Download PDF
CC BY-NC-ND 4.0 · Journal of Clinical Interventional Radiology ISVIR 2024; 08(01): 011-021
DOI: 10.1055/s-0043-1775981
Original Article

Safety Profile of Intra-Arterial Tirofiban as a Rescue Therapy during Mechanical Thrombectomy in Acute Ischemic Stroke

Karthikeyan Muthugounder Athiyappan 
1   Department of Interventional Radiology, Kovai Medical Center and Hospital, Coimbatore, Tami Nadu, India
,
Mathew Cherian
1   Department of Interventional Radiology, Kovai Medical Center and Hospital, Coimbatore, Tami Nadu, India
,
Pankaj Mehta
1   Department of Interventional Radiology, Kovai Medical Center and Hospital, Coimbatore, Tami Nadu, India
,
Santhosh Poyyamoli 
1   Department of Interventional Radiology, Kovai Medical Center and Hospital, Coimbatore, Tami Nadu, India
,
Nikhil Handihal Reddy 
1   Department of Interventional Radiology, Kovai Medical Center and Hospital, Coimbatore, Tami Nadu, India
,
Anupchakravarthy Jayaraj
1   Department of Interventional Radiology, Kovai Medical Center and Hospital, Coimbatore, Tami Nadu, India
,
Shaheer Ali Palathingal
1   Department of Interventional Radiology, Kovai Medical Center and Hospital, Coimbatore, Tami Nadu, India
› Author Affiliations
› Further Information
   Permissions and Reprints

Abstract

Purpose This article studies the safety profile and role of intra-arterial (IA) tirofiban as a rescue therapy in acute ischemic stroke (AIS) patients undergoing mechanical thrombectomy.

Methods This is a retrospective observational study conducted among AIS patients with large vessel occlusion (LVO) eligible for endovascular revascularization and in whom IA tirofiban is given as rescue therapy. If the target vessel shows reocclusion following initial recanalization, flow limiting or significant residual stenosis after thrombectomy, or requires balloon angioplasty or stenting, IA tirofiban at a dose of 0.4 μg/kg/min was administered through the microcatheter in the target vessel followed by intravenous infusion of 0.1 μg/kg/min. The primary safety measure of the study was the incidence of symptomatic hemorrhage.

Results The total number of patients in the study group was 82, 36 were in the tirofiban group and 46 were in the non-tirofiban group. Immediate successful reperfusion was achieved in 31 patients (86.1%) and 41 patients (89%) in the tirofiban and non-tirofiban groups, respectively. Note that 19.4 and 25% of patients in the tirofiban group required adjunct techniques of angioplasty and stenting, respectively. Also, 2.7% patient in the tirofiban group had a symptomatic hemorrhage, while 8.7% in the non-tirofiban group had symptomatic intracranial hemorrhage. On multinomial logistic regression, history of transient ischemic attack, truncal occlusion and watershed infarct pattern predicted the usage of IA tirofiban during mechanical thrombectomy.

Conclusion Usage of IA tirofiban with or without adjunct techniques as a rescue therapy during mechanical thrombectomy in LVO improved recanalization rates without increasing the risk of symptomatic hemorrhage.

Keywords

mechanical thrombectomy - rescue therapy - tirofiban

Ethical approval

The study was conducted in the Department of Interventional Radiology, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India, after approval by the local ethical and scientific committee.




Publication History

Article published online:
23 January 2024

© 2024. Indian Society of Vascular and Interventional Radiology. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

 

  • References

  • 1 Adams Jr HP, Bendixen BH, Kappelle LJ. et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 1993; 24 (01) 35-41
    CrossrefPubMedGoogle Scholar
  • 2 2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients with Acute Ischemic Stroke Regarding Endovascular Treatment: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association - PubMed. Accessed December 22, 2021 at; https://pubmed.ncbi.nlm.nih.gov/26123479/
    PubMed
  • 3 Goyal M, Menon BK, van Zwam WH. et al; HERMES collaborators. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 2016; 387 (10029): 1723-1731
    CrossrefPubMedGoogle Scholar
  • 4 Nogueira RG, Jadhav AP, Haussen DC. et al; DAWN Trial Investigators. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med 2018; 378 (01) 11-21
    CrossrefPubMedGoogle Scholar
  • 5 Albers GW, Marks MP, Kemp S. et al; DEFUSE 3 Investigators. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med 2018; 378 (08) 708-718
    CrossrefPubMedGoogle Scholar
  • 6 Goyal M, Demchuk AM, Menon BK. et al; ESCAPE Trial Investigators. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 2015; 372 (11) 1019-1030
    CrossrefPubMedGoogle Scholar
  • 7 Campbell BCV, Mitchell PJ, Kleinig TJ. et al; EXTEND-IA Investigators. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 2015; 372 (11) 1009-1018
    CrossrefPubMedGoogle Scholar
  • 8 Millán M, Remollo S, Quesada H. et al; REVASCAT Trial Investigators. Vessel patency at 24 hours and its relationship with clinical outcomes and infarct volume in REVASCAT trial (randomized trial of revascularization with solitaire FR device versus best medical therapy in the treatment of acute stroke due to anterior circulation large vessel occlusion presenting within eight hours of symptom onset). Stroke 2017; 48 (04) 983-989
    CrossrefPubMedGoogle Scholar
  • 9 Qureshi AI, Siddiqui AM, Kim SH. et al. Reocclusion of recanalized arteries during intra-arterial thrombolysis for acute ischemic stroke. AJNR Am J Neuroradiol 2004; 25 (02) 322-328
    PubMedGoogle Scholar
  • 10 Janjua N, Alkawi A, Suri MFK, Qureshi AI. Impact of arterial reocclusion and distal fragmentation during thrombolysis among patients with acute ischemic stroke. AJNR Am J Neuroradiol 2008; 29 (02) 253-258
    CrossrefPubMedGoogle Scholar
  • 11 Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms (PRISM-PLUS) Study Investigators. Inhibition of the platelet glycoprotein IIb/IIIa receptor with tirofiban in unstable angina and non-Q-wave myocardial infarction. N Engl J Med 1998; 338 (21) 1488-1497
    CrossrefPubMedGoogle Scholar
  • 12 Kwon JH, Shin SH, Weon YC, Hwang JC, Baik SK. Intra-arterial adjuvant tirofiban after unsuccessful intra-arterial thrombolysis of acute ischemic stroke: preliminary experience in 16 patients. Neuroradiology 2011; 53 (10) 779-785
    CrossrefPubMedGoogle Scholar
  • 13 Kim JW, Jeon P, Kim GM, Bang OY, Byun HS, Kim KH. Local intraarterial tirofiban after formation of anterograde flow in patients with acute ischemic stroke: preliminary experience and short term follow-up results. Clin Neurol Neurosurg 2012; 114 (10) 1316-1319
    CrossrefPubMedGoogle Scholar
  • 14 Seo JH, Jeong HW, Kim ST, Kim EG. Adjuvant tirofiban injection through deployed solitaire stent as a rescue technique after failed mechanical thrombectomy in acute stroke. Neurointervention 2015; 10 (01) 22-27
    CrossrefPubMedGoogle Scholar
  • 15 Goh DH, Jin SC, Jeong HW, Ha SY. Mechanical solitaire thrombectomy with low-dose booster tirofiban injection. Neurointervention 2016; 11 (02) 114-119
    CrossrefPubMedGoogle Scholar
  • 16 Kang DH, Kim YW, Hwang YH, Park SP, Kim YS, Baik SK. Instant reocclusion following mechanical thrombectomy of in situ thromboocclusion and the role of low-dose intra-arterial tirofiban. Cerebrovasc Dis 2014; 37 (05) 350-355
    CrossrefPubMedGoogle Scholar
  • 17 Yang M, Huo X, Miao Z, Wang Y. Platelet glycoprotein IIb/IIIa receptor inhibitor tirofiban in acute ischemic stroke. Drugs 2019; 79 (05) 515-529
    PubMedGoogle Scholar
  • 18 Pandian JD, Sudhan P. Stroke epidemiology and stroke care services in India. J Stroke 2013; 15 (03) 128-134
    CrossrefPubMedGoogle Scholar
  • 19 Zhang S, Hao Y, Tian X. et al. Safety of intra-arterial tirofiban administration in ischemic stroke patients after unsuccessful mechanical thrombectomy. J Vasc Interv Radiol 2019; 30 (02) 141-147.e1
    CrossrefPubMedGoogle Scholar
  • 20 Pan X, Zheng D, Zheng Y. et al. Safety and efficacy of tirofiban combined with endovascular treatment in acute ischaemic stroke. Eur J Neurol 2019; 26 (08) 1105-1110
    CrossrefPubMedGoogle Scholar
  • 21 Huo X, , Raynald, Wang A. et al. Safety and efficacy of tirofiban for acute ischemic stroke patients with large artery atherosclerosis stroke etiology undergoing endovascular therapy. Front Neurol 2021; 12: 630301
    CrossrefPubMedGoogle Scholar
  • 22 Mehndiratta M, Pandey S, Nayak R, Alam A. Posterior circulation ischemic stroke-clinical characteristics, risk factors, and subtypes in a North Indian population: a prospective study. Neurohospitalist 2012; 2 (02) 46-50
    CrossrefPubMedGoogle Scholar
  • 23 Zhao W, Che R, Shang S. et al. Low-dose tirofiban improves functional outcome in acute ischemic stroke patients treated with endovascular thrombectomy. Stroke 2017; 48 (12) 3289-3294
    CrossrefPubMedGoogle Scholar
  • 24 Baek JH, Kim BM. Angiographical identification of intracranial, atherosclerosis-related, large vessel occlusion in endovascular treatment. Front Neurol 2019; 10: 298
    CrossrefPubMedGoogle Scholar
  • 25 Cho KH, Kim JS, Kwon SU, Cho AH, Kang DW. Significance of susceptibility vessel sign on T2*-weighted gradient echo imaging for identification of stroke subtypes. Stroke 2005; 36 (11) 2379-2383
    CrossrefPubMedGoogle Scholar
  • 26 Suh HI, Hong JM, Lee KS. et al. Imaging predictors for atherosclerosis-related intracranial large artery occlusions in acute anterior circulation stroke. J Stroke 2016; 18 (03) 352-354
    CrossrefPubMedGoogle Scholar
  • 27 Gong J, Shang J, Yu H. et al. Tirofiban for acute ischemic stroke: systematic review and meta-analysis. Eur J Clin Pharmacol 2020; 76 (04) 475-481
    CrossrefPubMedGoogle Scholar
  • 28 Kellert L, Hametner C, Rohde S. et al. Endovascular stroke therapy: tirofiban is associated with risk of fatal intracerebral hemorrhage and poor outcome. Stroke 2013; 44 (05) 1453-1455
    CrossrefPubMedGoogle Scholar
  • 29 Lee JI, Gliem M, Gerdes G. et al. Safety of bridging antiplatelet therapy with the gpIIb-IIIa inhibitor tirofiban after emergency stenting in stroke. PLoS One 2017; 12 (12) e0190218
    CrossrefPubMedGoogle Scholar
  • 30 Wu Y, Yin C, Yang J, Jiang L, Parsons MW, Lin L. Endovascular thrombectomy. Stroke 2018; 49 (11) 2783-2785s
    CrossrefPubMedGoogle Scholar
  • 31 Yu T, Lin Y, Jin A. et al. Safety and efficiency of low dose intra-arterial tirofiban in mechanical thrombectomy during acute ischemic stroke. Curr Neurovasc Res 2018; 15 (02) 145-150
    CrossrefPubMedGoogle Scholar
  • 32 Kang DH, Yoon W, Kim SK. et al. Endovascular treatment for emergent large vessel occlusion due to severe intracranial atherosclerotic stenosis. J Neurosurg 2018; 130 (06) 1-8
    PubMedGoogle Scholar
  • 33 Yi HJ, Sung JH, Lee DH. Safety and efficacy of intra-arterial tirofiban injection during mechanical thrombectomy for large artery occlusion. Curr Neurovasc Res 2019; 16 (05) 416-424
    PubMedGoogle Scholar