186/s13063-021-05552-7CrossRefPubMedPubMedCentral

37.

Xiao Z, Theroux P (1998) Platelet activation with unfractionated heparin at therapeutic concentrations and comparisons with a low-molecular-weight heparin and with a direct thrombin inhibitor. Circulation 97:251–256. https://doi.org/10.1161/01.cir.97.3.251CrossRefPubMed

38.

Zhang L, Zhou X, Liu Y, Ding C, Wang Y, Yang H (2020) The utility of diffusion-weighted MRI lesions to compare the effects of different heparinization schemes in intracranial aneurysms treated by endovascular intervention. Front Neurol 11:609384. https://doi.org/10.3389/fneur.2020.609384CrossRefPubMedPubMedCentral

Title: Feasibility and safety values of activated clotting time–guided systemic heparinization in coil embolization for unruptured intracranial aneurysms
Authors: Hyuk Jang
Byung-Rae Cho
Dong-Kyu Jang
Dong-Sub Kim
Publication date: 20-11-2023
Publisher: Springer Vienna
Keywords: Thrombosis
Heparin
Aneurysm
Aneurysm
Intracranial Aneurysm
Published in: Acta Neurochirurgica / Issue 12/2023
Print ISSN: 0001-6268
Electronic ISSN: 0942-0940
DOI: https://doi.org/10.1007/s00701-023-05869-z

Advances in Alzheimer's

Alzheimer's Disease
Independent Medical Education

Alzheimer's research and care is changing rapidly. Keep up with the latest developments from key international conferences, together with expert insights on how to integrate these advances into practice.

This content is intended for healthcare professionals outside of the UK.

Supported by:

Lilly

Developed by: Springer Healthcare IME

Learn more

ERS Congress 2024

Springer Medicine

Feasibility and safety values of activated clotting time–guided systemic heparinization in coil embolization for unruptured intracranial aneurysms

Abstract

Objective

Methods

Results

Conclusion

Advances in Alzheimer's

ERS Congress 2024

Springer Medicine

Abstract

Objective

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 12/2023

Surgical timing and indications for decompressive craniectomy in malignant stroke: results from a single-center retrospective analysis

Endoscopic transoral resection for an upper cervical chordoma in a pediatric patient

Distal placement of balloon guide catheter facilitates stent-retriever mechanical thrombectomy for acute ischemic stroke in the anterior circulation

Additional imaging for newly diagnosed brain lesions suspected to be brain tumors

Intramedullary feeder aneurysm of a cervical epidural arteriovenous fistula causing myelopathy: a case report and literature review

Routine healthcare data for adverse events after spinal surgery

Advances in Alzheimer's