Endovascular complications: Antiplatelet management for flow diversion

Up to 3−5% of the general population is affected by cerebral aneurysms that are associated with both modifiable as well as non-modifiable risk factors ranging from familial to acquired neurovascular conditions. The initial treatment option was aneurysm clipping and evolved to including primary or adjuvant endovascular treatment. Aneurysm re-rupture, although rare, can have devastating consequences such as intracranial bleeding and carotidcavernous fistula. Emergent surgery in view of delayed aneurysm rupture in patients maintained on dual antiplatelet therapy presents with the need to carefully assess the procedure-related risk factors and evaluate the patients’ platelet function. With the advent of novel technology, flow diverters came into play. These devices utilize the deployment of metallic stents into the parent artery that serves the diversion of blood flow away from the pouching aneurysm. Despite their efficacy, flow diverter insertion and catheter manipulation come with a risk of developing ischemia and stroke, hemorrhage and aneurysm re-rupture, in-stent thrombosis and stenosis, and aneurysmal occlusion amongst other complications. The prospect of thromboembolic events necessitates the use of aggressive antiplatelet regimen with the dual antiplatelet regimen utilizing clopidogrel and aspirin used most frequently. Prasugrel and Ticagrelor have been shown to be superior to Clopidogrel in terms of thromboembolic consequences in cardiovascular literature. Given their potential benefit over the current standard of treatment in this patient population, more extensive randomized-controlled studies are warranted for the evaluation of the efficacy and non-inferiority of Prasugrel and Aspirin or Ticagrelor and Aspirin to Clopidogrel and Aspirin.