From the Research
The ideal P2Y12 reaction unit (PRU) level for endovascular flow-diverting stent placement in cerebral aneurysms is between 0-100 PRU, with an optimal target of approximately 50 PRU, as suggested by the most recent study 1.
Key Considerations
- The P2Y12 receptor plays a crucial role in platelet aggregation, and its inhibition is essential to prevent thrombus formation on the metal surface of the flow diverter while allowing endothelialization of the stent and aneurysm occlusion.
- The study by 1 found that the majority of periprocedural ticagrelor PRUs were <100, and PRUs at the time point of thromboembolic complications were >120, suggesting that safe ticagrelor PRU levels might be lower than those commonly applied for clopidogrel.
- Another study 2 also suggested that the safe PRU range for patients receiving ticagrelor should be shifted to 0-100, which is lower than that of clopidogrel.
Recommendations
- Patients should begin dual antiplatelet therapy (DAPT) with aspirin and ticagrelor at least 7 days before the procedure.
- For urgent cases, a loading dose of ticagrelor can be given 6 hours before intervention.
- P2Y12 testing should be performed 4-6 hours after loading or after 5-7 days of maintenance therapy to ensure adequate platelet inhibition.
- Post-procedure, continue DAPT for 3-6 months, then transition to aspirin monotherapy indefinitely.
Important Notes
- The precision of VerifyNow P2Y12 assessment of clopidogrel response may be limited, with significant fluctuations in PRU values within a 24-hour period 3.
- The use of alternative antiplatelet agents, such as prasugrel, may be considered in patients who are non-responders to clopidogrel or ticagrelor 4.