Cangrelor

Cangrelor

Emergent stenting of both extra- and intracranial occlusions during acute ischemic stroke procedures is complicated by the need for immediate platelet inhibition to prevent thromboembolic complications.

Cangrelor is a new antiplatelet therapy with a P2Y12 inhibiting effect, with a rapid onset and offset of action, owing to its short half-life 1).

Cangrelor may be a feasible alternative for patients requiring immediate intervention with the use of endoluminal devices. It allows the possibility for a secure transition to long-term ticagrelor and progression to surgery in the setting of unexpected complications 2).

Cangrelor presents many advantages compared to standard therapy in patients undergoing stent placement related to its pharmacokinetic profile, rapid onset of action, ease of transition to oral P2Y12 antiplatelet agents, and measurability 3)

Findings suggest that cangrelor is a promising alternative in acute stenting for the treatment of cerebrovascular pathology. However, further studies with larger samples are required to accurately elucidate its safety and effectiveness in neuroendovascular procedures 4).

Five prior case series have been published evaluating the results of IV cangrelor in neurointerventional procedures. Paul et al. sought to combine the data from all prior studies and analyze only ischemic stroke interventions.

A prospectively maintained database was reviewed to identify all cases of IV cangrelor administration during acute ischemic stroke intervention. Nine additional patients were identified who have not been previously published. In addition, a literature search was performed to identify five prior publications of cangrelor in neurointervention. The data from these was combined with our institution in a pooled-analysis.

Overall, 129 patients who received IV cangrelor during an acute ischemic stroke intervention were identified. The asymptomatic intracranial hemorrhage rate was 12.6%(11/87). The symptomatic intracranial hemorrhage rate was 6.2% (8/129). The rate of retroperitoneal hematoma and gastrointestinal bleeding were also low (1.5% and 0.8%, 2/129 and 1/129). There was one case of intraprocedural thromboembolic complication (0.8%) and no cases of intraprocedural in-stent thrombosis(0%).

IV cangrelor during endovascular intervention for ischemic stroke treatment appears to be safe, with a symptomatic intracranial hemorrhage rate of 6.2%. More research is needed to determine the ideal dosing regimen 5).

The recommended duration of dual antiplatelet therapy after drug-eluting stent placement presents a dilemma for patients with recent stenting who require urgent or emergency noncardiac surgery. We present the case of a patient with recent drug-eluting stent placement (<6 months) on dual antiplatelet therapy who underwent successful emergency cervical spine surgery with antiplatelet therapy bridged using cangrelor, an intravenous P2Y12 inhibitor antiplatelet agent. Our experience illustrates the multidisciplinary approach to a patient with high thrombotic and bleeding risk who underwent neurosurgery off both aspirin and a P2Y12 inhibitor 6)


1)

Abdennour L, Sourour N, Drir M, Premat K, Shotar E, Taylor G, Godier A, Mathout J, Lenck S, Bernard R, Carpentier A, Degos V, Clarençon F. Preliminary Experience with Cangrelor for Endovascular Treatment of Challenging Intracranial Aneurysms. Clin Neuroradiol. 2020 Sep;30(3):453-461. doi: 10.1007/s00062-019-00811-2. Epub 2019 Jul 15. PMID: 31309241.
2)

Cortez GM, Monteiro A, Sourour N, Clarençon F, Elhorany M, Grigoryan M, Mirza S, Dabus G, Linfante I, Aguilar-Salinas P, Murtaza Y, Aghaebrahim A, Sauvageau E, Hanel RA. The use of cangrelor in neurovascular interventions: a multicenter experience. Neuroradiology. 2020 Nov 11. doi: 10.1007/s00234-020-02599-2. Epub ahead of print. PMID: 33174182.
3)

Entezami P, Holden DN, Boulos AS, Paul AR, Field NC, Nourollahzadeh E, Yamamoto J, Dalfino JC. Cangrelor dose titration using platelet function testing during cerebrovascular stent placement. Interv Neuroradiol. 2021 Feb;27(1):88-98. doi: 10.1177/1591019920936923. Epub 2020 Jul 1. PMID: 32611215; PMCID: PMC7903542.
4)

Aguilar-Salinas P, Agnoletto GJ, Brasiliense LBC, Santos R, Granja MF, Gonsales D, Aghaebrahim A, Sauvageau E, Hanel RA. Safety and efficacy of cangrelor in acute stenting for the treatment of cerebrovascular pathology: preliminary experience in a single-center pilot study. J Neurointerv Surg. 2019 Apr;11(4):347-351. doi: 10.1136/neurintsurg-2018-014396. Epub 2018 Dec 14. PMID: 30552167.
5)

Paul AR, Entezami P, Holden D, Field N, Dalfino J, Boulos A. Use of intravenous cangrelor and stenting in acute ischemic stroke interventions: a new single center analysis and pooled-analysis of current studies. Interv Neuroradiol. 2021 May 4:15910199211014417. doi: 10.1177/15910199211014417. Epub ahead of print. PMID: 33945341.
6)

Hu TY, Peeters SM, Nagasawa DT, Kamdar NV, Brook RP, Sun J, Park S, Moreland NC, Cruz D, Macyszyn L, Press MC. Cangrelor Bridging Within 6 Months of a Drug- Eluting Stent in a Patient for Emergency Cervical Spine Surgery: A Case Report. A A Pract. 2019 Jul 15;13(2):69-73. doi: 10.1213/XAA.0000000000000994. PMID: 30864953.

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