(638) Eptifibatide Transitioned to DAPT Using P2Y12 Levels Following Neurovascular Stents or Devices

Introduction: Dual antiplatelet therapy (DAPT) remains the primary strategy to prevent thromboembolic complications related to intravascular stents or flow diverters. Rapid intravenous (IV) antiplatelets are often required during device placement. Limited data exist to guide periprocedural antiplatelet regimens, including transitioning to DAPT. Here, we describe the use of eptifibatide, including timing, dosing and transitions to DAPT in patients who received neurovascular stents or flow diverters.

Methods: This is a retrospective analysis of adults who received eptifibatide during placement of a neurovascular stent or pipeline embolization device from January 1, 2016 to May 18, 2023. The primary outcome was the incidence of platelet function assays (P2Y12 level; VerifyNow®) sent, within 24 hours of eptifibatide. Secondary outcomes were stent occlusion, intracranial hemorrhage (ICH), adequate platelet inhibition (P2Y12 level < 194 PRU), and antiplatelet adjustment.

Results: Of 44 patients, 27 (61%) were treated for stenotic lesions, 15 (34%) unruptured aneurysms, 1 ruptured aneurysm, and 1 dural AV fistula, with the majority being emergent (70%) procedures. The median age was 70 years; 23 (52%) were male. All patients received an eptifibatide bolus, intra-arterial (n = 28), IV (n = 21), or both (n=7). Median bolus dose was 97 mcg/kg (IQR 85,179). Post-procedure, eptifibatide continued in 13 (30%) patients (median dose 1 mcg/kg/min); 12/13 (92%) were transitioned to oral DAPT after a median of 1.27h overlap with eptifibatide. Oral antiplatelets were given at a median of 8.5h (5.1, 13.6) after eptifibatide. Median P2Y12 pre-op was 186 (148,247) and post-op was 108 (58,182) with the majority (74%) sent at a median of 11.8h (6.6,34.8) after the procedure. There were 6 dose increases, 3 dose decreases, and 6 switched agents based on the first post-op PRUs. There were 33/34 (97%) patients who had at least one P2Y12 level < 194 PRU. Five (11%) patients had stent occlusion and 5 (11%) had an ICH.

Conclusions: The use of eptifibatide for neurovascular procedures varies based on indication. Transitions to DAPT are guided by platelet function assays, however it remains unknown if the optimal time to assess this is within 24 hours or if platelet inhibition should be measured 48 hours from eptifibatide.