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. 2021 Oct;27(5):682-694.
doi: 10.1177/1591019921991394. Epub 2021 Feb 4.

P2Y12 inhibitors in neuroendovascular surgery: An opportunity for precision medicine

Axel Rosengart  1 , Malie K Collins  2 , Philipp Hendrix  3 , Ryley Uber  4 , Melissa Sartori  4 , Abhi Jain  5 , Jennifer Mao  6 , Oded Goren  1 , Clemens M Schirmer  1   7 , Christoph J Griessenauer  1   7
Affiliations

P2Y12 inhibitors in neuroendovascular surgery: An opportunity for precision medicine

Axel Rosengart et al. Interv Neuroradiol. 2021 Oct.

Abstract

Introduction: Dual antiplatelet therapy (DAPT), primarily the combination of aspirin with a P2Y12 inhibitor, in patients undergoing intravascular stent or flow diverter placement remains the primary strategy to reduce device-related thromboembolic complications. However, selection, timing, and dosing of DAPT is critical and can be challenging given the existing significant inter- and intraindividual response variations to P2Y12 inhibitors.

Methods: Assessment of indexed, peer-reviewed literature from 2000 to 2020 in interventional cardiology and neuroendovascular therapeutics with critical, peer-reviewed appraisal and extraction of evidence and strategies to utilize DAPT in cardio- and neurovascular patients with endoluminal devices.

Results: Both geno- and phenotyping for DAPT are rapidly and conveniently available as point-of-care testing at a favorable cost-benefit ratio. Furthermore, systematic inclusion of a quantifying clinical risk score combined with an operator-linked, technical risk assessment for potential adverse events allows a more precise and individualized approach to new P2Y12 inhibitor therapy.

Conclusions: The latest evidence, primarily obtained from cardiovascular intervention trials, supports that combining patient pharmacogenetics with drug response monitoring, as part of an individually tailored, precision medicine approach, is both predictive and cost-effective in achieving and maintaining individual target platelet inhibition levels. Indirect evidence supports that this gain in optimizing drug responses translates to reducing main adverse events and overall treatment costs in patients undergoing DAPT after intracranial stent or flow diverting treatment.

Keywords: Precision medicine; antiplatelet; hemodynamics; neurosurgery; thrombolysis.

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Conflict of interest statement

Author’s Note: Philipp Hendrix is also affiliated with Department of Neurosurgery, Saarland University Medical Center and Saarland University, Faculty of Medicine, Homburg/Saar, Germany.

Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

Figure 1.
Figure 1.
Platelet reactivity and therapeutic range of P2Y12 inhibition.
Figure 2.
Figure 2.
Perioperative on-treatment platelet reactivity-based de-escalation and escalation strategies.
See this image and copyright information in PMC

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